African programme: Kenya

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Kenya ophthalmic programme

Kenya is one of the East African countries with a coastline bordering the Indian Ocean and astride the equator. The country has an area of 225,000 square miles and a population of about 30 million people. The prevalence of blindness is estimated as 0.7%, with cataract contributing 43%, trachoma 19% and glaucoma 9%.

The Kenya Ophthalmic Programme (KOP) is a Ministry of Health (MOH) programme receiving administrative support from the Kenya Society for the Blind (KSB). It started as a small project in 1956 but has grown into a major National Programme rendering comprehensive eye care (CEC) through a network of about 70 Government and NGO static and outreach service delivery points scattered all over the country. About half a million patients are treated annually.

The KOP priorities are:

• To make the existing eye units fully operational before building new ones
• Improve training of all cadres of eye workers
• Generate income so that services can be sustained
• Adopt a primary health care approach in prevention of blindness.

The KOP falls under the Primary Eye Care Division of the Department of Preventive and Promotive Health of the MOH.

In 1966, the Ministry of Health created the National Prevention of Blindness Committee (PBC). The PBC meets quarterly and brings together representatives of all the stakeholders in prevention of blindness.

The KOP Secretariat is the technical arm of the PBC and is housed by the Kenya Society for the Blind. The KOP Coordinator heads it. Under the KOP Coordinator there are the Primary Eye Care Manager, the National Eye Health Information Officer and the National Eye Drop Production Unit.

In 1993, the Ministry of Health officially recognised Primary Eye Care as an Element of Primary Health Care. Through collaboration with Education and Re habi litation program mes funded by the KSB and other NGOs like Christian Blind Mission Inter national and Sight Savers International, the KOP is able to offer comprehensive eye services. The country is divided into ten ophthalmic zones each under a Zonal Eye Surgeon (ZES). A zone geo-medical unit has a referral eye unit (Govern ment or NGO). Under the zonal eye unit are the district and mobile eye units. Personnel at the districts includes the Ophthalmic Clinical Officers (OCO), OCO Cataract Surgeons (OCO/CS), Community Health Workers and Outreach Drivers. In the near future the KOP plan to train Ophthalmic Nurses (one year course) who will be in-charge of rendering community eye care services, especially health promotion. Low Vision Therapists’ training is being discussed at the Prevention of Blindness Committee. There is a feeling by most of the PBC members that the OCOs and the nurses can render refraction services to avoid creating too many cadres of eye care workers. Short management courses for eye care managers have been recommended. Training of equipment Ophthalmic Technicians is an urgent need. Hospital Maintenance Technicians are not trained to repair / service instruments and equipment.

Performance

Cataract surgical services

The method of surgery is ECCE with PC IOL implant. Table 1 shows Kenya’s 1999 cataract surgical rate (CSR) against those of the other countries in the Region:

Table 1. Cataract surgical rates in the region

VISION 2020 CSR target is 3,000

Constraints being addressed by the Kenya Ophthalmic Programme include:

• Shortage of personnel
• Shortage of equipment and supplies plus difficult procurement procedures
• Poor staff remuneration leading to poor motivation in the Government sector
• Hospital charges not harmonised. Some NGOs render free services while patients attending Government eye units have to pay for the total cost of the operation (a World Bank structural adjustment require ment)
• Deteriorating outreach services due to increased operation costs and reduced funding
• Poor social marketing strategy.

The need for cataract surgical services is growing with time, despite an increase in the number of operations done as shown in Table 2.

Trachoma

Trachoma still endemic in over 30 districts in Kenya. The control of trachoma has been part of primary eye care. The number of trichiasis operations done per year has been less than 2,000, mainly due to lack of funds for training and also trichiasis sets. Only 12 out of 30 workers trained in trichiasis have trichiasis surgical sets. Since 1985, the African Medical and Research Foundation (AMREF) has been operating a pilot trachoma control project in a small area covering Ngong and Magadi divisions of Kajiado district. The University of Nairobi has now evaluated this project and the report will be made public soon. Their model utilises community volunteers (Visiting Health Monitors) supervised by trained Village Health Monitors in implementation of the SAFE strategy. The aspects of the model approved by the PBC will be replicated in other trachoma endemic districts in Kenya.

Childhood blindness

The Kenya Government, the WHO and UNICEF have teamed up in a joint venture to fight against both clinical and sub-clinical forms of vitamin A deficiency. Our Primary Eye Care Project has been conducting workshops for community health workers on prevention of childhood blindness. Vitamin A distribution has been added to a pre-existing immunization (EPI) network. The two main referral eye units (Kenyatta National Hospital and Kikuyu Mission Hospital) have specialists deal ing with surgically avoid able childhood blindness. More Zonal referral eye units need similar services.

Human resources

The total number of ophthalmologists in the country is 50. Thirty of these are in Nairobi City. The ophthalmologist per population ratio in Kenya is 1: 600,000.

The total number of Ophthalmic Clinical Officers [including cataract surgeons] is 100.

The OCO per population ratio in Kenya is 1:300,000. The OCOs are the key workers in public service and in the rural areas.

VISION 2020 activities Kenya

In May 2000, the PBC authorised the KOP to:

• Create a working group to prepare a 4 – year VISION 2020 strategic plan to be launched by early 2001 (members: IAPB, PBC, KSB, CBM, SSI, OEU, Lions, and AMREF)
• Strengthen reporting of VISION 2020 activities
• Utilise the PBC and all KOP planned workshops to promote and plan for VISION 2020. This was successfully initiated at this year’s Kenya National Ophthalmic Workshop [KNOW 2000] and the Ophthalmological Society of East Africa Conference [OSEA 2000]
• Create and upgrade ‘Right to Sight’ Eye Units which will spearhead the intended increase in the cataract surgical rate and improvement of quality of cataract surgery
• Create and survey [Rapid Epidemiological Assessment] ‘GET 2020 Districts’ where trachoma control activities (using the SAFE strategy) will be intensified
• Workout incentives for workers in poor and undeserved areas
• Strengthen regional cooperation under the IAPB
• Support the creation of the Ophthmological College of Eastern Africa.