Strategy for National Eye Care for Vision 2020 in Bangladesh. Prepared by Dr. A. M. Zakir Hussain

Transcription

1 Strategy for National Eye Care for Vision 2020 in Bangladesh Prepared by Dr. A. M. Zakir Hussain Dhaka, August

2 TABLE OF CONTENTS Acronym...2 Background The draft strategic plan Policy statement Results framework

3 ACRONYM BBS BCPS BMDC BNSB CBHC CC CDC CMSD DEC DEHC DGHS DP DSF ECHO ESD FY GDP GOB HEP HIS-EH HNPSP HPNSDP HRM HSM IAPB INGO JAG KAP M&E MLEP MOHFW MOLGRDC NCD NEC NEH NEHC NES NGO NIO NSAPR NTDs OSB OP Bangladesh Bureau of Statistics Bangladesh College of Physicians and Surgeons Bangladesh Medical and Dental Council Bangladesh National Society for the Blind Community Based Health Care Community Clinic Communicable Diseases Control Central Medical Stores Department District Eye Health Coordinator District Eye Health Committee Directorate General Health Services Development Partners Demand Side Financing Eye Care and Health Observatory Essential Services Delivery Financial Year Gross Domestic Product Government of Bangladesh Health Education and Promotion Health Information System-E Health Health Nutrition and Population Sector Program Health Population and Nutrition Sector Development Program Human Resource Management Hospital Services Management International Agency for the Prevention of Blindness International Non Governmental Organization Joint Advisory Group Knowledge Attitude and Practice Monitoring and Evaluation Mid Level Eye Care Personnel Ministry of Health and Family Welfare Ministry of Local Government, Rural Development & Cooperatives Non Communicable Diseases National Eye Care National Eye Health National Eye Health Committee Nursing Education and Services Non Governmental Organization National Institute of Ophthalmology National Strategy for Accelerated Poverty Reduction Neglected Tropical Diseases Ophthalmological Society of Bangladesh Operational Plan 3

4 OT Operation Theatre PHC Primary Health Care PIP Program Implementation Plan PIU Program Implementation Unit PPP Public Private Partnership RAAB Rapid Assessment of Avoidable Blindness SWAp Sector Wide Approach TK Taka UHC Upazila Health Complex USD US Dollar V2020 VISION 2020 WHO World Health Organization 4

5 BACKGROUND 1. Past activities Vision 2020 the Right to Sight, was launched by the World Health Organization (WHO) and International Agency for Prevention of Blindness (IAPB) in 1999 in Beijing to eliminate avoidable blindness by the year The 56 th session of the World Health Assembly of WHO, which was chaired by the Honorable Minister, incharge of the Ministry of Health and Family Welfare, Government of the People's Republic of Bangladesh, adopted the Vision 2020 formally. To facilitate attainment of the Vision 2020 goals in Bangladesh a Bangladesh National Vision 2020 Advisory Committee was formed in 2007 with Director General of Health Services as its chairperson and the line director of the National Eye Care Program as its member secretary. The terms of reference of the Committee includes: 1. Provision of guidance and technical and advisory support to the line director; 2. Identification of national eye care priorities and program/research priorities and their implementation, operationalization of the national eye care plan included in the sector-wide perspective plan of the Ministry of Health & Family Welfare, Government of Bangladesh; 3. Promotion of and support to mobilize resources; 4. Pursuance for the formation of district Vision 2020 coordination committees; 5. Obtaining BNCB endorsement on policy and other issues relevant to attainment of Vision 2020 goals. District Vision 2020 Committees were formed with support from international nongovernment organizations (INGOs). These committees draw members from upazila level public health officials, i.e., upazila health and family planning officers, Lions and Rotarians, representatives from education and religious sectors, from local bar councils and press clubs, local municipalities, NGOs, international NGOs (INGOs), private hospitals, local philanthropists, local public leaders and other stakeholders. These are headed by the head of the district health department, i.e., civil surgeons. The terms of reference of the District Vision 2020 Committees include: 1. identification of district eye care needs; 2. development of district eye care plans with targets; 3. Development of monitoring and evaluation plans and implementation strategies. 4. Rreviewing progress, achievements, challenges and lessons learnt to advise the district eye care managers; 5. Maintenance of a profile of the district eye care providers; 5

