Review of Management Strategies to Achieve Vision 2020 in India with Emphasis on Cataract Related Blindness

Blindness

According to WHO, blindness is defined as visual acquity in better eye is less than 3/60 or inability to count fingers in daylight at a distance of 3 meters. Preventable blindness is the blindness which can be prevented by attacking the causative factors like corneal blindness (vitamin-A deficiency, trachoma, infectious keratitis etc). Industrial blindness (by improving occupational safety conditions), ROP, Diabetic retinopathy, etc. Curable blindness is almost synonymous with cataract blindness. Others are glaucoma, inflammation of ocular tissues etc. Avoidable blindness includes both preventable and curable blindness. 85 percent of the blindness is estimated to be avoidable [1].

Vision 2020

In order to achieve a world in which no one is needlessly blind and where those with unavoidable vision loss can achieve their full potential, Vision 2020 was initiated. Launched in February 1999, Vision 2020 is the global initiative for the elimination of avoidable blindness, a joint programme of the World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB) with an international membership of NGO’s, professional associates, eye care institutions and corporations. Five conditions have been identified as immediate priorities within the framework of VISION2020 Programme. They are-Cataract, Trachoma, Onchocerciasis, Childhood blindness, Refractive error and low vision. In India, as there is no Onchocerciasis and Trachoma is declining, two more diseases are included recently in VISION 2020 India programme. These are Diabetic retinopathy and Glaucoma. They need special attention by all levels of eye health care personnel.

Objectives of VISION 2020

• Increase awareness, within key audiences, of the causes of blindness and the solutions to the problem.
• Advocate for secure the necessary resources to implement the WHO Global Action Plan 2014-19.
• Facilitate the planning, development and implementation of national VISION 2020/Eye Health programmes in all countries. National programmes have three main elements:
• Cost effective disease control
• Human resource development
• Infrastructure and technology VISION 2020 is built on a foundation of community participation. Overarching issues, such as equality, quality of services, visual outcomes and access the components of Universal Eye Health are addressed as a part of national programs [2].

Cataract Related Blindness: Present Indian Scenario and the Problem

In India, 80% of Blindness is due to cataract. Various modifiable risk factors associated with cataract include UV exposure, diabetes, hypertension, body mass index, drug usage, smoking and socio economic factors, but advancing age is the single most important risk factor for cataract. Nirmalan, et al. [3] studied the prevalence of cataract in a rural population (> 40 years) of Southern India as 47.5%; prevalence is more in women than men. Vashist, et al. reported prevalences of 58% in North India and 53% in South India in older age group (> 60 years). Overall, increasing age, lower socio economic status and Diabetes are found to be risk factors for cataract related blindness in India [4].

Eye Health Global Overview: Progress and Challenges

About 285 million people are visually impaired about 39 million of who is blind. 80% of the total or around 228 million people are avoidably impaired. Women are more vulnerable, in some contexts they are less likely to access services, and they are at great risk of some conditions such as trachoma. The rapidly increasing prevalence of diabetes, projected to rise to 552 million in 2030, will mean greater incidence of diabetic retinopathy and additional strains on health systems and eye health personal. Reducing avoidable blindness and rehabilitating those who are irreversibly visually impaired have enormous implications for the individual, their families and their communities. Preventing blindness increases access to education, employment, and enables greater participation in civil, political and social life. The economic arguments for eye health by research data shows for every dollar spent on improving eye health services, there is more than two fold return on investment, and in developing countries, the investment generates four fold returns [5]. The main elements a government needs to put in place to achieve Universal Eye Health are: • Comprehensive eye care services-offering a breadth of services covering the range of causes of vision impairment, from promotion, prevention to rehabilitation and care.

• Eye health integrated into health systems, attending to the six building blocks of a health system according to WHO: governance, human resources, medicines and technologies, and information.
• Access for everyone, including the poor, minorities, the disabled including vision impaired and people in rural areas. This requires adequate health outreach and promotion including in appropriate technologies and formats, and ensuring mainstream and targeted programs address barriers.
• Point-of-care payment should not prevent access: It should be free for the poorest.

