Year : 1995 | Volume
: 43 | Issue : 3 | Page : 143--149
Community eye care: Experiences in pilot projects in Basti and Salem Districts
Raj Kumar, P Bandyopadhyaya, JJ Limburg
From Danish Assistance to the National Programme for Control of Blindness (DANPCB), Danish International Development Agency (Danida), New Delhi, India
Danida Support Unit, A-l/148, Safdarjung Enclave, New Delhi 110 029
|How to cite this article:|
Kumar R, Bandyopadhyaya P, Limburg J J. Community eye care: Experiences in pilot projects in Basti and Salem Districts.Indian J Ophthalmol 1995;43:143-149
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Kumar R, Bandyopadhyaya P, Limburg J J. Community eye care: Experiences in pilot projects in Basti and Salem Districts. Indian J Ophthalmol [serial online] 1995 [cited 2021 Sep 23 ];43:143-149
Available from: https://www.ijo.in/text.asp?1995/43/3/143/25291
BASTI DISTRICT, UTTAR PRADESH
Basti is a backward district in the northeastern part of the Indian state of Uttar Pradesh (U.P.), with a population of 2.75 million (1991 census), 95% of which is rural. It comprises 4,500 villages and 6 towns. The district is divided into 19 revenue blocks. The literacy rate is 20.24%.
Design of Pilot Project
The design of the pilot project for Basti district included the following resources and activities:
1. Development of 9 Primary Health Centres (PHCs): Appointment of paramedical ophthalmic assistant (PMOA) with basic eye care equipment.
2. Establishment of 2 District Mobile Units (DMUs).
3. Development of 5 Community Health Centres (CHCs): Appointment of ophthalmic surgeon and other staff with one operation theatre and necessary equipment.
4. Establishment of an eye bank.
5. Training of ophthalmic surgeons and paramedical ophthalmic assistants.
Most of the resources required were additional staff, infrastructure and equipment. A situational analysis to study the need for these resources was done. In striking contrast to what was expected, this analysis revealed availability of the following infrastructure and resources within the district:
All the 19 block level PHCs had permanent buildings which included one operation theatre.
A PMOA had been appointed in all the upgraded PHCs but without a separate room or basic eye care equipment.
A DMU was officially sanctioned but no staff or vehicle existed.
Most staff positions in the government sector were filled, hence only a few vacancies were left.
The District Hospital had 10 beds for eye patients and the operation theatre was used twice a week.
The contribution of the private sector was meagre with only 2 full-time practicing ophthalmic surgeons. There were hardly any active nongovernment organisations (NGOs) in the entire state.
The immediate task in the district was to utilise the existing infrastructure to the optimum instead of acquiring additional resources. The presence of both private and voluntary eye care sevices was negligible.
In April 1991, the District Blindness Control Society (DBCS), and the office of the District Programme Coordinator (DPC) were set up. To establish the credibility of the programme, the first activity undertaken was introduction of 'School Eye Screening' in two blocks, namely, Rudhauli and Khalilabad. The strategy involved the school teachers as the primary screeners. The referred school children, suspected to have poor vision were examined in detail by the PMOA at the PHC. The needy children were provided with corrective glasses by authorised private opticians against payments made by the DBCS. Later, during the following years, 1992 to 1994, this programme was extended to cover the whole district (Table).
The second activity during the first year was rehabilitation of the incurably blind under the aegis of the National Association for the Blind (NAB). Based on the encouraging results in one block (Haraiya), this programme is now being extended in a phased manner to 6 more blocks in the district.
In January 1992, Basti became the venue of the first-ever district planning exercise for the DBCSs in the country. District planning is now an integral part of the induction training of the newly appointed District Programme Managers (DPMs) in the country.
For the year 1992-93, the activities included regular eye camps by the DMU (not yet functional), expansion of the school eye screening programme, provision of essential eye drug kits to the PMOAs accompanied with regular monthly review meetings, and rehabilitation services in one block. During the following years, identification and treatment of trachoma through volunteers, general census of the blind in the age group of 40 and above by volunteers, accelerated publicity to mobilise operable cases, and training of the PMOAs in clinical skills, were included in the activities. However, throughout the 3-year period, the focus remained on cataract surgery.
