MINISTRY OF HEALTH MALAWI VISION 2020 EYE CARE ACTION PLAN

MINISTRY OF HEALTH MALAWI VISION 2020 EYE CARE ACTION PLAN 2011-2016

FOREWORD Blindness and visual impairment have profound human and social economic consequences in all societies. Blindness significantly contributes to the macroeconomic costs of a country though ill health, human capital productivity loss, need for long-term rehabilitation, as well as special education. In developing countries such as Malawi, where despite the needs, facilities for rehabilitation and special education are absent to large extend, blindness and visual impairment result in lower quality of life and contributes to increasing poverty levels for individuals affected, their families and society at large. Furthermore, blindness is associated with lower than average life expectancy in developing country settings, thus blindness is an indirect cause of early mortality especially for the poor and is an impediment to poverty reduction since the blind do not have an enabling environment that allows them to meaningfully participate in development activities and community life. It is against this background, that this plan is considered an integral part of Malawi Growth and Development Strategy (MGDS). This plan succeeds the Malawi Vision 2020 Eye Care Plan 2005-2010, that was developed following the Fifty Sixth World Health Assembly resolution urging member states to eliminate avoidable blindness by 2020. It translates the WHO Vision 2020 Right to Sight strategy into a local plan guided by Malawi's Poverty Reduction Strategy and Fourth National Health Plan for implementation of the planned eye care activities through the six-year Health Sector Strategic Plan..The Government of Malawi, has a strong commitment in eye care through health policies including shortlisting eye care amongst EHP under Eye, ear and skin infections and NTDs which includes management of Onchocerciasis as depicted in the new HSSP. The plan of action will provide a unifying national focus and enable more coordinated implementation of eye care interventions in Malawi. It also helps to translate more clearly eye care interventions to be implemented in the coming six (6) years through the Health Sector Strategic Plan.. The Ministry of Health hence wishes to strengthen collaboration with all its development partners to encourage increased financing (through basket or earmarked arrangements), coordination and implementation of the planned eye care activities. Through this plan, therefore, Malawi will continue to join the rest of the world in reducing the burden of blindness and to further develop comprehensive and sustainable eye care programmes. Right Honarable K.Kachali. VICE PRESIDENT AND MINISTER OF HEALTH 2

APPRECIATION The Ministry of Health would like to express its appreciation to our partners in Eye Care Services (Sightsavers, Lions Aid Norway, CBM, and International Centre for Eye Education) for their untiring contribution to the development process of this plan. In particular we also acknowledge their financial contribution to the printing of this document. ACKNOWLEDGEMENTS The Ministry of Health through the National Prevention of Blindness Committee (NPBC) would like to acknowledge the efforts of all committees and stakeholders that were engaged at different stages of development of this National Eye Care Action Plan 2011-2016.I would like to pay special tribute to the following groups and individuals:.dr George Chithope-Mwale, the Director of Clinical Services and the Chairperson of the NPBC for the leadership and guidance throughout the development of this document. Mr. Bright B. Chiwaula and Mr Michael P.Masika who facilitated the first workshop of the drafting committee. Dr Ann Phoya the Director of SWAp for the support given in the drafting of this document. NPBC which drafted this document in a logical fashion manner. The committee also served as an editorial team. It was composed of Dr Titha Dzowela (Deputy Director of Clinical Services, Dr Joseph Msosa, Dr Khumbo Kalua, Dr Gerald Msukwa, Mrs Mercy Masso, Country Director Sightsavers, Mr Stefan Dolfel,CBM Country Representative,,Mrs Hilda Kazembe Country Officer (ICEE),Ms Edna Tembo,Country Representative LAN, Dr Petros Kayange,(CoM) Dr Will Dean Nkhoma Hospital,Mr Godfrey Kadewele and Mr Frank Kumbanga. All stakeholder who constructively critiqued and reshaped the document at the Senior Management meetings, The Ministry of Health also wishes to thank all the different NGOs and International Organizations who have participated in this process, namely CBM (International Disability and Development Organization), International Centre for Eye Education, Lions Aid Norway and Sightsavers. These cooperating partners have also supported eye care programs and have presented an invaluable gift to the people of Malawi. Government of Malawi, therefore remains sincerely thankful to them. All other stakeholders not specifically mentioned are also sincerely acknowledged for their various contributions. Willie Samute SECRETARY FOR HEALTH 3