6 6. Facilitation of coordination to avoid duplications and overlaps; 7. Support for mobilization of resources; 8. Identification of needs and areas to improve infrastructure, human resources development and management, equipment and other supplies. Bangladesh was also the first country in the South-East Asia Region of WHO to develop a plan in 1980 for a national program on prevention of blindness, which triggered a global concept of development of national programs on blindness prevention, supported technically by WHO. The program in Bangladesh was taken up under the aegis of the Bangladesh National Council on Blindness (BNCB), with support from the Royal Commonwealth Society for the Blind (RCSB), now known as the Sightsavers International. This national eye care plan of 1980 was developed immediately after Bangladesh ratified the Vision This was subsequently incorporated in 2003 in the second sector-wide perspective plan of the Ministry of Health and Family Welfare, widely known as the Health, Nutrition and Population Sector Program (HNPSP) Some of the activities of this plan were funded by the Sightsavers International. In 2003 BNCB formed a review committee, which assessed eye care service capacity at the base nationally and drafted a new national eye care plan in 2005 (the second national eye care plan), after series of consultations and workshops across the country between period, participated by the Ministry of Health & Family Welfare staff from national to the most fringe level, by national and international non-government organizations, eye care experts and the relevant auxiliary staff. These activities were supported by the Sightsavers International and ORBIS International. The plan prioritized three eye care problems, namely, cataract, childhood blindness and low vision. Along with these three prioritized areas other problems that were focused were: cornea and retina related problems and glaucoma. This plan was followed by a ground breaking event- creation of a post of line director for National Eye Care in the sector-wide five year plan of the Ministry of Health & Family Welfare, Government of Bangladesh.The 2005 national plan emphasized on capacity building for secondary care and on strengthening the primary health care infrastructure so that primary prevention and referral of medical cases may be institutionalized. The plan underscored the role of coordination, in particular at the district level. The plan also laid emphasis on public-private partnership including nongovernment organizations for effective attainment of the Vision 2020 goals. The current sector-wide plan of the Ministry of Health & Family Welfare, Govt. of Bangladesh, i.e., Health Population and Nutrition Sector Development Program (HPNSDP), has the following NEC relevant key objectives: 1. Awareness on blindness prevention; 2. Control of childhood blindness; 3. Strengthening of coordination between Government-NGO and private eye 6

7 care providers; 4. Building of capacity of eye care service providers; 5. Voucher scheme for eye care services; 6. increasing the country cataract surgical rate. The sector-wide plan underscored the importance of ocular trauma, due to agricultural and occupational accidents; ocular growth and malformations. A strategy was drawn for early detection and management of these problems, as these interventions provide appreciable social and economic dividend. A major thrust has been given to improvement of infrastructure and technology at secondary level service centers; establishment of vision centers at upazila level, for correction of refractive errors and identification of cataract and other ophthalmic problems for referral; introduction of child sight testing in primary schools; introduction of subspecialty services at tertiary level; demand side financing; management of information systems; and involvement of primary health care infrastructure for providing eye care. The other areas are: increase in awareness of the people on blindness prevention, strengthening coordination between government, NGOs and the private sector, introduction of vouchers to increase accessibility of the poor, elderly, women and children to cataract surgery. Some of the crucial activities completed under the plan are: SICS guideline; Treatment protocol; Examination protocol; Eye care manual for primary health care workers; Guideline for OT and ward management for nurses and paramedics; Guideline for counseling in eye care; Functioning district vision 2020 in 30 districts; Age and gender specific cataract surgery reports on standard formats sent to IAPB and WHO regularly; Cataract surgical outcome monitoring (CSOM); Earmarking of community clinics as referral point to upazila health complexes (vision centers). The World Health Assembly in May 2013 approved a Global Action Plan Towards Universal Eye Health. Its key elements are: To strengthen national efforts to prevent avoidable visual impairment including blindness, through inter alia, better integration of eye health into national health plans and health service delivery, as appropriate; To implement the proposed actions in the global action plan on universal eye health in accordance with national priorities, including universal and equitable access to service. 7

8 The three strategic objectives of the WHO plan are: 1. Address the need for generating evidence on the magnitude and causes of visual impairment and eye care services and using it to advocate greater political and financial commitment by Member States to eye health; 2. Encourage the development and implementation of integrated national eye health policies, plans and programmes to enhance universal eye health with activities in line with WHO s framework for action for strengthening health systems to improve health outcomes; 3. Address multi-sectoral engagement and effective partnerships to strengthen eye health. The WHO plan of action has eight areas of focus which are: 1. Service delivery; 2. Medical products and technology; 3. Eye health work force; 4. Eye health information; 5. Eye health financing; 6. Leadership and governance; 7. Improving access and quality of care; and 8. Research in eye health. The objectives of the WHO plan focus on: development/ strengthening of national policies, plans and programs for eye health and prevention of blindness and visual impairment; increase and expand research for the prevention of blindness and visual impairment; improve coordination between partnerships and stakeholders at national and stakeholders at national and international levels for the prevention of blindness and visual prevention of blindness and visual impairment; monitoring of progress in elimination of avoidable blindness at national, regional and global levels. Activities of some of the international NGOs working in close proximity to the National Eye Care program are given below. Orbis International has been working in Bangladesh since It started through Flying Eye Hospital program and established its long term program from Orbis works through partners to build capacity through training, quality enhancement, systems development, public education and evidence base advocacy. Orbis s work focuses on the following six areas of eye care sector in Bangladesh.: (1) Disease Control focusing childhood blindness including ROP, Diabetic Eye Diseases with an emphasis to Diabetic Retinopathy; (2) Human Resource Development in terms of fellowships and hands-on training in sub-specialties, clinical team approach and continued medical education using Orbis tools (Flying Eye Hospital, Hospital Based Program, long and short term fellowships, voluntary faculty and Cyber- Sight/Telehealth); (3) Facility strengthening by providing upgraded technology, appropriate equipment and accessories as well as renovating infrastructure, e.g., child friendly hospital facility; (4) Systems strengthening e.g., HMIS, integrated MIS 8