To combat cataract blindness, which is responsible for over 80% of all blindness, Basti district set up eye camps in all the 19 blocks. The existing non-functional mobile unit was made functional by hiring a vehicle for transport of the operating team, purchase of necessary drugs and other materials by the DBCS, and by the collective effort of all the government ophthalmic surgeons. As a result, during the year 1992-93, the number of cataract operations in the district increased to 2,942 as compared to 1,015 in the preceding year, of which, the contribution of the mobile unit was 1,839 (62.5%). In the following year, 1993-94, this contribution was 1588 (66%), of a total of 2,405 surgeries performed [Figure:1].
Some Important Inferences
The experience in Basti district clearly demonstrates that setting up of effective and functional mobile units in all the other districts of the State is crucial if the volume of cataract surgery in rural areas is to be increased.
The surgical volume of 2,405 operations performed during 1993-94 represents a surgical rate of 0.87 per 1,000 population in the district, as against a requirement range of 2.5 to 3.0 per 1,000 population.
A very small contribution was made by nongovernment organizations and private practitioners [Figure:2].
Despite a large number of eye camps that were planned and organised each year, the per camp 'productivity' was far too less. For example, during the year 1992-93, 136 eye camps were conducted with an average surgical volume of 13 cataract operations per eye camp. During the year 1993-94, this average was 11 per eye camp. The optimum surgical volume expected from an eye camp in Uttar Pradesh was 30; thus, the efficiency of the eye camps was just 40%. The main reason for low surgical volume was due to case mobilisation and case recruitment and not due to nonavailability of cases as reported. The district ophthalmic surgeons operated only those eyes with vision less than 1/60, with the result that persons officially classified as blind (vision less than 6/60) were denied surgery. In other words, any increase in case finding was nullified by a high case rejection. Another reason for low surgical volume was that, too many camps were a managerial strain on the core team. In future, the focus should shift to fewer, regular camps with higher surgical volume.
The quality of services, including the preoperative and postoperative management needs to be up graded. The routine operation theatre procedures were not followed. Also, the routine follow-up of the patients and regular assessment of postoperative visual acuity were not done.
Organization of an Eye Camp
Based on the experiences, the following strategy is suggested for organising eye camps in a district:
1. A fixed weekly schedule of organising the eye camps should be followed with rotation of the constituent blocks in the district. The block(s) having a permanent eye care facility, e.g., a District Hospital, or a charitable eye hospital may be excluded from the eye camp schedule. This will result in a more equitable coverage of all the areas.
2. A target of 50 operations per eye camp with one operating ophthalmic surgeon should be fixed. The PMOA of the respective PHC should be made directly responsible for organising and selecting the cases. Any eye camp with a performance of less than 25 surgeries should be carefully reviewed by the DBCS.
3. The Block Medical Officer should be made responsible for the organisation of an eye camp in the block as the camp coordinator and the PMOA be made in-charge of case mobilisation, operation theatre arrangements and follow-up. There is an urgent need to redefine the role of PHC medical officer in relation to blindness control programme. The suggested revised responsibilities for a PHC medical officer are:
To organise eye camps in the block with close collaboration of the DMU and DBCS.
To provide supportive supervision to the PMOA for efficient work at the PHC.
To mobilise the male health workers and supervisors appointed in the PHC for identification and mobilisation of cataract and trachoma cases.
To treat minor eye conditions as part of the regular PHC outpatient clinic.
Greater Efficiency for PMOAs
To augment the efficiency of the PMOAs, the following measures were taken:
Supply of primary eye care equipment and basic furniture to all the PMOAs.
Supply of essential drugs every month. This resource was linked with the review meeting of all the PMOAs, held on the 4th of every month. A format has been introduced to get a feedback on their performance each month.
Training of all the PMOAs in 3 batches for two weeks each at the M.D. Eye Hospital, Allahabad, in refraction, retinoscopy, ophthalmoscopy, preparation of the patient for surgery, postoperative care, and in organising eye camps.
Rehabilitation of the Incurably Blind
In the Haraiya block, the rehabilitation project was started by the Shikshit Yuva Sewa Samiti, a nongovernment organisation, with the following activities:
Census to identify blind persons
Treatment of the curably blind
Rehabilitation of the incurably blind, i.e., mobility, economic and social benefits like pension and free/concessional travel
Integrated education of the blind children in the regular schools
The focus of the project was on community-based rehabilitation as opposed to the conventional institutional care for the blind. Under the programme, a blind person is made socially acceptable and a beneficial member of his own family. Till date, 254 incurably blind persons in this block have been identified, of whom, 179 have been trained or rehabilitated.