Table of Contents FOREWORD... APPRECIATION... ACKNOWLEDGEMENTS Table of Contents... LIST OF TABLESLIST OF ABBREVIATIONS... LIST OF ABBREVIATIONS... 1 INTRODUCTION AND BACKGROUND... 1.1 Historical Background... 1.2 Global perspective of Eye Care... 1.3 National Perspective... 2 MAGNITUDE OF BLINDNESS, CURRENT INTERVENTIONS AND SERVICES Error! Bookmark not defined. 2.1 Introduction... 2.2 Major Eye Conditions and Services... 2.2.1 Cataract... 2.2.2 Trachoma... 2.2.3 Childhood Blindness... 2.2.4 Refractive Errors and Low Vision... 2.2.5 Glaucoma... 2.2.6 HIV/AIDS related Eye Conditions... 2.2.7 Diabetic retinopathy and Vitreo-retinal Services... 2.2.8 Other Ophthalmic Conditions... 2.3 Human Resource Development... 2.3.1 Ophthalmologists... 2.3.2 Cataract Surgeon... 2.3.3 Ophthalmic Clinical Officers (OCO)... 2.3.4 Ophthalmic Nurses... 2.3.5 Optometrists... 2.3.6 Optometry technicians... 2.3.7 Equipment Technicians... 2.3.8 Primary Eye Care Workers (PECW)... 2.4 Training Institutions... 2.4.1 Malawi College of Medicine... 2.4.2 Malawi College of Health Sciences... 2.4.3 Mzuzu University... 2.5 Infrastructure, Health Care Technology, IT, Drugs and Supplies... 2.5.1 Infrastructure... 2.5.2 Health Care Technology... 2.5.3 Health Information Technology... 2.5.4 Drugs and Medical Supplies... 2.6 Research... 2.7 Information, Education and Communication (IEC)... 2.8 Advocacy... 2.9 Monitoring and Evaluation... 2.10 Coordination and Supervision... 4

2.11 Financial Resources 3 CHALLENGES... 3.1 Major Constraints to Prevention of Blindness in Malawi... 4 OBJECTIVES AND STRATEGIES OF THE MALAWI NATIONAL EYE CARE PLAN... 4.1 Development of Human Resources... 4.2 Infrastructure and Health Technologies... 4.3 Supply Chain Systems and Logistics... 4.4 Disease Prevention and Health Promotion... 4.5 Quality of Care and Supervision Systems... 4.6 Research, Monitoring and Evaluation... 4.7 Effective Management, Stewardship, Policy-, Institutions- & Systems development... ANNEX 1: NECP Implementation Plan and Budget 2011-2016... 5

LIST OF ABBREVIATIONS AIDS - Acquired Immune Deficiency Syndrome APOC - African Programme for Onchocerciasis Control CBM - Int. Organization for Disability and Development CDTI - Community Directed Treatment with Ivermectin CHAM - Christian Health Association of Malawi CMS - Central Medical Stores CoM - College of Medicine CSR - Cataract Surgical Rate DHMT - District Health Management Team DIP - District Implementation Plan DRF - Drug Revolving Fund ECCE-IOL - Extra Capsular Cataract Extraction with Intraocular Lens EHP - Essential Health Package EPI - Expanded Programme of Immunization HIV - Human Immune Deficiency Virus HMIS - Health Management Information System HSA - Health Surveillance Assistant ICEE - Int. Centre for Eye Education IEC - Information, Education and Communication ITI - International Trachoma Initiative LAN - Lions Aid Norway LCIF - Lions Clubs International Foundation MACOHA - Malawi Council for the Handicapped MCHS - Malawi College of Health Sciences MoH - Ministry of Health MSTG - Malawi Standard Treatment Guidelines NECP - National Eye Care Plan NGOs - Non-Governmental Organization NPBC - National Prevention of Blindness Committee NTD - Neglected Tropical Diseases OCOs - Ophthalmic Clinical Officers OMAs - Ophthalmic Medical Assistants ON - Ophthalmic Nurse PECs - Primary Eye Care PHC - Primary Health Care PoW - Programme of Work QECH - Queen Elizabeth Central Hospital SADC - Southern Africa Development Community SAFE - Surgery Antibiotics Face Washing and Environmental Sanitation SWAps - Sector Wide Approaches VHCs - Village Health Committees WHO - World Health Organisation ON - Ophthalmic Nurse 6

