Advocacy to improve the delivery of eye care

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Advocacy has a role to play in any eye care initiative. It can help individuals or organisations to obtain more resources, and it can support programme implementation and service delivery. This article focuses on using advocacy as a tool for improving the delivery of eye care services – both in terms of reaching more people, and in terms of improving the quality of services available for specific eye conditions.

When planning an advocacy strategy aimed at improving eye care delivery, it is important to identify those groups who are in a position to make a difference. These are the targets for advocacy – the people at whom you need to direct your efforts. They can make important decisions that directly affect service delivery or simply influence others in a way that will improve the situation.

If these key target groups can see the benefits of what is being advocated, it will be easier to both get their support and ensure that this support is sustained. For example, education officials would like a reduction in school drop-outs; diabetologists would like better compliance to follow-up, and so on. Hence, it is important that the design of an intervention or programme should offer benefits to all – it should be a ‘win-win’ solution. Those who are advocating for better delivery of eye health services (whether they are eye health providers, hospital managers, or VISION 2020 national coordinators) should therefore clearly communicate these benefits – supported by the relevant evidence – to the groups that are the targets for their advocacy.

Target groups for advocacy

The following groups are key targets for advocacy:

Policy makers (government)

Policy makers at all levels of government should be targeted by those advocating for better eye care delivery. Policy makers are in a position to create and implement regulations. They can also offer incentives and monitor compliance.

Let us take the example of refractive error. Amongst the section of the population undergoing formal education or already in employment, one of the major eye care interventions required is refractive error services. In this case, a key group of policy makers to target could be those in education and industry (or labour), as they are in a position to improve access to refractive error eye care for these two population groups. For example, they can encourage eye examinations of students by instituting school screening programmes; they can also encourage eye examinations among the workforce by providing financial incentives to companies who screen their employees for refractive error.

Advocacy messages targeting policy makers should focus on the positive impact that initiatives will have, which in turn will reflect well on policy makers themselves. In the case of refractive error services, advocacy can focus on the positive impact these services will have on education (better attendance and better academic results) and on the increased productivity that will result in the workforce.

Community leaders

These individuals, who can be elected community leaders, local industrialists, village elders, or heads of local voluntary organisations such as Lions and Rotary, have direct contact with the community and can exercise significant influence on them. The support of these individuals has a significant impact on general eye care, especially on the success of community-oriented activities such as community outreach and screening.

Advocacy targeting community leaders needs to focus on the magnitude and impact of visual impairment and blindness, as well as on causes, treatment options, costs, and benefits. Once these leaders come to understand the problems and the possible solutions, they can usually be persuaded to support eye care work. It is useful to remember that many people in this group may also directly benefit from eye care services. In addition, they have a direct interest in the community they represent, as their position of influence is due in large part to their efforts to help the community.

Following successful advocacy to community leaders, it is likely that they will become proactive in promoting eye care and can be counted upon to provide tangible support for setting up outreach activities or permanent primary eye care facilities. They can also provide support for the development of a community-based referral system and can play a significant role in encouraging community members to sign up as potential cornea donors.

Health professionals

Health professionals are key targets for advocacy to improve eye care delivery. For some eye conditions, community screening is not cost-effective; health professionals can be invaluable allies in finding patients at risk. They can also play a crucial role in early detection and referral. This is true not just of eye health professionals, but of health professionals in general. For example, midwives or obstetricians, as shown in the next section, can play a role in identifying babies at risk of retinopathy of prematurity.

Better eye care delivery: specific eye conditions

This section examines advocacy to improve eye care for specific conditions. It is useful to be aware of the way in which care is usually sought and delivered for each specific condition, in order to identify key targets for advocacy in each case.

Diabetic retinopathy

Diabetes is often diagnosed by a physician and care is provided either by them or by specialist diabetologists or endocrinologists. In many developing countries, ongoing monitoring of diabetes is often done by workers in independent clinical diagnostic laboratories and medications are obtained directly from pharmacists, based on previous prescriptions. These groups of practitioners all therefore have access to people known to have diabetes, who are otherwise hard to reach (it is not cost-effective to find people with diabetes through community screening¹). They are therefore very well placed to identify diabetic retinopathy (DR), an ocular complication associated with diabetes. This condition, which eventually leads to blindness, can be halted, but not reversed – so early diagnosis is essential.