The initial census and identification of blind persons by the community-based rehabilitation volunteers has resulted in increased attendance in the eye camps. Moreover, the project was able to identify more blind persons in collaboration with a hospital or an eye care facility. Based on these encouraging experiences, the project is now being extended to 7 blocks in a phased manner.
Management of Trachoma
Uttar Pradesh is one of the 5 states of India with highest prevalence of trachoma. In order to identify and treat the active cases of trachoma in young children, community-based volunteers in 29 villages were provided with training, trachoma detection cards (developed by WHO) and oxytetracycline eye ointment tubes. One hundred twenty-five children were found with active trachoma and were provided with the antibiotic tubes to be used for one week. The follow-up one month later demonstrated that the follicles had disappeared and there was no resistance to oxytetracycline. This proves that management of trachoma is feasible through the village-based trained volunteers. In response to this, the Uttar Pradesh government has recently decided to provide 450 antibiotic tubes to every PHC in the State. Under another programme, efforts are being made to provide safe drinking water to every village in the State.
During the past four years of its existence, the DBCS in Basti district has had little or no supervision from the State headquarters, possibly because of the State's large size and number of districts (66 districts). For better programme management, introduction of decentralised supervision at the division levels is suggested. There are 11 divisions, each with 4 to 8 districts. The supervision could be effected by the Divisional Commissioner through the District Magistrates of the constituent districts. The District Programme Manager of the headquarter district of the division could become the focal point for the division. The role of the state programme cell could then be restricted to establishing linkages with the division headquarters and not the districts directly.
During the last 3 years, Basti district has had 5 District Magistrates, 3 Chief Medical Officers and 7 different State Programme Officers. The continuity of tenure is an important prerequisite for efficient management, productivity and sustainability in any organisation. The government of India can ensure this by linking the assistance of the following officials in the state/district:
State Programme Officer - District Programme Manager - District Ophthalmic Surgeon - Incharge, Mobile Ophthalmic Unit - Other government ophthalmic surgeons in the district - PMOAs
To improve the work culture and boost the morale of the staff, commendations in form of prizes for the best performing PMOAs in the district and sponsorship for training programmes may be instituted or conferences organized for ophthalmic surgeons making substantial contribution.
The authors thank the following persons for their contribution: Drs. D. Gogna, G.P. Verma and B.P. Tripathi, Eye Surgeons; Mr G. Agarwal of Shikshit Yuva Sewa Samiti; Dr. R.C. Srivastava, Rotarian; Ms. Renuka Kumar, ex-Chief Development Officer; and all the District Magistrates and Paramedical Ophthalmic Assistants of Basti district.
SALEM DISTRICT, TAMIL NADU
The District and its Infrastructure
Salem is one of the oldest and largest districts of Tamil Nadu (T.N.) in South India with a population of 3.9 million (1991 census), of which, 71% is rural and 29% is urban. The literacy rate is around 40%. The district is divided into 4 divisions with 10 talukas, consisting of 65 towns and over 8,000 villages.
In the health sector, besides a medical college attached to the District Hospital, there are 8 taluka and 9 non-taluka hospitals, 35 Primary Health Centres (PHCs)/Community Health Centres (CHCs), 82 additional Primary Health Centres and 666 subcentres. All the hospitals are under the control of a Deputy Director of Medical Services. There are about 450 medical practitioners, 300 nurses and over 1,000 health workers.
The medical college/district hospital has a full-fledged ophthalmology department with 12 beds for eye patients in addition to an attached District Mobile Unit. The State Mobile Unit in Coimbatore, Aravind Eye Hospital, Madurai and St. Joseph Eye Hospital, Tiruchirapalli, organise a number of eye camps in the districts each year. In addition to the government infrastructure and personnel, there are a number of private practitioners, including ophthalmic surgeons in Salem district.
Design of Pilot Project
The design of the pilot project for Salem district included the following resources and activities:
1. Establishment of 2 additional mobile units with a total budget of Rs. 2.36 million for a 4-year period; and, strengthening the staff and equipment of the existing District Mobile Unit (DMU) with a budget of Rs. 370,000.