India: Towards Universal Eye Health

Most eye care programs in India have been structured around cataract, initially through surgical eye camps and then building the hospital base. India now has a good network of secondary eye hospitals in the voluntary and government sector. The primary eye care approach has become part of India’s National Program for control of blindness. Funds have been allocated to establish 5000 primary eye-care centers during the 12th five year plan. While there has been some progress in both government and voluntary sectors, more infrastructures is required. Enabling policies, minimum standards and technologies are also needed to expand eye-care services at the community level [6].

Prevalence of Cataract in India

Survey conducted by MoH & FW during the year 2006- 07 revealed that prevalence of blindness has come down from 1.4% to 1%. Along with other cause of blindness; cataract still remains the major challenge, due to raised awareness, increased longevity of life and increasing population. Considering current population (121 crore) of India as per census 2011, 1% blindness constitutes approximately 1 crore 21 lakhs. Out of this approximately 62% i.e., 7.2 million are blind due to cataract. As per NPCB incidence of cataract is 0.4 to 0.5% thus the number of new cases of cataract to be operated upon each year comes to 6.15 million. Approximately 7 million people are blind due to cataract at any point of time (prevalence) and 6.15 million cataract cases are added each year (Incidence).India is performing 6 million cataract surgeries every year [7].

Achieving major public health impact requires interventions which should reach a large share of those who need them and are effective and affordable. In many of the cases, the greatest challenge was to ensure access to a simple and cost-effective technology or treatment that could be delivered or administered by basic health workers. In the case of treating millions of cataract suffers in India, the task was to reach those in need and to ensure that the surgical treatment offered was of adequate quality to solve the problem, without needless complications. This represents a vast challenge, given major limitations in both the reach and quality of health care delivery in India, but one that the government, working with the key partners and deploying low-cost technologies, has been able to accomplish to as remarkable degree. The cataract program in India, in its several phases, demonstrates some of the key features of “scaling up’’: introducing better and affordable technologies when they become available, building demand for a service that was previously unavailable, and getting to low unit costs by serving large numbers of patient efficiently. Initially, the goal of a broad coverage of services to treat blindness and severe vision loss was achieved by public education to convince people that treatment was possible, and by the use of ‘’eye camps’’ to bring screening and treatment services to remote and impoverished areas that had not previously been well served by either government or private providers. Services then needed to be reoriented and upgraded, focusing on quality as well as quantity. Achieving good outcomes from treatment required the systematic introduction of improved techniques, training and retraining, attention to monitoring and partnership between government and a broad range of funding and service-provision organizations to achieve high-volume, low-cost surgery.

Current Status of Cataract Blindness in India and the Apprehension

But is it enough to solve the problem? What is the ground reality of cataract related blindness in this country and whether India will be able to achieve VISION 2020? A recent study shows-Using age-specific data for those aged 50+ years it was observed that prevalence of blindness at different age cohorts (above 50 years) has reduced over three decades with a peak in 1989. Projections show that among those aged 50+ years, the quantum of cataract surgery would double (3.38 million in 2001 to 7.63 million in 2020) and cataract surgical rate would increase from 24025/million 50+ in 2001 to 27817/million 50+ in 2020.Though the prevalence of cataract blindness would decrease, the absolute number of cataract cases would increase from 7.75 million in 2001 to 8.25 million in 2020 due to a substantial increase in the population above 50 years in India over this period. Considering existing prevalence and projected incidence of cataract blindness over the period 2001-2020, visual outcomes after cataract surgery and sight restoration rate, elimination of cataract blindness may not be achieved in India [8].

The Possible Solution

Therefore, in order to achieve VISION 2020 in India, the following management strategies may be implemented as they have successfully reduced prevalence of Cataract related blindness presently to 1%, as per NPCB statistics.

• Execution of 12th Five year Plan (NPCB) at the government level.
• Wider coverage of the national population under Rashtriya Swasthya Bima Yojana (RSBY) scheme for cataract surgery.
• Training and implementation of high volume low cost cataract surgery (MSICS): The Arvind model and other projects.
• Involvement for more corporate sectors to execute corporate social responsibility (CSR) for cataract surgery.

National Programme for Control of Blindness (NPCB): 12th Five Year Plan

NPCB was launched in the year 1976 as a 100% centrally sponsored scheme with the goal of reducing the prevalence of blindness to 0.3% by 2020. Rapid survey on avoidable blindness conducted under NPCB during 2006- 07 showed reduction in the prevalence rate of blindness from 1.1 percent (2001-02) to 1 percent (2006-07). With a view to achieve the above said objective, the government has decided to continue this scheme during the 12th plan with increased assistance for various components under the scheme.

