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Challenges of delivering cataract services in Nigeria

Professor Mpyet discusses the challenges in providing cataract services in Nigeria
CALEB MPYET: Thank you very much for having us share our experience from Nigeria, a developing country setting. Nigeria has a population of about 178 million people. About 94 million of these people live in rural areas. And there are about three ophthalmologists that serve one million Nigerians. These ophthalmologists perform an average of 100 cataract surgeries each year. Cataract services area therefore not readily available, because the few services are mainly located in the major cities. Therefore, the rural areas remain unserved. And the effect of this is that the services are under utilised, since they are located far away from the people that need these services most.
Therefore, in rural settings, traditional healers have come in to fill the gap. And because these traditional healers are readily available in the rural communities, they perform couching on cataracts, leaving patients with unpleasant outcomes, like blindness and sometimes painful blind eyes. To create a demand for cataract surgical services is a challenge for most eye care providers in this setting, because in the first place, most patients do not have enough information about what cataract is, about what can be done for cataracts, and where such services can be obtained.
This is in contrast to traditional healers, who are available in the rural communities, and therefore, can readily provide the services to these people that reside in rural communities.
When patients eventually get information and decide to go to the cities to get treated for cataracts, they are faced with very difficult road networks and poor transport services. Also, the appointment system in many eye hospitals and clinics mean that many patients have to present several times before they eventually get scheduled for surgery.
The result of this is an increase in the indirect costs, which is often a major deciding factor on the uptake of cataract surgery. There’s also a long waiting list, which adds to the patient’s anxiety by the time they eventually come to the operating theatre.
In developing countries, it is required that about 2,000 cataracts– the cataract surgical rate should be about 2,000 a year. However, at present, the cataract surgical rate is only about 300. Now in this low cataract surgical rate often leads to inefficiency at the hospital level. Getting on the list for surgery does not automatically guaranteed that surgery would be done. So there are usually delays and cancellations for various reasons. These reasons can include power failure, absence of the surgeon who may turn up sick. And then there’s also the lack of efficient use of allocated theatre time. Surgeons also have great difficulties with the equipment, which are in short supply very often.
Many of these factors add up to make cataract surgery inaccessible to many patients. To overcome these barriers, one of the first steps that need to be taken is the need for us to demystify cataract surgery. This means that we need to provide patients with essential information, so that they’re able to make decisions on cataract surgery. This information can be provided either by eye care workers or patients, satisfied patients, who have undergone cataract surgery before. If we’re able to provide this at a local level, it is usually easy to convince and counsel elderly patients to accept cataract surgery. Another thing we need to also do is to develop referral systems and modify the appointment systems in most of our eye clinics.
This means linking health workers in rural settings with eye hospitals as part of a team. Eye clinics that are located in cities need to have primary eye care clinics in rural communities that refer patients to them directly. This can be done as a group referral, so that patients that are coming from the village come as a group. They know who they’re going to see. And they are sure also that they are going to be seen on that day. This makes it less daunting for patients in major cities and in big hospitals.
We also need to have eye care workers, or general health workers, change their attitude about blindness from cataracts, such that any person that is cataract blind can or should be treated as an emergency in the eye clinics. This means that a patient that shows up to the clinic should be evaluated same day. And unless there are absolute contraindications, such a patient should be able to get onto the surgery table the very next day. And this will reduce multiple visits and the indirect cost of surgery.
The first step to manage efficiency that we took in our hospital was to manage theatre time by providing more surgical instrument sets, more operating tables, and having the right mix of theatre time, of theatre staff. We took this step when we discovered that less than 50% of the allocated theatre time was spent on actual surgery. Improving patient turnover means most surgeries can be done within the allocated theatre time, efficiency will be increased, and this will result in a reduction in the waiting time for surgery, and also reduce both the direct and the indirect costs of surgery to the patient. Staff motivation is also closely linked with satisfaction with their work.
And this means we need to provide the staff with good working conditions, adequate and functional equipment, and help them to have a team approach on all aspects of patient management, from the referral from the primary eye care centres, to managing the outcomes of cataract surgery. I would want to leave us with three take-home messages. The first is that we need to provide simple information to patients about what cataract is, how cataracts can be managed, and where such treatment can be obtained. The second thing we need to do is to develop linkages between primary eye care centres and hospitals, and eye hospitals for a seamless referral system.
And lastly, we need to ensure cataract surgery programmes are efficient, so that patient turnovers increase. This will reduce the waiting time and the cost of surgery to patients. Thank you very much.

In this step Professor Caleb Mypet discusses how to create demand and deliver high output and high quality cataract services in challenging circumstances.

Cataract services are not readily available in Nigeria. At present there are about 3 ophthalmologists per million population and most eye care services are located in the major cities far away from the people that need them. As a result, patients are often uninformed about what and where to seek the treatment of cataract. Rural patients turn to traditional healers for “couching” (a procedure that involves dislodging the cataractous lens into the vitreous, using an sharp instrument and physical pressure on the eye).

Traditional healer © ODI CC BY-NC 2.0

When patients go to the cities for treatment, they are faced with:

  • Difficult access and transport services
  • A hospital appointment system
  • Several hospital visits before surgery is scheduled.
  • Direct and indirect costs is often a major deciding factor on uptake of surgery.
  • Anxiety due to long waiting time for surgery

The low surgical rate often is linked with inefficiency at hospital level. Getting on the list for surgery does not usually guarantee it will be done. Delays and cancellations for various reasons such as power failure, absence of the surgeon and lack of efficient use of allocated theatre time, difficulties with equipment etc.

Professor Mpyet suggests a number of key approaches to addressing these challenges in the video. Can you suggest or share effective methods from your own setting, that can be used to address patient information on cataract surgery? Which challenges must be considered before implementing your preferred approach, either in your setting or in Zrenya our hypothetical case study from week 2?

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