2. Provision of vitamin A solution, drugs, spectacles and food to poor patients (budget, Rs. 1.248 million).
3. Establishment of a workshop for maintenance and training purposes at the district headquarters (budget, Rs. 628,000).
4. Information, Education and Communication (IEC) activities (budgeted expenditure, Rs. 340,000).
5. Mobility and assistance to the paramedical ophthalmic assistants (Rs. 245,000).
6. Research, rehabilitation and other miscellaneous work.
School Eye Screening
To establish credibility of the programme, the District Blindness Control Society undertook school eye screening as its first programme during the first year (1991) of the pilot project. Under this programme, Salem became the first district in the country to launch the school eye screening programme. The first training programme for the school teachers in Karipatty in Ayothiapattinam block was organised during June, 1991. Later, children of the middle school (classes 6 to 8) were screened. In the following months, the programme was extended to Salem (rural), Attur, Gangavalli and Thalaivasal blocks.
Based on the initial experiences in school eye screening in Salem district, a training module with a slide set, an instructional video programme titled 'Mukhai's Story' (prepared in Salem), and other materials were developed and mass distributed by the Danida Support Unit, New Delhi. This package has since been adopted in many parts of the country for implementing the school eye screening programme.
In the following years, all the 16 blocks in the district were covered. Till date, 107,510 out of a total of 158,957 children of the middle school (classes 6 to 8) from 468 schools have been screened. Of these, 5,180 children were referred for examination by the PMOAs in the upgraded PHCs. Of those who reported, 475 children were prescribed glasses and 377 issued glasses. The high drop out of the referred children could be due to 3 factors:
1. Visits to private opticians for refractive correction and purchase of glasses without any reference.
2. Very low refractive corrections were not prescribed by the PMOAs.
3. Some PMOAs encountered administrative problems in the PHCs.
For the year 1992-93, the project plan included cataract surgery, school eye screening, orientation and training, and IEC activities. The main focus was on cataract surgery. A target of 12,000 operations (calculated at 3 per 1,000 population) was fixed for the year, with the main strategy being mass eye camps and fixed-day surgery in the taluka hospitals. The plan for the year (1993-94) remained similar except that the target was revised to 17,800 operations. For the year 1994-95, the target has been fixed at 12,840 operations.
Other activities planned for the year 1994-95 include school eye screening; training of ophthalmic surgeons, operation theatre nurses and male health workers; and extensive IEC activities.
As the first priority under the project plan, mass eye camps and fixed-day surgery at the taluka hospitals were chosen as means to increase the rate of cataract operations.
The number of cataract operations done in Salem district during 1989-94 is shown in [Figure:3].
The State Mobile Unit in Salem district contributed 1,371 cataract operations during 1991-92 and 2,087 and 2,641 cataract operations in the following 2 years [Figure:4]. Among 8 State and Central Mobile Units in Tamil Nadu, the contribution by the Coimbatore Unit was the highest.
The 12 beds for eye patients in the Medical College, Salem, provided for 279, 308 and 137 cataract operations, occupancy rates being 46%, 51% and 23%, respectively, during the past 3 years. The fixed-day surgery in the taluka hospitals yielded 239, 330 and 487 cataract operations (1991-93), of which, 70% were done at Government Hospital, Mettur, alone. For example, the major voluntary hospitals, namely, Aravind Eye Hospital, Madurai; St. Joseph Eye Hospital, Tiruchirapalli; and J.K.K. Hospital, Komarapalyam, together have contributed more number of cataract operations than the entire contribution of the government hospitals and eye camps - 4,912/7,083 during 1991-92 (69.3%), 3,386/7,585 during 1992-93 (57.1%) and 3,386/7,126 during 1993-94 (47.5%) [Figure:5].
A sample cataract survey was conducted in Salem during July 1993, covering persons aged 50 years and above. It revealed the following findings:
A backlog of 120,000 eyes (23,000 persons; 4% prevalence) existed.
The aphakia rate (surgical coverage of the total estimated load) was found to be 46% in Salem, compared to 33% in Tumkur (Karnataka) and 22% in Purnea (Bihar) [Figure:6]. This finding indicates that the eye care service is better in Salem than in other pilot districts.
Among the causes for cataract surgery not being done, the fear of surgery (30%) and lack of motivation (23%) accounted for majority of all the causes [Figure:7].
As regards the place of surgery, private clinics, Aravind Eye Hospital, St. Joseph Eye Hospital and mass eye camps accounted for approximately 20% each of all the cataract surgeries [Figure:8].