PECs - Primary Eye Care PHC - Primary Health Care PoW - Programme of Work QECH - Queen Elizabeth Central Hospital SADC - Southern Africa Development Community SAFE - Surgery Antibiotics Face Washing and Environmental Sanitation SWAps - Sector Wide Approaches VHCs - Village Health Committees WHO - World Health Organisation 7

1. INTRODUCTION AND BACKGROUND This document is the second formal National Plan for the Prevention of Blindness in Malawi. The plan was developed within the context of the Vision 2020: Right to Sight global campaign and Malawi's Health Sector Strategic Plan which includes eye care as one of the Essential health Care package(ehp) to intervention. This plan serves to strategically refocus eye care activities in Malawi in order to promote synergy among all stakeholders. 1.1 Historical Background Formal eye care services were first introduced by the Nyasaland Protectorate Government well before the Federation of Rhodesia and Nyasaland (1953-1961) established the first eye care department at QECH in Blantyre with one ophthalmologist and two medical assistants. After self-government in 1963, the Malawi Government through the Israeli Technical Assistance support provided eye care services and the training of ophthalmic medical assistants who after completion of the course were deployed in other districts of Malawi. Since 1964 eye care services have expanded considerably to cover all districts of Malawi through various Government- and NGO initiatives. The following table shows role and scope of the main development partners of the Government of Malawi in Eye Care:. Table 1: Development partners and their roles: Partner Sightsavers CBM LAN ICEE Role and Scope Work with government and development partners at all levels to promote and strengthen effective delivery of eye health services, with particular focus on fast track initiatives on disease control and human resource development, promotion of Primary Eye Care strategy, and strengthening systems and structures for delivery of eye health services. Support to service delivery as well as human resource and systems development in Malawi through co-funding of Community Based Rehabilitation Projects on district level, and collaboration / partnership with Nkhoma Hospital, College of Medicine, MACOHA and MoH. Support of outreach activities of the MoH, infrastructure development of Central and District Hospitals, human resource and systems development, with focus on PEC and PHC integration. Support to optometry training programme Optometry Giving Sight Support to optometry training programme 8

1.2 Global perspective of Eye Care This plan has been developed in the context of the VISION 2020: The Right to Sight, which is the global initiative to eliminate avoidable blindness, promoted by the World Health Organization. Its aim is to eliminate avoidable blindness by the year 2020. The long-term aims are to develop a sustainable comprehensive health care system to ensure the best possible sight for all people and thereby contributing to poverty reduction in Malawi and improving the quality of life of its citizens. The priorities for this plan are based on the VISION 2020, which indicates that almost 80% of blindness, and visual impairment is a result of five preventable or treatable conditions (cataract, refractive errors/low vision, trachoma, glaucoma and childhood blindness). For each of these conditions there are cost-effective interventions that if fully implemented will contribute towards a substantial reduction of the burden of blindness from the global projected 75 million blind people to less than 25 million by 2020 globally. In line with this global target, WHO prioritized three interventions including: Cost-effective disease control interventions; Human Resource development; Infrastructure développent; 1.3 National Perspective This plan has been developed in line with the government's poverty reduction strategy (Malawi Growth and Development Strategy MGDS) at national level, and the Health Sector Strategic Plan (2011-2016) of the Ministry of Health. This plan elaborates the essential eye care interventions which the Ministry of Health will facilitate to be implemented as part of the six-year Health Sector Strategic Plan (2011-2016) of the Ministry of Health. This plan also serves as a government's response to the Fifty Sixth World Health Assembly resolution urging member states to eliminate avoidable blindness by 2020. The MOH has since established a National Prevention of Blindness Committee (NPBC) to advise the Government and stakeholders on the implementation of this plan. Membership of the NPBC is as follows: Director of Clinical Services - Chairperson WHO Representative Heads, Eye Departments of Blantyre, Lilongwe, Zomba, Mzuzu and Nkhoma Hospitals Director, Malawi College of Health Sciences Executive Director, CHAM Executive Director, MACOHA Country Coordinator, CBM Representative, Malawi College of Medicine Country Officer, International Centre for Eye Education Country Director, Sightsavers Country Director, Lions Aid Norway Representative, Malawi Union of the Blind 9