9 and reporting, management systems, adaptation of quality protocol and quality assurance; (5) Policy advocacy and research based evidence; and (6) Public education and awareness raising. Orbis aims at reaching 20 million people children and adult diabetic population suffering from eye problems. One of its approaches is to work with all partners in eye health and its development NGO involved in eye care in order to establish a network of national programs with a focus to reduction of childhood blindness including ROP as well as comprehensive eye care in diabetic eye diseases with an emphasis to DR including VR surgery. Orbis for the first time introduced a rural DR project in 3 northern districts and developed a model for scaling up in partnership with BADAS (Bangladesh Diabetic Society). Under the childhood blindness reduction program 2 million children will be screened across Bangladesh. 0.8 million children will be treated medically and optically and 20,000 pediatric surgeries will be done. The aim of its research (clinical, operational system) is to develop innovative model and system in order to improve access and quality eye care services, evidence generation, adopt best practices and scaling up of successful model/approaches, For 2014, total annual budget of Orbis is about 2.3 million USD. Orbis currently works in 10 districts and in next five years from 2015 Orbis has a plan to work in 16 districts in all 7 divisions. The priority programs include: Childhood Blindness Reduction including ROP, Comprehensive Quality Eye care (Diabetic Eye Diseases including DR and integrated PEC). Orbis will work with international and national partners to develop a national coalition in eye health for sustainable impact in eye health. Around 5% of total country budget of CBM contribute to eye health projects, which is BDT 36,68,700 for CBM also works with partners and its services include cataract surgeries, glaucoma and other surgeries, training of teachers, primary assessment of refractive error, staff training and capacity building on OT management and refraction. CBM supports Trusts and NGO hospitals to deliver quality eye care services (mainly cataract) to poor and marginalized communities, It works for Rights promotion and Rehabilitation of persons with visual impairment through advocacy, empowerment and community mobilization. CBM supports direct eye care (cataract surgery) in 17 districts and has been implementing community based rehabilitation activities. In future CBM has a plan to support partners in establishing sub specialties like diabetic retinopathy, childhood blindness, glaucoma and low vision services; strengthening community outreach and school screening; promoting disability Inclusive practices in eye health; developing and integrating eye health services with CBR programs. CBM (previously Christoffel-Blinden-Mission) is a German based international development organisation founded more than 100 years ago. It stepped into Bangladesh in 1972 to treat the disabled war veterans. In the subsequent years, CBM expanded its service coverage in partnership with local NGOs. In the framework of global Vision 2020 Right to Sight, CBM is currently supporting 3 eye health partners in the districts of Tangail, Kushtia and Kishoreganj in Bangladesh. In 2013, a total of persons were 9

10 screened for eye diseases and received surgery support through partner hospitals. The Fred Hollows Foundation, Bangladesh, has been working in Bangladesh since The timeline marks its first phase in Bangladesh. The Foundation worked intensively with government in developing 10 district hospitals: Brahmanbaria, Satkhira, Jamalpur, Narail, Kishoreganj, Gazipur, Cox s Bazar, Natore, Tangail and Kushtia (covering a population more than 23 million); that can provide standard eye care services. Infrastructure development, developing skilled human resources for better eye care services, creating demand at the community level, conducting RAAB (Rapid Assessment of Avoidable Blindness) & KAP (Knowledge Attitude and Practice) survey, establishing separate eye unit in district hospitals and raising community awareness are the highlights of the Foundation. The Fred Hollows Foundation, Bangladesh, in its second phase (2013 to 2017), has been working with private partner NGOs in Barisal and Chittagong, specially focusing in remote rural places which are most underserved in terms of eye health care. It is also working alongside with its 10 government district hospitals. In addition some other district hospitals which will also come under a collaborative arrangement. These are: Comilla, Chandpur, Lakshmipur, Feni, Chittagong, Khagrachhari,Rangamati, Bandarban, Barisal, Bhola, Patuakhali, Barguna, and Pirojpur. The major focus of The Foundation in the second phase is to work strongly through public private partnership and effectively manage the cases of diabetic retinopathy. FHF Bangladesh has for the first time taken DR services in a government district hospital, i.e., Brahmanbaria as a pilot project in In the year 2013, the number of DR patients treated with laser at the Brahmanbaria Sadar Hospital is 534. FHF also supported BIRDEM for renovation and training of ophthalmologists and paramedics at BIRDEM for DR. Alongside this, FHF has carried out communication campaign for people to actively seek DR services if they have diabetes for long. FHF Bangladesh has plans to continue its work in Barisal through Islamia (IIEI&H) and Chittagong through CEITC covering 14 districts. It will continue its work focusing on the most vulnerable and marginalized population, especially women and ethnic communities. FHF has a budget of 1.87 million USD for 2014 for providing quality eye care services in10 district hospitals and in 14 districts of Chittagong and Barisal Division. This amount will be spent in the areas of skill development of service providers, renovation, refurbishment and up-gradation of service centers, conducting research and creating demand at the community level. Helen Keller International has been implementing a DR action research on diabetic retinopathy and also vitamin A supplementation. The geographical areas covered are Chittagong and Feni districts. Under HKI supported DR services 20,519 patients were screened for diabetic retinopathy (DR); a total of 12,238 patients received information through BCC campaign, and 6,100 patients were referred, of who 3, 296 received treatment for DR. 10