Unfortunately, most of these practitioners are unaware of DR and of its treatment.²

Even when they are aware of it, referral to treatment and follow-up is often far from satisfactory. At present, equipment that can remotely diagnose DR could be installed in the premises of professionals who see many patients with diabetes.³

Advocacy to address DR should be targeted directly at practitioners, informing them of the important role they can play in preventing and treating it. Advocacy can also be targeted at decision makers within medical training institutions, to convince them to include the diagnosis and treatment of diabetic retinopathy, as well as patient counselling and remote diagnostic techniques, in their curricula. Such a curriculum should be adapted for the different audiences – physicians, health workers, pharmacy owners, and laboratory technicians/owners.

Successful advocacy can result in the following:

• better follow-up and compliance
• a reduction in the number of patients presenting with late-stage DR.

Better eye care for children

Generally, paediatricians and other maternal and child health practitioners are in a very good position to identify conditions such as squint, congenital cataract, congenital glaucoma, and nystagmus in children. Similarly, midwives or obstetricians will be the first to know that a baby was delivered prematurely and grossly underweight – both leading risk factors for retinopathy of prematurity. With timely referral and intervention, many of these conditions can be addressed. Support from these groups of health practitioners is therefore essential to ensure that no child becomes needlessly blind.

Here again, advocacy should be targeted at health practitioners themselves, in particular at those who have influence amongst their peers (for example, the heads of professional bodies) and at those who have supervisory or management responsibilities. There should also be advocacy for the inclusion of these eye conditions (their causes, clinical manifestations, and management) in the training curricula of all relevant practitioner groups.

Successful advocacy can result in the following:

• increased attendance in paediatric eye clinics (in the short term)
• a reduction in avoidable childhood blindness (in the long term).

Corneal infections

Field trials have shown that, for people with corneal infections, the combination of immediate use of antibiotics and referral to an eye hospital has dramatically reduced progression into ulceration and subsequent loss of vision.^4,5 The individuals who get corneal abrasions tend to be rural farm workers who often resort to treatment from traditional healers or primary health physicians. These healers, either by giving the wrong treatment or by delaying treatment or referral, often make the condition worse -this can lead to vision loss.

Advocacy in this regard should be targeted at primary care physicians and traditional healers. It should focus on education and on creating awareness about the causes and progression of corneal infection, and what interventions are possible at primary level.

Successful advocacy can therefore significantly reduce the incidence of corneal blindness, especially in the rural farming community.

Low vision and rehabilitation

Although patients who are blind or have low vision often come into contact with eye care professionals, they are not always referred to rehabilitation or low vision services. This needs to change in order for these individuals to lead a more normal life and become productive members of the community. In this case, advocacy has to be directed primarily at ophthalmologists and optometrists, in order to encourage them to refer patients to appropriate low vision or blindness rehabilitation services.

Successful advocacy can result in rehabilitation services that reach more people, both those who are blind and those who have low vision.

References

1 Hoerger TJ, Harris R, Hicks KA, Donahue K, Sorensen S, Engelgau M. Screening for type 2 diabetes mellitus: a cost-effectiveness analysis. Ann Intern Med 2004;140(9):689–699.

2 Perumalsamy N, Ramasamy K, Kaliaperumal K, Sekar A, Karthika A, Nirmalan PK. A pilot study on awareness of diabetic retinopathy among non-medical persons in South India: the challenge for eye care programmes in the region. Indian J Ophthalmol 2004;52:247–251

3 Perumalsamy N, Sathya S, Prasad NM, Ramasamy K. Software for reading and grading diabetic retinopathy: Aravind diabetic retinopathy screening 3.0. Diabetes Care 2007;30:2302–2306.

4 Upadhyay M, Karmacharya S, Koirala S, Shah D, Shakya S, Shrestha J et al. The Bhaktapur eye study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol 2001;85(4):388–392.

5 Srinivasan M, Upadhyay MP, Priyadarsini B, Mahalakshmi R, Whitcher JP. Corneal ulceration in Southeast Asia iii: prevention of fungal keratitis at the village level in south India using topical antibiotics. Br J Ophthalmol 2006;90(12):1472–1475.