Objectives

• To reduce the backlog of blindness through identification and treatment of blind at primary, secondary and tertiary levels based on assessment of overall burden of visual impairment in the country.
• Develop and strengthen the strategy of NPCB for ‘’Eye Health’’ and prevention of visual impairment, through provision of comprehensive eye care services and quality service delivery.
• Strengthening and up gradation of RIOs to become center of excellence in various sub-specialties of ophthalmology.
• Strengthening the existing and developing additional human resources and infrastructure facilities for providing high quality comprehensive Eye Care in all districts of the country.
• To enhance community awareness on eye care and lay stress on preventive measures.

• Increase and expand research for prevention of blindness and visual impairment
• To secure participation of Voluntary Organization/Private Practitioners in eye care.

Strategies

• Decentralized implementation of the scheme through District Health Societies (NPCB).
• Reduction in the backlog of blind persons by active screening of population above 50 years, organizing screening eye camps and transporting operable cases to eye care facilities.
• Development of eye care services and improvement in quality of eye care by training of personnel, supply of high-tech ophthalmic equipment, strengthening follow up services and regular monitoring of services.
• Screening of school age group (Primary & Secondary) children for identification and treatment of Refractive errors, with special attention in under-served areas.
• Public awareness about prevention and timely treatment of eye ailments.
• Special focus on illiterate women in rural areas. For this purpose, there should be convergence with various ongoing schemes for development of women and children.
• To make eye care comprehensive, besides cataract surgery, provision of assistance for other eye disease like Diabetic Retinopathy, Glaucoma Management, Laser Techniques, Corneal transplantation, Vitreoretinal Surgery, treatment of childhood blindness etc.
• Construction of dedicated eye wards and eye OT’s in district hospitals in NE states and few other states as per need.
• Development of mobile ophthalmic units in the district level for patient screening and transportation of patients
• Continuing emphasis on primary healthcare (eye care) by establishing vision centers in all PHC’s.
• Participation of community and Panchayat Raj institutions in organizing services in rural areas
• Involvement of private practitioners in the program.

Target for the 12th Plan

During the 12th Plan, the scheme would consolidate gains in controlling cataract blindness and also initiate activities to prevent and control blindness due to other causes. This would be done by further increasing cataract surgery rate, increasing coverage, providing assistance for treatment of other eye diseases, strengthening of existing eye care infrastructure and developing new eye care infrastructure and human resources, involvement of community including panchayats and voluntary organizations etc. The scheme would be uniformly implemented throughout the country. Funds for implementation of the scheme would be utilized on the on the following activities:

• Performing 3.3 crore cataract operations with above 95% being IOL implementation
• Assistance to NGOs for management of other eye diseases (other than cataract) like Diabetic Retinopathy, Glaucoma Management, Laser techniques, corneal transplantation, Vitreoretinal, Treatment of childhood blindness etc.
• Screening of school age group for detection of refractive errors and providing 44 lakh free spectacles to poor school age group children.
• Spectacles for near work (Presbyopia) to 10 lakh old persons.
• Setting up 5000 vision centers at Rs 1 lakh with basic screening equipment catering 50000 populations per center.
• Enhancing capacities for eye care services in public sector by providing assistance to hospitals at various levels.
• Training of other medical personal including nurses in ophthalmic techniques, ophthalmic assistants etc.
• Collection of 2.50 lakh donated eyes(after death) for transplantation in persons with corneal blindness
• Providing non-recurring assistance to 20 voluntary organizations at Rs 40 lakh for setting up/expanding eye care services for semi urban/rural population.
• Strengthening of existing 20 lakh eye banks at Rs 25 lakh and 100 eye donation centres at Rs1 lakh to facilitate collection and processing of donated eyes.
• Construction of 25 dedicated eye wards and eye OTs renamed as dedicated eye unit in district hospitals in states as per need.
• Utilizing ophthalmic manpower such as-eye surgeons, ophthalmic assistants, eye donation counsellors, outside government sector on contractual basis.
• Intensive use of IEC to promote awareness among masses about eye care.
• Setting up of 400 multipurpose district mobile ophthalmic units as per the need.
• Involvement of private practitioners in the program.
• Maintenance of ophthalmic equipment supplied to regional institutes of ophthalmology, medical colleges, district/sub-district hospitals, PHC/Vision centers.
• Strengthening of training activities for eye care personnel to get the knowledge of modern eye care techniques and ultimately its utilization for the benefits of the public.
• Regular monitoring and evaluation through management information system to ensure more transparency in funds utilization and access of real time data as well as release of funds on the basis of data entry in MIS (NPCB) by NGOs/private sector [7].