Head of Ophthalmic Training, Malawi College of Health Sciences Representative (2) of Mid Level Personnel - Clinical and Nursing Representative, Ministry of Education The Programme Manager, NTD ` It is through an established task force of the committee that this plan has been developed in order to Highlight eye care services/interventions that are planned to be implemented in the 2011-2016 Health Sector Strategic Plan Establish clear and relevant guiding policies and strategies for ongoing coordination of eye care services implementation and assurance of the quality of the eye care services throughout the country. 10

2. SITUATION ANALYSIS 2.1 Introduction With an estimated population of 13.6 million people ( reference 2008 Census), and an estimated prevalence rate of blindness of 1%, Malawi has about 136,000 blind people in the country of which up to 80% of all the burden of blindness is due to preventable or treatable conditions. A number of community- and hospital based surveys conducted in Malawi and neighboring countries estimate that cataract is the major cause of blindness, contributing to 50% of all blindness. Other causes of blindness include Glaucoma which contributes 15%, Trachoma 15%, and childhood blindness resulting from congenital cataract, Vitamin A deficiency, Measles and harmful traditional practices contributes 6%. 2.2 Major Eye Conditions and Services 2.2.1 Cataract It is estimated that there are 68,000 blind (0.5% of the total population) due to cataract in Malawi. And for every cataract blind person there are four more people with cataract who also require surgery. In 2010, 9,700 cataract operations were performed in the country; and this translates to a cataract surgery rate (CSR) of 746 1. According to the Vision 2020, the recommended minimum CSR target for Africa is 2,000 and therefore Malawi is required to significantly increase its efforts to achieve the target CSR. Nkhoma Hospital Eye Department is now offering modern state of the art technique with ultrasound to remove the cataract. This phacoemulsification surgery allows much faster recovery and less need for glasses after surgery. 2.2.2 Trachoma Malawi is known to be endemic for blinding trachoma. Prevalence surveys (2008) conducted in Mchinji and Chikwawa districts showed a prevalence of active Trachoma of 21.7% and 13,6 % respectively (in children aged 1-9 years). Malawi is actively addresses trachoma in various districts. However, through the donation programme of the drug Zithromax by ITI, and through improved coordination amongst stakeholders, successful implementation of the SAFE strategy as a future intervention will be enhanced. In addition. more districts will be surveyed to determine trachoma prevalence and expand the donation programme to other, endemic areas. 1 CSR represents number of cataract operations per 1 million population 11

