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Pakistan Institute of Community Ophthalmology
10
District Comprehensive Eye Care Program
NWFP and FATA, Pakistan.
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80% of blindness is avoidable
through either prevention or treatment. |
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Cataract surgery can be one of
the most cost-effective of all health
interventions. |
This proposal fits with the aims and strategies of the
recently launched WHO Vision 2020 global initiative to
eliminate avoidable blindness by 2020. Vision 2020
is an important global initiative, being actively
promoted by UN agencies, governments, eye care
organisations, health professionals and NGOs, and it
recognises the crucial role of governments in blindness
prevention activities. The proposal shares the
Vision 2020 strategy of training eye care personnel
and establishing appropriate infrastructures and
technologies to facilitate the prevention and cure of
blindness.
Blindness imposes a huge social and economic cost on
individuals, their families and on national governments
and yet 80% of blindness is avoidable. Both WHO and the
World Bank note that cataract surgery is one of the most
cost effective of all health interventions. This
programme aims to work within the government structure
to establish an accessible, affordable and sustainable
comprehensive eye care programme to reduce the level of
preventable and curable blindness in three districts of
North West Frontier Province (NWFP) and the seven
Federally Administered Tribal Areas (FATA) of Pakistan.
The programme will be developed over four and a half
years to ensure that capacity and sustainability are
achieved. By the final full year of the programme
period (2003), nearly 9,000 sight-restoring cataract
operations will be carried out annually. From this we
assess that, by the year 2005, the programme should have
reached the Vision 2020 Cataract Surgical Rate target
for Pakistan for that year, meaning that it will be well
on the way to covering the incidence of new cataract
blindness. By the same year the programme should be
conducting over 60,000 blindness – preventing
non-surgical treatments annually. It will then move on
to address Vision 2020 cataract targets for subsequent
years, and other major blinding conditions.
This programme is identified in the National Plan for
the Prevention of Blindness (NPPB) as a forerunner to
the development of similar programmes in other
provinces.
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Location:
The programme is taking place
in three districts of North West Frontier Province
and the seven Federally Administered Tribal Areas
of Pakistan.
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Karak
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Swabi
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Kohistan
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Mohmand
Agency
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Orakzai
Agency
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Khyber
Agency
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Kurram
Agency
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North Waziristan Agency
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South
Waziristan Agency
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Bajaur
Agency
Who took the initiative:
SSI’s programme partner, the Pakistan Institute for
Community Ophthalmology (PICO), took the initiative for
this programme in accordance with Government of Pakistan
national policy.
Programme Beneficiaries:
The beneficiaries will be curably blind persons (of whom
there are currently estimated to be over 60,000) and
visually impaired people living in the programme area,
and those at risk from blinding diseases.
Women as
beneficiaries:
PICO consider NWFP/FATA to be the most socially
conservative province in Pakistan, hence the cultural
context of this programme is that women’s access to
health services is more limited than men’s. However,
there is a strong commitment by the staff at PICO to
gender fairness in terms of access to eye care services,
and they understand, and will work within, the
prevailing culture to implement strategies which should
increase women’s access to eye care services. Two
female ophthalmic technicians have been trained at PICO
to work in this programme, and the Ophthalmic
Technicians course at PICO is co-ordinated by a female
faculty member.
Two major obstacles for women in accessing health care
services are the limitations placed on their travel, and
the unacceptability of being examined/treated by men.
Strategies to overcome these obstacles will include
increasing accessibility of services within communities,
thus reducing the need to travel, and training women
health workers (for example primary eye care training
for Lady Health Workers & Visitors).
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Local Partner:
Sight Savers’ local partner is the Pakistan Institute
of Community Ophthalmology (PICO). PICO is the pre-eminent
community ophthalmology institute in Pakistan, and
is headed by Professor Mohammad Daud Khan, who is
both Provincial (NWFP) and National Co-ordinator for
the Prevention of Blindness Programme. PICO’s
main aim is to reduce the problems of curable and
preventable blindness in Pakistan through the promotion
and implementation of Community Ophthalmology, or
community-oriented eye care programmes, in eye care
delivery nationally.
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Existing Situation in Programme
Area/Needs of Beneficiaries:
The NWFP/FATA area is a particularly poor and
underserved area of Pakistan and over 90% of the
population live in rural areas. The average monthly
household income in rural Pakistan as a whole
is 3,248 rupees (£40).
Based on a 1987-90 WHO-sponsored population-based
survey, the prevalence of blindness in NWFP was
estimated to be 1% and in FATA 1.78%. The population
of the programme area is 4.8 million, of whom over
70,000 are estimated to be blind. The new incidence
of blindness is estimated at 20% of the prevalence, so
an estimated 14,000 new cases of blindness develop
each year. When the original proposal was submitted,
there were only 5 ophthalmologists and 4 ophthalmic
technicians working in the programme area, and there
was very limited infrastructure and availability of
ophthalmic equipment. Less than 1,000 major eye
surgeries were carried out a year in the programme
area, and this level of surgery did not impact on the
backlog of 60,000 curably blind people, indeed the
backlog would have continued to grow as the new
incidence of blindness was added.
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Proposed Measures:
The programme will support the training and deployment
of ophthalmic staff and the provision of appropriate
infrastructure and ophthalmic equipment to establish
10 local eye units, within the government health structure.
These measures will enable a diagnostic, treatment
and surgical service to be provided to the local population.