Screening for refractive errors and cataract was also carried out among textile weavers and magnesite miners. Of a total of 2,592 workers suspected on initial screening, 1,854 workers were examined, of whom, 1,081 were prescribed glasses. In addition, 194 workers were identified with operable cataracts, of whom, 112 were operated in government hospitals.
Like other pilot districts, one of the blocks in Salem (Sankaragiri) launched a project for Community-Based Rehabilitation (CBR) of the incurably blind persons. Although officially not a part of the DBCS activity, the project was aimed at bringing the curative and rehabilitation activities closer to each other to enable a comprehensive eye care service in the district. With the encouraging experiences, the CBR project has already covered Mettur block. In the Sankagiri and Mettur blocks, 436 incurably blind persons have been identified from 432 villages. Of these, 213 have been rehabilitated socially within their own families, 156 assisted with economic rehabilitation, 313 provided mobility and 208 blind persons provided state pension. In addition to these 436 persons, another 510 blind persons have been provided treatment, mostly in the eye camps and government hospitals.
The project is now being extended to the entire district in a phased manner with Salem (rural) and Rasipuram blocks already being covered by the project. It is hoped that the CBR together with the curative services should be able to create a climate of total eye care in the district in the coming years.
Some Important Inferences
The 4-year experience of Salem pilot district provides clear directions to the programme in Tamil Nadu for the next decade.
Contribution by Various Sectors versus Expenditure
More than 75% of the entire contribution of cataract surgery in Tamil Nadu has been made by voluntary institutions alone [Figure:9]. These figures, however, do not take into account the surgeries done by private ophthalmic surgeons. Assuming that the private ophthalmic surgeons contribute 25% of all surgeries, as found in the sample survey (July 1993) in Salem district, the government sector in its entirety probably contributes less than 15% of the total cataract surgery done. This is contrary to the expenditure pattern of the NPCB in Tamil Nadu where more than 75% of the expenditure is on the recurring costs of the government units. A much broader approach in this regard is, therefore, necessary.
The futility of the Mobile Ophthalmic Units
The 5 State Mobile Units (staff strength of 46 each) and 3 Central Mobile Units (staff strength of 16 each) in Tamil Nadu contribute an average of less than 2,000 cataract surgeries in one year. Similarly, the average contribution of the District Mobile Units was less than 500 during the year 1993-94 (as against 650 during 1992-93). In view of the low output as against high costs, as well as, institutional surgery as the ultimate objective of any eye care programme, closure of all the mobile units and concentration on service delivery through the district and taluka hospitals and, the voluntary/private sectors, is advisable.
The states of Punjab, Haryana, Gujarat and Himachal Pradesh have already shifted to hospital surgery and the eye camps are being gradually wound up. More and more patients are reporting to private ophthalmic surgeons. Even in Maharashtra, the so-called 'eye camps' are in reality institutional surgery in the rural hospitals and CHCs.
Upgradation of Institutional Surgical Facilities
As per the suggestion, the closure of mobile units will enable the state government to divert resources for better institutional surgery in its hospitals.
Privatization of Eye Care
Approximately 85% of the cataract surgery in Tamil Nadu is being done in the non-government sector, of which, approximately 75% is contributed by voluntary organisations and 25% by practicing ophthalmic surgeons. This clearly indicates the trend towards the private sector. The low costs and better surgical facilities in the non-government sector compared to the government sector offers a strong argument to shift cataract surgery to the private/voluntary sector in its entirety.
Information, Education and Communication (IEC) campaign
There already exists a fairly good awareness about eye care in Tamil Nadu. With the vast network of media channels now available, it is possible to convert the current awareness into a strong-felt need of the community.
Programme Management at the State Level
In view of the managerial problems experienced during the last 4 years (1990-94), a better management structure is needed at the state level for a better coordinated approach.
With the available resources and necessary changes in the administrative set up, eye care for all in Tamil Nadu is not a distant dream.
The authors gratefully thank Dr. J.J. Limburg, Chief Advisor, DANPCB, for having peer reviewed this report.
The authors also thank the following persons for their contribution: Dr. A. Shanmugasundaram and Dr A.K. Raghu, eye surgeons; Mr. M.S. Ramaiah, ex-District Collector; Dr. Veerabaghu, ex-dean, G.M.K. Medical College; Mr. C. Ramalingam of the Citizens Welfare Association; Drs. V. Siddharthan, Ravichandran and Sundararajan, private ophthalmic surgeons and all the Paramedical Ophthalmic Assistants and Divisional Development Officers of Salem.