2.2.3 Childhood Blindness The major causes of childhood blindness in Malawi are congenital cataract, and corneal scars from measles, Vitamin A deficiency, harmful traditional practices, bacterial infections and trauma. There are an estimated 6,500 blind children in Malawi (estimated prevalence of 1 per 1,000 children). Although the prevalence of childhood blindness is lower than adults, the number of blind years for a child is much higher. Currently the control of childhood blindness is largely through routine EPI, Vitamin A supplementation and other childcare health services. Congenital cataract and glaucoma are treated through surgery. Vision 2020: Right to Sight requires the establishment of paediatric centres and the training of paediatric oriented ophthalmic teams. A paediatric centre has been established in Blantyre at QECH. 2.2.4 Refractive Errors and Low Vision The estimated overall prevalence of significant refractive errors is 1%, while in the age group 11-16 years it is estimated to be 2%. Refractive errors are correctable through improved access to spectacles. Currently, limited refractive services are provided through a partnership of public health facilities, CHAM hospitals and private optical workshops. As well, school screenings are conducted to a limited extent although Vision 2020 identifies school health as the main strategy for early identification of refractive errors in children, and Low Vision services are provided at Central Hospitals in Lilongwe, Blantyre and in Nkhoma Hospital. 2.2.5 Glaucoma The magnitude of the disease is not known. According to global estimates in the region, the prevalence of glaucoma can be extrapolated as 15% of blindness. Currently glaucoma is treated surgically by trabeculectomy. Medical treatment is not effective because compliance is very poor and the drugs are not affordable for many people. Strategies and initiatives are being developed for screening, referral and post-operative follow-up of glaucoma patients in the communities. 2.2.6 HIV/AIDS related Eye Conditions With the high prevalence of HIV/AIDS among the general population, related eye conditions such as retinopathies, tumours and infections are on the increase. It is estimated that up to 25% of HIV positive persons will develop ocular manifestations. Currently most of the common conditions are being treated according to current HIV/AIDS related conditions guidelines in the health system. 2.2.7 Diabetic retinopathy and Vitreo-retinal Services The prevalence of diabetic retinopathy is on the increase due to the general increase of diabetic diseases. Currently, the government is referring patients abroad for treatment of Vitreo-retinal diseases, thereby increasing health costs for the country. However, by 2012 Kamuzu Central Hospital in Lilongwe will have established a Vitreo-retinal centre to increasingly provide specialist services in the country. 12

2.2.8 Other Ophthalmic Conditions Other ophthalmic conditions associated with trauma, tumours, eye infections and harmful traditional practices are treated within the current health care system. 2.3 Human Resource Development The implementation of this plan will require adequate personnel in the eye care departments to provide services at all levels. An eye care team 2 should ideally comprise of an ophthalmologist, optometrist, ophthalmic clinical officer, an ophthalmic nurse, equipment technician and a primary eye care worker. There is, at present, a critical shortage of eye care personnel in all categories at all levels of the health system. The human resource situation at the different levels of care is as follows: 2.3.1 Ophthalmologists There are currently 8 Ophthalmologists registered with the Medical Council of Malawi working; an estimated population ratio of 1 ophthalmologist per 2 million people. 5 are with the Government Hospitals, 2 with the College of Medicine and 1 is with Nkhoma Mission Hospital. The College of Medicine has a postgraduate training programme for ophthalmologists (M.Med.). The first graduates are expected to start in 2011 and expected to complete by 2015.It is expected that at least 13 ophthalmologists should be working in Malawi by 2015. 2.3.2 Cataract Surgeon A cataract surgeon is a trained Ophthalmic Clinical Officer who has completed at least one year advanced training and internship in cataract surgery. Currently there are 4 cataract surgeons in the country. There is capacity to train 4 cataract surgeons per year, so by 2015 a further 20 cataract surgeons should be trained. 2.3.3 Ophthalmic Clinical Officers (OCO) An OCO is a clinical officer who has undergone a one year training in ophthalmology and is awarded a diploma in ophthalmology. The total number of OCOs in service in the country is 46. Vision 2020 minimum targets are one OCO for a population of 100,000. With the shortage of ophthalmologists and optometrists, OCOs provide clinical and refraction services. By 2015 at least 70 OCOs are to be trained. 2.3.4 Ophthalmic Nurses There are currently none practicing, and there is no capacity to providing ophthalmic nursing training. Therefore there is a need to identify training institutions outside the country where ophthalmic nurses can be trained. By 2015, 8 ophthalmic nurses should be trained. 2 WHO recommendation for Africa for ratio eye care team / population: 1 Ophthalmologist / 500,000; 1 Optometrist / 250,000; 1 OCO / 250,000; 1 nurse / 100,000; 1 equipm. technician / 1 Mio.; 1 PHC worker / 10,000; 13