Economic Cost of Cataract Surgery Procedures

A study showed average provider’s direct cost was highest for PE procedures (25.55 US dollars) compared to MSICS (17.03 US dollars) and ECCE-IOL (16.25 US dollars). The difference can be attributed to the cost of equipment and materials. Average direct and indirect patient costs were highest for ECCE-IOL (19.85 US dollars), while the costs for PHACO and MSICS were identical (12.37 US dollars). ECCE-IOL had the highest total costs and MSICS had the lowest total costs from societal perspective. Therefore, Government and NGO hospitals providing cataract surgeries should invest in regular cost analyses, reviews of the literature on effectiveness, and formal cost-effectiveness analyses in order to plan economically effective interventions [12].

In health programs, where there is chronic scarcity of funds, as evidenced by a 20 percent reduction in health from annual national budget (India Today December, 2014), interventions which are cheaper and yet provide equally good outcomes should be adopted and actively propagated. Study shows that MSICS is comparably as effective as PE in terms of visual rehabilitation and increasing the quality of life in cataract patients. However, MSICS is significantly less expensive and does not require the capital expenditure and maintenance of Phaco machine which requires a dependable source of energy, which is usually a limiting factor in developing countries. Training in PE also has a steeper learning curve. The foldable IOL’s used in PE are also far more expensive than the rigid polymethyl methacrylate IOL’s used in MSICS. Treating cataract in the developing world is a formidable challenge with significant barriers like cost, lack of awareness and shortage of trained personnel. MSICS with its shorter surgical time and its requirement for less expensive and less technology dependent equipment can help in overcoming this challenge. Health care expenditures are continuously rising throughout the world. Regular cost-effectiveness studies should be carried out in various fields to look for the best intervention amongst the alternatives. This will ensure proper channelization of resources for a sustainable growth in the medical field [13].

Until recently, MSICS was considered as a low-tech, unproven poor cousin to the gold standard phacoemulsification. Several recent articles have compared MSICS to PE and demonstrated almost equivalent outcomes. Moreover, how much ever we may espouse providing the gold standard for the entire cataract population, in reality even if that were desirable, ’’phacoemulsification for all’’ (cataracts) in India is neither practical nor feasible. The advantages of MSICS as low- cost ‘’equally effective’’ technique makes it an alternative, especially in an unequally developed country like ours. Therefore, in order to make sight affordable and to remove cataract related blindness from India, high volume low cost cataract surgery is the answer. This could be achieved through the Arvind Model and various other community assisted models.

Aravind Eye Hospital Model

The Aravind Eye Care System, an NGO with a 30-year history of providing very low-cost vision care, has been a leading partner to the government of India in its blindness program and a leading example of social entrepreneurship in the health sector. Among the NGOs providing cataract treatment in India, Aravind is by far the largest, conducting more than 1000 screening camps and performing close to 1 million cataract surgeries each year. Within the context of Cataract Blindness Control Program (CBCP), Aravind’s role was particularly significant in Tamilnadu, where some 95 percent of the surgeries were performed under the organization’s auspices. Aravind had its start in 1976 when its founder, Dr. Govindappa Venkataswamy, after mandatory retirement from government service at age 58, opened a 12-bed hospital in the South Indian city of Madurai. Starting with a little money but a strong sense of mission toward saving the vision of those in need and inspired serendipitously, by the large scale success of the McDonald’s fast food marketing strategy, over time Dr. Venkataswamy established a network of specialty eye hospitals throughout India that uses a sustainable business model to provide high-quality patient care. He devoted himself to this effort until his death in 2006, his family continues his work. Three key elements define the Aravind business model:

• Economies of scale-With excellent management and high patient volume, Aravind keeps productivity high, with surgeons performing 25-40 procedures daily; unit costs are maintained at the very low level of about 10 USD per cataract operation.
• Cross-subsidies-Aravind provides free or very low- priced care to two-thirds of its patients with the revenue derived from the one-third of patients who are able to pay moderate prices. The only difference in the treatment of those who do and don’t pay is the amenities, such as the air conditioning in the recovery room.