11 Sightsavers International is supporting both government and non-government partners for reduction of avoidable blindness including cataract, childhood blindness, refractive error, and low vision. Its strategy is to integrate eye health with existing health systems and advocacy, supported by evidence, community development programs and disability movement through hands-on training, community mobilization, hospital based program, and health education with the help of local health care organizations. Sightsavers is working on system development through human resource and infrastructure development both in government and nongovernment organizations (national and international). Sightsavers plans to work for 34 million people of 11 districts in Bangladesh both in eye care and for social inclusion for education. Sightsavers aims at strengthening of cataract surgery, comprehensive PEC, community education and screening, care for refractive error and low vision; more community based activities (provision of awareness and screening, linking with nutrition and EPI program); advocacy for integrated HMIS for eye health; more emphasis for linking public and private sector for sharing information; Increased effort to build a sustainable referral network; and generation of evidence through research. Sightsaver s budget for 2014 is about BDT 34,312,956 which will be spent in few focused areas that include (i) Service delivery: primary eye treatment, refraction services including dispensing of spectacles, school screening program, community outreach program, cataract surgeries for both adult and child, other surgeries, (ii) Capacity development: orientate field level government and NGO staff, training technical staff, both from government and NGO sectors, training management staff both from government and NGO sectors, and (iii) Infrastructure development: establishment of vision centre in both government and NGO sector, secondary eye care centre at government district hospitals, evaluation and research and standard protocol and guideline development. BRAC, with technical and financial support from Sightsavers. has planned to cover 11 city corporations and 37 upazilas under 4 districts of Sylhet division with its own fund. BRAC has started working towards 100,000 cataract surgeries up to December 2015 to reduce avoidable blindness from the above mentioned areas. This is a joint venture of NEC and BRAC where the technical supports are being providing by the NGO hospital partners. BRAC is carrying out community mobilization through its frontline health workers and staff. Besides, the NEC is providing the technical and advisory support for quality control to implement the program effectively and efficiently. This would leave municipalities in urban areas to be covered by the NEC office. Other eye care NGOs Apart from the above mentioned NGOs, a number of eye care organizations have been implementing eye health services in the country such as BNSB chain eye care facilities and are partnering with all the above INGOs for a long time. With the emergence of new players in the eye field, a comprehensive directory has to be in place for planning and reviewing the coverage and quality of eye care services in Bangladesh. 11

12 2. Problems 2.1 Disease load As per the Bangladesh National Blindness and Low Vision survey the age standardized blindness prevalence rate is 1.53%, which estimates blind adults aged 30 years and above. The rate was 1.72% among females and 1.06% for males (more in manually laboring people). Bilateral blindness was highest in Borishal division (2.28%), followed by Khulna (1.97%). The rate is lower in Chittagong division (1.43%), Sylhet division (1.31%) and Rajshahi division (1.21%), with the lowest in Dhaka division (1.13%). These figures most probably are reflections of poor availability of service providers and low utilization of available services. Cataract was found to be the major cause (79.6%) of blindness. Cataract surgical coverage was found to be only 32.5% overall. It was lower among females in rural poor population. Cataract is also the major cause of visual disability among the poor people globally. The income of individuals and families may itself be reduced due to blindness. There are, in addition, considerable amounts of opportunity costs lost to other family members, especially to the family care takers. Cataract surgery therefore can contribute to poverty alleviation and improve quality of life. Strong advocacy hence may be conducted among the policy makers and planners with necessary facts and figures to allocate enough resources to promote cataract services. The Bangladesh, national prevalence survey estimated 4,200 cataract cases per million population and an incidence rate of 840 per million. According to this survey there are cataract blind in Bangladesh which are treatable. With a cataract surgery rate under the NEC program at present at 1,172 per million it is obvious that the present backlog in the prevalence of cataract will hardly be addressed adequately.. The survey 1 also revealed that low vision prevalence is 0.56% among people aged 30 years and above. The main reason of this is retinal diseases (38.4%), corneal diseases (21.5%), glaucoma (15.4%) and optic atrophy (10.8%). It has been estimated that Bangladesh has a prevalence of about low vision cases among adults aged 30 years and above. According to a WHO estimate globally 284 million people suffer from visual impairment; 39 million of who are blind and the remaining 245 million suffer from low vision. About 90 per cent of these people live in the developing world. WHO estimates that 80 per cent of these visual impairments can be avoided. As per a Rapid Assessment of Avoidable Blindness, conducted in the 6 districts of Borishal division in Bangladesh 2 the rate of blindness estimated among a population of 5,000 was 1.8 per cent. The prevalence of blindness between 2000 and 2013 therefore seems to have increased. This is not unusual since an increase in longevity in Bangladesh would tend to increase blindness and cataract, as these are more pronounced in advance age. The ongoing survey shows a staggered rate of blindness among the 10 districts studied, e.g., from a prevalence rate as low as 0.46 per cent in Brahmanbaria district to as high as 3.46 per cent in Natore, 3.02 per cent in Cox's Bazar and 2.72 per cent in Narail districts. Sixty four per cent to 85 per cent of these blindness are due to cataract; of which 72 per cent to 98 per cent were avoidable. On average while 0.55 per cent of the population in general was found to be blind, blindness among people aged 50 years and above was 0.75 per cent. On 12