2.3.5 Optometrists Currently, no optometrist are available in the public health sector. In the private health sector, are 4 optometrists. However, there is a four year degree course in optometry at Mzuzu University. By 2015 a total of 47 optometrists are expected to be qualified and practicing. 2.3.6 Optometry technicians There are currently no optometry technicians in Malawi. However, a 3 year diploma course at MCHS has been developed. It is expected that by the year 2015 there will be 40 trained and working optometry technicians in the country. 2.3.7 Equipment Technicians Although Equipment Technicians exist in the health services, there are currently only two in the country who are oriented to maintain ophthalmic equipment. A further three will need to be trained by 2013. 2.3.8 Primary Eye Care Workers (PECW) There are currently around 10,500 DCAs - Disease Control Assistants (formerly known as Health Surveillance Assistants) in the country, 60 Community Based Rehabilitation Workers, and 2 Cataract Case Finders. There is a need to engage the MoH to revise the DCA curriculum to accommodate eye health care. Currently about 3,000 DCAs have been trained in primary eye health care, and by 2015 all DCAs are expected to be trained. 2.4 Training Institutions 2.4.1 Malawi College of Medicine Four year postgraduate training in ophthalmology at this college commenced in 2005. Two ophthalmologists have successfully completed their M. Med (ophthalmology) qualification in 2010. The capacity of the College is to enlist up to four (4) trainees per year, and the urgent need to increase funding and attract more students into the Programme. 2.4.2 Malawi College of Health Sciences In Malawi the training course of OCO admits medical assistants and clinical officers, to a Diploma or Advanced Diploma in clinical ophthalmology respectively. On completion of the training the graduates are expected to provide clinical eye care services. Optometry technicians are trained for 3 years and receive an Optometry Technician Diploma. After completion, they are deployed to work under optometrists in Central and District Hospitals. In addition, MCHS has established a 12-18 months Cataract Surgeon Training Course for OCO s, depending on entry qualifications. 14

2.4.3 Mzuzu University Since 2008, Mzuzu University is training Optometrists at degree level (Bachelor of Science) in a four year course. By 2015, it is expected that 47 optometrists should be trained and practicing. 2.5 Infrastructure, Health Care Technology, Information Technology, Drugs and Supplies 2.5.1 Infrastructure All the Government Central Hospitals - Kamuzu Central Hospital, Queen Elizabeth Central Hospitals, Mzuzu, and Zomba have dedicated eye departments, with eye wards and theatres. Only one CHAM hospital - Nkhoma Hospital, has a dedicated eye department. However, infrastructure at Kamuzu Central Hospital is dilapidated and therefore requires immediate comprehensive maintenance. All district hospitals have space for Outpatient Clinics. However.the rooms are too small to accommodate equipment and consultation services. Theatre services are provided using the general theatres which allocate at least a day during the week. Patients requiring admission share the general wards. There is need to expand space for provision of outpatient services; which will include establishment of minor theatres at the district hospitals. 2.5.2 Health Care Technology All central hospitals currently have basic ophthalmic equipment for diagnosis and surgery. A standardized equipment list is non existent. There is need to develop a standard list and to upgrade and procure new and up to date diagnostic and surgical equipment/instruments. At district hospitals, equipment is in critical shortage, with a majority of district hospitals lacking basic diagnostic and operating equipment. There is need to come up with a minimum requirement for each level of care and procure the necessary equipment. Currently outreach clinics, use hospital equipment thereby disrupting continuity of services at the base hospital. There is no separate equipment to facilitate outreach services. Equipment maintenance services are poor, with no dedicated services for maintenance of eye health equipment 2.5.3 Health Information Technology Information technology for collection of eye health data is inadequate. Collection of eye health data is manual and not computerized. HMIS only captures data on cataracts and 15

