National prevention of blindness programmes
David Yorston responds to questions (Q) on National Prevention of Blindness Programmes, providing answers (A) based on his experience in Africa and elsewhere. Dr Yorston (Christian Blind Mission International: CBMI) was formerly Ophthalmologist at Kikuyu Eye Unit, Kenya, and is now practising at Moorfields Eye Hospital, London
Q: Are National Programmes relevant to VISION 2020 ?
A: A key part of VISION 2020 is devolving decision making and planning to district level – the idea of planning services for units of one million people. Generally, when we have tried to plan for larger populations, we have not been successful. This has led some people to question whether national prevention of blindness programmes have any role in VISION 2020 . Well managed national programmes can play a major part in implementing VISION 2020 . However, ineffective programmes risk becoming irrelevant as the focus of activity will inevitably shift to the districts.
Q: What should National Programmes focus on?
A: The main task of a national prevention of blindness programme should be to provide a framework for VISION 2020 at the district level. Globally, VISION 2020 is successful because it has pooled experience and expertise from many sources, and we have all agreed to pursue some clearly defined goals rather than independently pursuing our own priorities. In the same way, at national level, a multitude of isolated, independent programmes will not be the most efficient way to eliminate avoidable blindness. A national programme can help by providing guidelines in response to a variety of questions – for example:
- How should we monitor cataract outcomes?
- Which districts should have the highest priority for full implementation of SAFE?
- What is the minimum standard of equipment and supplies for district eye clinics?
- All of these issues are best decided at national level.
Secondly, national programmes are vital for human resource development. They must advise the government about the numbers and cadres of eye workers that are needed, how they should be trained, and what they should do. Again, this must be done at national level. It would be unacceptable if ophthalmic assistants were permitted to do cataract surgery in one district, but not in another. The programme should ensure that eye workers are not only trained, but also empowered – that is:
- They are suitably equipped and supplied
- They have a realistic job description
- They have authority to plan their work within the limits of the job description
- They receive continuing medical education
Finally, national programmes should act as channels of communication. They should be constantly sharing good ideas, spreading the message that avoidable blindness can be defeated, encouraging the best programmes, and helping the rest to improve. An effective national programme will ensure that there is no such thing as an isolated eye worker.
Q: Who are the key players in National Programmes?
A: National prevention of blindness programmes are usually planned and run by prevention of blindness committees (PBC). Ideally all groups contributing to prevention of blindness should be represented on the PBC.
Ministry of Health
An effective prevention of blindness programme needs official government support. The MoH representative should be sufficiently senior to act as an effective advocate for prevention of blindness within the Ministry. They should have the authority to make decisions that will affect prevention of blindness. It can be very frustrating to spend long periods formulating plans and proposals, only to have them ignored by the MoH.
Eye care professionals
These should include not only ophthalmologists, but also para-medical eye workers, optometrists, eye nurses, and orthoptists. All of us are involved in prevention of blindness, and we all have different insights and priorities. An effective programme will make good use of all these differing skills.
The international non-government development organisations usually provide the funds for prevention of blindness in developing countries. Sadly, INGDO’s may be viewed solely as a source of cash! Major INGDO’s, such as Sight Savers International, and CBMI, have many years of experience of prevention of blindness programmes in many different countries. This expertise is at least as important as their money. The ideal is partnership, in which the PBC and the INGDO sit together and plan how the INGDO can contribute most effectively.
In some countries service clubs, such as Lions and Rotary, make a major contribution to prevention of blindness. Sometimes this can lead to problems, as service club eye clinics may take place outside the framework of the national programme. The best way to handle this is not to ban eye camps (which is usually impossible!) but to include the service clubs in the national programme, by involving them in the development of eye services.
Major teaching institutions, and other successful centres of excellence, should be represented on the PBC. Other programmes may be able to learn from their experience, and decisions about human resource development will have important implications for their training programmes.
Few PBC have any lay representatives, which is a pity. We need to be reminded that we are not dealing with a million cataracts, but with a million people, and their families, every one of whom is experiencing different problems because of their visual disability.
Other expertise / celebrities
The main obstacles to prevention of blindness are not technical or clinical, but are due to failures in management and administration. More skilled managers and business people should be appointed to PBC’s, not because they are interested in prevention of blindness, but because they know how to manage a large enterprise successfully and profitably.
We need advocates who will raise awareness of prevention of blindness. This is most likely to be achieved by involving a local celebrity – a sporting personality, a film star or entertainer, or a traditional leader.
In general, we should be more imaginative and appoint people to national PBC’s who would not normally sit on MoH committees.
Q: What are the problems facing National Programmes?
A: Sometimes national programmes try to do the wrong things. The primary focus for implementation of VISION 2020 is at the district level. National programmes cannot micro-manage individual district eye care teams. The national PBC has to give the guidelines to the districts and then let them do the work.
Secondly, national programmes are often perceived as being remote and out of touch. One of the most important tasks of the national programme is to promote networking and sharing of ideas. If this is done effectively, then the national programme will be close to every eye worker.
Finally, prevention of blindness on a national scale is bound to be a political issue. Sadly, care for blind people is frequently hampered by rivalry between different eye care professions, government departments, and NGO’s. It has been said that if we spent as much energy fighting blindness as we expend on fighting each other, we could achieve the goals of VISION 2020 by 2015! We must bury past differences, and work together for a common programme. National programmes which can do that effectively will make a huge contribution to eradicating avoidable blindness.