13 average per cent of these blindness were avoidable. The 2000 survey put this figure at 90%. This improvement between 2000 and 2013 may be an artifact, difference in the methodology of the two studies, due to a higher level of awareness among the masses or due to the effect of the government and the NGO driven services in the remote areas of the country. While the 2000 survey showed a cataract related blindness rate to be 80%. The 2013 study found that 76.66% of the blindness is due mainly to cataract and to a minor degree due to the squeal of cataract extraction combined. This condition has been seen to be particularly alarming in Natore, where it is 97 per cent. The rate of surgery with bilateral cataract at visual acuity of <3/60 and <6/18 is also lowest in Natore-53.1 per cent and 28.1 per cent respectively. On average in the eight districts that this data come from these rates respectively are 71 per cent and about 42 per cent. Another estimate based on the 2000 survey rounds up the size of the blind people in Bangladesh to , among people aged 30 years and above 3. If this absolute figure is applied to a rate of 1.8 per cent the absolute number of blind among the same age bracket would be more than 880,000 in The Bangladesh National Blindness and Low Vision Survey estimates the following: 1. An age standardized prevalence rate of 1.53% blindness among adults 30 year and above; 2. 80% of the bilateral adult blindness due to cataract, followed by uncorrected aphak(6.2%) and macular degeneration (3.1%); ,000 blind people in the country; 4. Estimated low vision (among adults) 13.8%, mainly due to cataract (74.2%), refractive error (18.7%) and macular degeneration (1.9%). According to the study the population blindness and cataract may be caused by old age and due to lack of nutrients and wrong medication. Surgery was correctly identified as the only corrective measure by the people for cataract. While people in general were found to believe that for cataract no voo-doo or faith healing works, many respondents thought that conjunctivitis is due to bad air and hence should be treated accordingly. For any eye problem people usually prefer the local allopathic and traditional healers. The cause of not seeking medical care in case of eye problems is poverty, lack of knowledge, distance, lack of social support, less than welcome attitude of providers, fear of surgery, belief on curse and attitude that in an advanced age there is hardly any use of operation etc. As per the 2000 survey 1 the country had about 40,000 childhood blindness, with an annual child cataract surgery rate of 2000 per year now. The size of the population has increased by 20 million between 2000 and The child population was about 47% in 2000, which is about 43% as of the latest figure available in Taking these figures into consideration the absolute number of child blindness should be about 42,000 in Estimated population in Bangladesh is about 160 million 5. There are about 64 million children living in Bangladesh. Using the WHO global 13

14 estimate of Childhood blindness prevalence of 0.75/1,000 children, there are about 48,000 blind children in Bangladesh 6. t is estimated that for every one million people in Bangladesh, there would be 300 blind children expected (total 48,000) of which around one third (100 children) are blind from cataract. Of the estimated children suffering from cataract are suffering from cataract which are due to un-operated cataract. Another are blind due to preventable corneal scarring. For every million population 300 blind children are estimated. About one third of them are due to cataract. This would require 100 uniocular and 200 bilateral cataract surgeries per million population. Of the childhood blindness 25% would have to be prevented at community level as these are due to vitamin A deficiency, malnutrition, diarrhea and measles. Childhood eye care services are available in 16 centers in Bangladesh. Model child eye care centers will be established in 4 district hospitals as per recommendation of evaluation of BCCC (Bangladesh Childhood Cataract Campaign). Childhood blindness in Bangladesh is 0.80 per thousand 1. But there is a possibility that this figure in fact may be less than even 40,000 in absolute figure which needs to be evaluated or a comprehensive study would be required to plan address the situation., Due to recent improvement in child health care, reduction of U5 mortality and IMR and society's value attached to children new diseases like Retinopathy of Prematurity (ROP) has been emerging which also needs proper planning. Childhood blindness unfortunately is not to be seen in case of valuation of the elderly people in the family or in the society. Hence we would not project any lessening of the old age related blindness or cataract load, unless some targeted and coordinated interventions were taken for them in any defined geographical locations. According to a Bureau of Statistics study in the overall prevalence of any type of disability for all levels of difficulty in Bangladesh is about 9.07%, The proportion for males is 8.13% whereas that for females is 10.00%. The proportion in rural area for both sexes is 9.63% whereas in urban area, the proportion is 7.49%. Individually, 14.01% suffer fro some kind of disability, but because one person may have more than one type of disability at the same time, the net percentage stands at 9.07%. Visual disability accounts for about 44% of all disabilities. While globally uncorrected refractive error is the main problem in the mid-income and low-income countries cataract is the main cause of visual impairment. Although refractive services have been initiated in 32 district hospitals and 5 vision centers have been started at sub districts/upazila level. The Bangladesh National Blindness Survey 1 found that the number of refractive error in Bangladesh is 27,250 adults and 9,925 children per million of population. This means that there are about 3.3 million adult refractive error cases with <6/12 visual acuity and 1.3 million children aged 5-15 years, with refractive error at <6/18 visual acuity, at an estimated prevalence of 4% 8. It is estimated that there are about 1,950 adults and 120 children per million of population who would be benefited from low vision related services. The 2000 survey 1 suggests that Bangladesh had about five million people, including children, suffering from refractive errors. The number of low vision, according to the 2000 survey 1 was about three times that of blindness. Prevalence of low vision is 13.8% of among the people aged 30 years or more 9. The rate of Low Vision in general is 0.56% (LD, NEC). In absolute figure 14