• Vertical integration-Recognizing that the imported intraocular lenses constituted a major component of the total surgical costs, Aravind obtained a transfer of technology through the US-based Seva Foundation, and additional support from the Combat Blindness Foundation, to permit it to manufacture these lenses at a fraction of the cost. The manufacturing activity scaled up quickly, from 35000 in 1992-93 to nearly 600000 lenses in 2000. Now, at the Aurolab subsidiary established for this purpose, a workforce of about 200 young women from the rural backgrounds produces lenses to a global standard of quality that are used at Aravind, as well as at facilities throughout India. The affordably priced intraocular lenses are exported to 85 countries around the world, providing another source of revenue for Aravind. The system of eye hospitals also is considered one of the India’s premier ophthalmic training institutions, providing a steady flow of well- prepared professionals and support staff. Aravind got financial and technical support from WHO, Seva Foundation. Lion’s Club, Sight savers International, Christoffel Blinden Mission etc [14].

The SNC Model

Sadguru Netra Chikitsalaya (SNC), Sri Sadguru Seva Sangh Trust, Chitrakoot, is located in a remote and economically deprived region in Central India, It is one example of a hospital which has been able to create demand for cataract surgery even amongst hard-to-reach, and had also made surgery affordable. To overcome the barriers, the hospital management initiated an outreach program in the summer months. Free eye check-ups, free transportation and free diet and counseling services motivated people to accept the services and this led to a gradual increase in the volume of patients. To raise awareness of the services offered, SNC distributed educational materials, organized regular meetings with the influential members of the community and engaged the local community in key events at the hospital. To reduce fear, which affects people’s willingness to accept surgery, SNC adopted the following approaches:

• Using a model (dummy) lens during counseling to explain to patients about IOL implants.
• using the local language or dialect to counsel the patients
• explaining the facilities available in the hospital Today, SNC is engaged in providing outreach services through ten outreach teams and 26 vision centers within a 250 km radius of the hospital [15].

The SN Model

Sankara Nethralaya was started by Dr. SS Badrinath, a young vitreo-retinal surgeon of international repute, to fill the wide gap between the need and availability of eye care in the country at a time when ophthalmic disorders were treated along with other ailments in a general hospital. It was started with the Nobel objective of providing world class eye care with a personal touch at nominal costs to paying patients and totally cost free to indigent patients without any disparity. SN treats 40 percent of its patients totally cost free, this includes the large number of patients who turn up at the Jaslok Ophthalmology Center, its community care center in Chennai and its centers throughout the country every day and patients screened at the large number of outdoor community screening camps, it is noteworthy that patients needing treatment at the outdoor eye screening camps are transported to the base hospital, provided food, shelter, treatment including surgery, medicines and dropped back at their village totally cost free. SN is the only eye care institution which performs cataract surgeries right at the door step of the patients; this is made possible through the Mobile Eye Surgical Unit (MESU), a medico-engineering marvel, an operation theatre on wheels developed jointly with the IIT-Madras. MESU performs surgery totally cost free to the most socially and economically backward people with very low awareness levels living in the most remote, inaccessible regions of the country including hilly, tribal pockets not served by the most basic Medicare, people who would not be able to avail eye care if it is provided cost free in a base hospital due to many reasons [16].

The CAFE Model

Community assisted and financed eye care project was initiated in 16 villages of West Godavari district, in Andhra Pradesh, between October2001 and February 2006. The idea was to create a community fund for eye care on the basis of the participation of all members of a captive community, irrespective of any determinants. It was implemented through a field team that collected a payment of one rupee per person per month on a yearly basis for the entire family. An identity card, ensuring accountability, costing five rupees was issued for each person, with a photograph that was taken by field workers. This fund collected from the members of the community covered a complete eye examination at the secondary level eye care center, including cataract surgery with intraocular lens (IOL) implantation when needed and minor surgeries in the economy category(costing the equivalent of USD25). More than 70

percent of the population of these villages registered, the approximate population included was 50000. Over a period of four years, 65 percent of the families utilized the hospital services, with 23637 outpatients and 1805 children examined and 1859 cataract surgeries with IOL performed [17].