The programme will also train primary health care
staff in primary eye care & the referral of patients
with eye conditions, plus basic eye health education
to increase awareness of preventative eye care measures.
The programme will also work to establish local systems
to meet the costs of the poorest patients. These
activities should increase the accessibility, and
affordability, of eye care services to the population
of NWFP/FATA. In addition, the programme
will work to develop activities to cover the budgeted
recurrent costs, such as salaries and monitoring costs,
following the end of the programme funding period.
The programme framework in section 8 provides a concise
description of the programme activities.
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Human, material and technical resources:
All staff employed by, and working with, the programme
are local. The costs of 23 key staff are budgeted
for in this proposal. A further 18 staff will
be funded by a combination of government & NGO
funding, and the government of NWFP will pay the salaries
of 90 other medical staff working in the 10 district
eye units. Provision is made in the budget for
appropriate training of 2,490 health workers at primary
level and 10 ophthalmologists and 20 ophthalmic technicians
at secondary level.When the proposal was submitted
the existing infrastructure in NWFP/FATA was wholly
inadequate. Refurbishing eye units, and constructing
where necessary (i.e. where facilities do not already
exist), along with providing appropriate ophthalmic
equipment, is a crucial programme strategy, and is
included in the budget.
PICO is a highly-regarded partner of SSI’s.
SSI will ensure they are provided with appropriate
support to develop and implement this programme, and
an Organisational Assessment Consultancy will
be carried out to assess what, if any, further support
can be provided to strengthen their capacity.
CEC-MAP1
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Executive Summary
Final Evaluation Report:
The National Prevention of Blindness Committee in
Pakistan has been a powerful and visionary force for
eye care in the country since the early nineties.
The Pakistan Institute of Community Ophthalmology
(PICO), with ongoing support from Sight Savers International,
has been a key player in that movement for two decades.
When the NPBC adopted Vision 2020, PICO set out an
ambitious proposal to operationalise and institutionalise
Vision 2020 in 3 Districts and the 7 Federally Administered
Tribal Agencies of North West Frontier Province.
This report presents the final evaluation of the 10
District Comprehensive Eye Care (DCEC) Programme,
which was implemented by PICO and the MoH with support
from Sight Savers International and the European Union.
This field work for this evaluation took place between
August 23rd and September 4, 2004.
The team was led by Dr. Paul Courtright from the Kilimanjaro
Centre for Community Ophthalmology (Tanzania) and
also included Wilma Van Berkel, (SSI UK), Joseph
Banzi (KCCO), Niaz Ullah Khan (SSI Pakistan) and Dr.
Nadeem Jan (PICO).
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Evaluation Process:
The
Terms of Reference for this evaluation were developed
collaboratively by PICO and SSI Pakistan and Regional
Offices. The evaluation was to cover the
accomplishments of the programme at programme and
outcome level. Additionally, the evaluation intended to
identify key learning for consideration by stakeholders
in this particular programme and by the national and
provincial stakeholders across Pakistan.The evaluation
team also identified five key themes – each represented
by a question. This hierarchy of question provided a
tool for organizing the specific investigations and
orders the findings and conclusions.
Did the programme provide a platform for delivery of eye
care at the district level?
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How should the programme continue to build capacity
in the district?
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How can DCECs continue to
increase utilisation of services?
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How can the DCEC programme become fully institutionalised
within
the government
system? |
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How can programmed activities achieve long term
financial & organizational sustainability? |
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Programme Plan:
The
overall aim of the programme was the reduction of
preventable and curable blindness through the establishment
of district comprehensive eye care programmes.
The key elements of the strategy for each district
CEC can be summarized as:
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Establishment of dedicated infrastructure and
equipment in the district hospitals. |
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Establishment of government funded teams consisting
of (at minimum) a district ophthalmologist and two
ophthalmic technicians with orientation in community
ophthalmology |
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Training of primary health care staff and community
workers to be able to identify, treat or refer
patients. |
With this ‘platform’ in place, referral
mechanisms can be put in place.
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Systematic outreach through ophthalmic teams
conducting regular outreach screening at health
units with the assistance of primary level staff and
community based organizations. |
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Lady
Health workers and other primary staff providing
referrals on an ongoing basis. |
Underpinning the functioning of this primary/secondary
eye care complex are:
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District
CEC committees maintaining an overview in terms of
planning, monitoring and coordination of eye care
within the district. |
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Specific
strategies to encourage all members of the
community, in particular women and the poor, to use
services. |
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Conclusions and Findings:
The
ten-district comprehensive eye care programme has had
great success in creating a practical platform for eye
care service delivery at the district level. The ten
eye care teams are committed to a district-based
approach employing systematic outreach services; use of
services by the population continues to grow. This
programme also provides a replicable and sustainable
model for the development of district eye care plans
within a government structure. Effective advocacy, by
PICO in particular, has led to wide acceptance of and
commitment to comprehensive eye care at district,
provincial and federal level.
The evaluation has concluded that, to a very great
extent, comprehensive eye care has been
institutionalised at district level within the
government structure. After clear and detailed
planning, direct project management (currently by PICO)
should be handled by district CEC committees.
Additional capacity building for district CEC committees
will be important.
There is a tremendous opportunity for comprehensive eye
care to be sustained at the district level, if the
strategies outlined at provincial level are shared and
embedded. Provincial stakeholders such as PICO and
donors need to support the established district and
provincial administrative and political structures
within a single provincial coordination structure.
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CEC-MAP1
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