15 this should therefore have been 2,250,000 in 2000 and should be 2,640,000 in The 2013 estimates would hardly be different since no vigorous or unique efforts were taken to reduce these numbers so far. The Childhood Blindness Survey in Bangladesh estimates that 31% of blindness was due to problem with the lens (cataract) and 27% due to cornea (vitamin A deficiency) including glaucoma (4%) and aphakia (5%). 67% of childhood blindness thus can be prevented. The study also found that 90% of the childhood blindness developed within first five years of their age. For Low Vision 12 centers were established, most of which are underutilized though due to lack of proper referral and un-availability of low vision devices. In Bangladesh, according to the International Diabetes Federation, there are estimated 4.8% of people who are diabetic 10. Based on the above prevalence of 4.8%, 7.4 million populations ought to be currently suffering from DM. About 25% to 27% 11 or over all 23.7% to 36.2% of the diabetic population, i.e., about 1.85 million populations have Diabetic Retinopathy. Laser treatment can now prevent of many of the blindness caused by DR. Diabetic Retinopathy screening program has been initiated in 3 districts in Bangladesh. The 2000 survey also estimated 25 per cent of the diabetic patients suffering from diabetic retinopathy. As life expectancy has been increasing and population aging, it is expected that ARMD will also be on rise in Bangladesh 12 Glaucoma affects a significant number of people and is one of the leading causes of permanent blindness. According to the National Blindness and Low Vision Survey 1 1.2% of all adult blindness is due to glaucoma. On the other hand, open angle glaucoma prevalence among Bangladeshis aged 35 years and above is 2.8% against a suspected rate of 11.2%. In absolute figure this is about one million 13.The 2000 survey estimated the rate of glaucoma among the people 35 years of age or above to be 2.8 per cent. For implementation of vision 2020,Bangladesh National Council for Blind (BNCB) of Ministry of Health and family Welfare, Government of the People's Republic of Bangladesh) and national Vision 2020 Committee has been formed. However, these committees needs to be activated and reformed (if required) to facilitate the planning and monitoring the achievements against the set target for Vision 2020 goal as well as set up and monitor the quality of services. 2,1 Quality of services Although post-operative cataract complications are extremely negligible- 10 to 12 per 100,000 operations, quality assurance of the clinical services still leaves room for improvement. Although standard operating procedures are available, pre and postoperative follow up functions and their documentations need institutionalization. Public sector clinical staff have formidable role of undertaking these responsibilities for which they are yet to be ready. Past orientation interventions do not seem to have borne any fruit. Whatever complications are noted are mainly due to non-compliance of the post-operative measures by the patients, especially in case of diabetic retinopathy. 15

16 The proportion of IOL surgery is only about 59% in Bangladesh. While Dhaka and Rajshahi divisions accounted for 65% of IOL surgery, Borishal division had less than 1% and Khulna 6.6%. The Bangladesh National Blindness and Low Vision survey 2000 showed that one quarter of intra-capsular cataract extracted eye was not corrected with a spectacle lens. This was more common among women, eye camp surgery recipients, illiterate people and rural inhabitants. For regulating quality of eye care service Bangladesh does not have any accreditation system or overall standards of service procedures. The Bangladesh Medical and Dental Council, which is entrusted with regulation of medical care by professionals and the State Medical Faculty, which regulates mid-level nonprofessional cadre of service providers, have no eye care related specific regulations and functions. 2.3 Backlog of treatable cases and human resources for eye care situation The level of skill and modern technology has brought in expediency in the time required for cataract operation. In skilled hands, if all the logistics and helping hands are available, should not take more than 3.5 minutes per operation. This would mean that conducting 100 cataract surgeries per day by an expert would not be a tall order. Unfortunately only 30% to 40% of a total of about 900 ophthalmologists available in the country are capable and willing to work at that pace, even when some incentives are provided to the service providers. This will be insufficient to remove the backlog that awaits surgical intervention, while new cases keep on piling up on the top of this backlog. The lack of philanthropy on part of the senior professionals is both attitudinal and monetary. Since in private chambers a cataract operation would fetch much handsome remuneration, so operation in public sector hospitals is sluggish. But the fact that most of the cataract cases occur among the poor, illiterate, elderly, non bread-earning rural population, who would not knock the door of these expensive service providers, do not get any attentive ears. Past orientation efforts to these elderly experts were not found to be useful. The cataract surgery rate is 1,172 on average per million population /year in Bangladesh. The total cataract surgeries in 2012 however, was slightly higher, i.e., 183,312, at a cataract surgical rate of 1,206 per million population /year (personal communication with the line director National Eye Care on 11 November 2013) the backlog of cataract patients waiting to be operated upon will only get longer. The present estimation for clearing this backlog is to raise this rate to at least 3,000 operations million/year. There are only 2,800 mid-level eye care personnel available in the country (personal communication with line director of National Eye Care Prof. Deen Mohamad Nurul Haque, 11 November 2013). The number of ophthalmologists trained per year is about 50 (LD, NEC).in Bangladesh. At this rate the country needs more formal type of mid-level eye care providers. There are no optometrist or orthoptist in Bangladesh. It is imperative that physicians trained to be ophthalmologists are destined to work as specialists and services that may be provided by less trained mid-level personnel are inducted to cater those services. This is one answer to remove the backlog that has been heaping with time. 16

