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Eye care planning at the district level: case studies from Asia and Africa

This article is adapted from: Cook, C., and Qureshi, B. VISION 2020 at the district level. Comm Eye Health Vol. 18 No. 54 2005 pp 85 - 89. Published online 01 June 2005. As you read, think about the challenges as described by the two case studies in Tanzania and Pakistan. Consider the similarities and differences in each case with your own setting or with Zrenya.

Background to planning at the district level

There is an African saying. The question is: “How do you eat an elephant?” The answer is: “One mouthful at a time, slowly, with a lot of help from your friends”. There is much that we can learn from this wisdom and apply to a district level plan. The question is: “How do you overcome the seemingly insurmountable problem of global blindness?” The answer is: “Piece by piece, in digestible portions, step by step, and working together as a team”.

  • Advocacy takes place globally and regionally
  • Strategic planning takes place nationally
  • But the actual implementation takes place at district level.

It is recommended that each of our district level should be for service units of about 1 million population (0.5-2 million). As indicated previously, this administrative unit of about 1 million may be called by different names in different countries, e.g. sub-district, district, region, province, etc. These are the ‘pieces of the elephant’. If we have a country of 40 million population, we should not plan just a single national programme, but 40 separate district level programmes that together make up the national programme (Figure 1).

Figure 1. The national VISION 2020 programme should be made up of separate district level VISION 2020 programmes. Figure 1. The national VISION 2020 programme should be made up of separate district level VISION 2020 programmes.

What is involved at the district level?

District level programmes are developed as one year operational plans, prepared as integral components of the district general health operational plan and guided by the five-year national strategic eye health plans. A comprehensive approach (preventive, curative, and rehabilitation) is built on equity, community involvement, focus on prevention, appropriate technology, and a multi-sectoral approach. In the past, these four elements have been working separately and without focus. All district programmes will have the same elements, but no two programmes will be the same because no two districts are the same.

Figure 2. Model VISION 2020 Programme (per million population).
Figure 4. Model VISION 2020 Programme (per million population).

Challenges and lessons learnt from experience: The Asian context

In 1996 the district programme concept was piloted in Bannu, located in the North West Frontier province of Pakistan. The district hospital had limited ophthalmic infrastructure, human resources, equipment and management.

There were two ophthalmologists, no paramedic staff, no separate operating theatre (it was shared with other specialties), no separate eye ward, and minimal equipment. The output was 150 cataract operations per year.

A collaborating partnership between the Pakistan Institute of Community Ophthalmology, the Government of North West Frontier Province, and an international non-governmental organisation (NGO) was established. The collaboration initially strengthened the district by providing equipment, as per the IAPB Standard List. The government posted two new ophthalmologists trained in ECCE and IOL implantation, and five paramedics were trained, with one of the paramedics trained in management. The infrastructure was upgraded with a separate eye theatre, a separate eye ward, and an outpatient complex. Primary eye care workers were trained in detection and treatment of minor disorders and referral of major ones.

The eye unit was evaluated after two years, and the cataract output had increased sevenfold to 1,050 operations. The programme now includes successful refractive and low vision services, and a trachoma control programme. Eye care services for children will soon be added.

It was agreed by the national committee that this model should be replicated in other districts in the country, with the support of NGOs. Thus far, 53 district programmes have been established out of a total of 119 districts in Pakistan resulting in a 375% increase in cataract surgical rate.

What have been the challenges?

One of the challenges was to build a stable and committed team. It was important to engage the government so that frequent transfers of staff would not take place. Motivation of the eye team to maintain high volume surgery was addressed by giving a forum to display surgical results every year and establishing a system of peer review. Monitoring of outcomes needs to be introduced so that the eye teams can maintain high standards of visual outcome.

What have been the key learning points?

  • The service started as a cataract service and gradually grew into a comprehensive eye care service
  • A primary eye care network is vital so that the unit is supported by a good referral system
  • Outputs, outcomes, and costs should be monitored
  • Necessary measures should be adopted to ensure sustainability.

Challenges and lessons learnt from experience: The African context

Paul Courtright, Susan Lewallen and Anthony Hall

The main challenge to the successful implementation of district programmes in Africa has been the lack of human resources, both clinical and managerial (Figure 3). In Kilimanjaro district there was one cataract surgeon for every 1 million population. The cataract surgeons were doing less than 500 cataract surgeries per year, and this needed to double. Effective management was required at the district level. Human resource development was a priority. We needed to train more cataract surgeons and effective managers.

Initiation of VISION 2020 programme, Kilimanjaro region, Tanzania.

Initiation of VISION 2020 programme, Kilimanjaro region, Tanzania

Figure 3. District plan in Africa.

Where we are now (in 2001) Where do we want to be (2004)
No manager One manager managing effectively
  • One cataract surgeon
  • Doing < 500 cataract surgeries per year
  • At least two cataract surgeons
  • Each doing >1000 cataract surgeries per year
  • >2000 cataract surgeries total per year
Cataract surgical rate (CSR) <500 CSR >2000

An effective district VISION 2020 programme: Kilimanjaro region, Tanzania

What management changes were made:

Hospital Community
Operating room efficiency was improved Development of the Direct Referral Site system to get services to patients and cataract patients identified and brought to hospital
Better management of clinical personnel – having the right number and mix Creation of team approach to service delivery
Hiring of manager Dedicated programme manager and counsellor
Hiring of clerks for registration and record keeping Defined roles of all partners

Cataract Surgical Rate (CSR) by district for 2004, Kilimanjaro region, Tanzania.

CSR by district in 2004, Kilimanjaro region,Tanzania

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Global Blindness: Planning and Managing Eye Care Services

London School of Hygiene & Tropical Medicine