17 While younger ophthalmologists have been found to be more receptive to the concept of addressing the national curse of avoidable blindness the posts of ophthalmologists in the public sector is limited. Therefore collaboration between public and private sector for providing effective eye care in the country is important. Sadly though the investment cost for establishing an eye care service point runs into millions of taka. Maintenance of the eye care equipment and machines is also fraught with the non-availability of trained bio-medical engineers in the country. One reason of the backlog is due to non-prioritization of eye care services at district level by the head of the district health office, i.e., civil surgeons. Past orientations have not brought in any considerable degree of success. The district Vision 2020 Committees are effectively functioning only in those districts where NGOs are providing active technical support. In many districts civil surgeons have to discourage hospitalization of the eye surgery patients as the available seats in district hospitals is inadequate even for more serious patients, albeit some other nonhospitalizable patients are found to occupy these scarce beds. Interestingly these officials have been said to discourage eye surgery even in private hospitals for some ill understood reasons. A collaboration between the line director of National Eye Care and the director of Hospital and Clinical Services, DGHS will be necessary to break this impasse. Anone reason of the backlog may be a poor rate of eye care services including cataract surgeries provided at district level. District hospitals suffer from inadequacy of equipment, trained human resources and sub-specialty services. Utilization of upazila health complexes, introduction of health vouchers and/or inclusion of most common eye care problems in the service package of universal health coverage may be useful in removing the backlog. To this end the cost for these services would be useful to know for ensuring an efficient service package in the universal health coverage system, when instituted in the country. Experience from Manikgonj and Kotalipara would be handy in this regard. There are only four eye hospitals in Bangladesh with full-fledged pediatric ophthalmic units against a need of 16. Two eye hospitals have corneal sub-specialty units and two eye banks in the entire country, while six vitreo retinal units are functional in the country. Obviously these few service providing units in the country fall far short of needs, 2.4 Paucity of funding Government allocation for the current five year plan period for eye care is a measly amount of Tk crores-slightly more than 3.5 crores per year! On the contrary International NGOs, like Sightsavers, ORBIS, Helen Keller International, CBM, Fred Hollows and BRAC working in the area of eye care in Bangladesh spend ten times more than this. In contrast India allocated Rs. 2,500 crores in its current five year plan for eye care. Eighty per cent of this amount goes to private sector. This amount will be doubled to next five years. At present Govt. of India provides Rs. 1,000 through the district blindness committees for each cataract operation the private sector. To bring cataract patients for surgery BRAC in Bangladesh gives Tk. 50 to its field workers. According to a 2011 data the total expenditure on health per capita is 17

18 USD 67 per annum-combined from all sources. In terms of GDP it is 3.7% ( 67% of this however, is paid from out of pocket by the service beneficiaries themselves. 2.5 Eye health service availability and utilization According to the national eye care capacity assessment 14, the country had 141 hospitals for eye care services. Of these 71 were in public sector (2 tertiary hospitals, 14 medical colleges and 55 district hospitals), 56 are NGO owned (53 secondary level and 3 tertiary level) hospitals and 14 in private sector (6 medical colleges).. According to a study conducted in , only 8% of the rural people are able to obtain health care services from government facilities and 2% of mothers seek care for their sick children from UHFWCs. Most of the people in rural areas (about 57%) prefer health services from Palli Chikitshoks, a village practitioner etc. In urban areas this is about 31%. Almost half of the rural women are not aware of the existence of a satellite clinic close to their homestead. The study found that less than one percent of the surveyed respondents have used the services of the union level public health facilities, who usually come within half a kilometer distance. Even at this poor rate of utilization an estimated 70% of the eye surgeries in Bangladesh is due to cataract. Most of the cataract surgeries are conducted in urban areas with Sylhet city topping the list 8. Eighty six percent of these surgeries are done in NGO clinics, 10% in government facilities and 4% in private hospitals. Out of 626 ophthalmologists 350 were found to be serving in Dhak city. Rajshahi city had 103 and the other cities had less than 100 ophthalmologists each. Borishal was found to have only 16. Mid-level eye care providers (618) were also distributed similarly. In this case Chittagong city however, had a slight edge over Rajshahi- 134 to 73. Borishal again was at the bottom with only 7. Forty seven percent of the ophthalmologists were found to be located in NGO hospitals, 40% in government hospitals and 13% in private hospitals. Sixty eight percent of the mid-level health care providers were found in NGO hospitals, 23% in government hospitals and 9% in private hospitals. Given this distribution, it is clear that personnel working in the government hospitals are conducting fewer operations than the NGO hospital based staff. However without having a system of regular updating on national level information appropriate planning is almost impossible. The following are the areas which will be collected through a concerted effort of Publicprivate-NGO partnership effort.. Number of general hospitals with eye department in public sector; Number of general hospitals with eye department in private sector and NGO sector; Number of beds for eye services in public sector hospitals: (National Eye Care Capacity Assessment 2003); Number of beds for eye services in private and NGO sectors: Number of ophthalmologists; Total cataract surgeries at district level per year in last three years. 18

19 VISION AND MISSION STATEMENTS Vision A world in which no one is needlessly blind and where those with unavoidable vision loss can achieve their full potential. Mission To eliminate the main causes of avoidable blindness by the 2020 by facilitating the planning, development and implementation of sustainable national eye care programme based on the three core strategies of disease control, human resources development and infrastructure and technology, incorporating the principles of primary health care. Goal Reduction of blindness by 50%, from 1.53% to 0.7% by Purpose Strengthen management and technical aspects of the eye care program for reducing preventable blindness including removal of cataract backlog in Bangladesh and for ensuring adequate availability of major eye care services at all nodal levels. The targets for the period Indicator Baseline Projected target No. of adult cataract patients undergone surgery per million Mid-2014 Mid ,164 (2009 NEC) No. of cataract patients received cash voucher No. of diabetic retinopathy cases received service NA NA No. of hospitals following standard protocols 150 (2009 NEC) No. of child cataract surgery performed annually 4,000 (2009 NEC) The targets for the period 1. 70% removal of cataract surgery backlog by 2017 and 100% by 2020; 19

20 2. >3 community health care providers per union in GO/NGO/private sector are capable to identify and refer cases of refractive error, cataract and suspected cases of glaucoma by 2020; 3. 20% of the primary schools by 2020 have teachers who identify students with refractive error, and cataract manually and refer them; 4. Creation and posting of mid-level ophthalmic personnel (optometrists and orthoptists) in 70% of the upazila health complexes by 2017 and in 100% upazila health complexes by 2020; 5. Identified physicians at all the upazila health complexes in the country by 2017 to diagnose and refer low vision, glaucoma, diabetic retinopathy and cataract cases to district hospital; 6. All district hospitals manage cataract (including in children above 10 years of age), low vision, glaucoma, diabetic retinopathy and follow up of all cases of cataract surgery by 2020; 7. All the poor (under safety net) children will get spectacles at all the upazila health complexes free of cost by 2020; 8. 50% of the identified poor people are covered under demand side financing for cataract surgery by 2020; 9. Sixteen adequately equipped pediatric tertiary facilities (one per ten million population) established to provide referral care including adult subspecialties and pediatric surgical services (at least one per division). 10. National HMIS data base created to inform the NEC for planning, decision making, resource allocation and reporting 20

21 STRATEGIC PLAN 1. Expected outputs 2. Responsive and skilled eye health workforce available at nodal levels; 3. Management related information is available for assessing performance and for management decision; 4. Adequate medical products, facilities and technology are available at all levels of health care infrastructure for eye care; 5. Effective leadership and governance system has been developed for eye care and for developing plans and financing the plans at all levels; 6. Standards and required measures are available and implemented for improving and assessing quality and quantity of care; 7. Research in eye care conducted to generate evidence and for assessing attainment of objectives and targets; 8. Community participates in planning, implementation and program review; 9. Access to eye care services improved at all levels and more specialized services are available at lower levels; 10. People are more aware of the eye care problems, their causes, how to prevent those and where to get treatment for the different types of eye care diseases. 2. Prioritized actions 1. Strengthen management and clinical skill at all levels for eye care; 2. Strengthen management information systems for monitoring and supervision; 3. Procure medical products, facilities and technology; 4. Build/strengthen effective leadership and governance system; 5. Improve quality of care; 6. Conduct health systems and population related research; 7. Conduct advocacy and awareness raising among policy makers, managers, farmers and industrial workers on prevention of ocular injuries; 8. Ensure community participation in planning and implementation of population based programs; 9. Establish, expand and enhance access of sub-specialty services at lower levels. 3. Strategic actions Strengthen management and clinical skill at all levels for eye care: (i) strengthen and activate BNCB, national and district Vision 2020 Committees; (ii) Form functioning of upazila Vision 2020 committees; (iii) strengthen project management at national and district levels; (iv) integrate national eye health program with primary health care structure and with urban health care structure, and establish vision centers at upazila health complexes; (v) establish subspecialty services (paediatric ophthalmology, vitreo-retina, cornea, oculoplasty, ocular trauma, glaucoma and low vision care) at teaching/ tertiary and divisional hospitals; (vi) Establishment of pediatric eye care facilities as per WHO recommendations including ROP service introduction in 21