other eye diseases although hospitals do collect comprehensive information. As such it is difficult to collect disaggregated information on other eye diseases to enable effective planning for interventions. Computer allocation is not prioritized to departments, and this cripples collection and storage of relevant data. There is need to revise the HMIS booklet to include more indicators on eye diseases and ensure that there adequate technology to aid collection and storage of relevant data. 2.5.4 Drugs and Medical Supplies Most eye care drugs are on the essential drug list, however eye care delivery to support this plan document requires additional drugs and supplies (see list of drugs required at each level in annex 1) In terms of supply there are constant shortages of both diagnostic and curative eye care drugs at all levels of the health delivery system. Supply of eye drugs from Central Medical Stores is erratic. Most of the eye drugs required are not included in the CMS drug catalogue,consequently NGO s play a gap filling role in drug supply. There is therefore a need to update the catalogue and improve on procurement and delivery to the hospitals. 2.6 Research Several research studies have recently been done in Malawi which have confirmed blindness to be of public health importance. These include trachoma studies in Chikwawa and Mchinji (2008), rapid assessment of avoidable blindness in south west zone (2010), situation analysis of services in south east zone (2010), childhood blindness studies (2007-2010), glaucoma, etc. More studies are planned for the period between 2011-2016. 2.7 Information, Education and Communication (IEC) Mobilization and sensitization of communities through IEC messages and materials are limited to specific diseases such as Trachoma and Onchocerciasis. There is therefore a need to develop more IEC messages and materials to cover all the priority diseases and also address barriers to the uptake of eye care services. 2.8 Advocacy Achievements in the area of advocacy are the inclusion of Eye care into the Essential Health Package (EHP) of the Government, and the establishment of structures in the MoH assigned to oversee and coordinate implementation of Eye care programmes and develop Eye care strategies and plans in Malawi, to be included into the Programme of Works II. However, advocacy efforts need to be further strengthened in order to ensure 16

adequate financing of this plan within the MoH Health Sector Strategic Plan 2011-2016. In addition, advocacy to non eye care stakeholders needs to be enhanced to ensure that eye health is mainstreamed in other development undertakings. 2.9 Monitoring and Evaluation Eye care services are being monitored through supervisory systems, standard reporting and routine data collection during patient care at various health facilities and health management levels in the country. Data is reported centrally to the assigned offices at the MoH, that in turn reports to international bodies such as International Agency for the Prevention of Blindness (IAPB). It is planned that the current HMIS form will be reviewed to include more accurate eye indicators that will be routinely monitored at national level. NPBC meetings to review progress in the implementation of the National Eye Care Plan are scheduled to take place every six month, and data regarding available human resources, infrastructure and equipment are reported. In addition, a mid term review of the implementation of the National Eye Care Plan is envisaged in 2013. A final review is planned for 2016. 2.10 Coordination and Supervision At national level, coordination and supervision of Eye Care activities fall under the Directorate of Clinical Services. The technical coordination functions for Eye Care Services are undertaken by the Assistant Director (Ophthalmology) to oversee implementation of all eye care issues as decided by the National Prevention of Blindness Committee (NPBC). The NPBC advises the Ministry of Health on issues pertaining to the practice of ophthalmology in Malawi. It is under the chairmanship of the Director of Clinical Services of the Ministry of Health. At zonal level, co-monitoring of eye care activities and plans is carried out by supervisors under the MoH, reporting to the Assistant Director of Clinical Services (Ophthalmology). At district level, the DHMT provides managerial supervision, while the Eye Care personnel conduct supportive supervisory visits to health care facilities within the districts. 2.11 Financial Resources Eye care services are supported by government, NGOs and other partners. Under the government budget, the budget line for eye care services is included under curative services. The resources provided are still inadequate to meet the basic needs for eye care for the whole country. The sources of funds for implementing this plan will be multiple, the key source being the health SWAp mechanism. Development partners will support implementation of the 17

plan where required, and in line with the respective organizations mandates and strategies. These costs cover all activities aligned to the respective building blocks of the Health Sector Strategic Plan of the Ministry of Health: 1. Human Resource Development 2. Infrastructure and Health Technologies 3. Supply chain systems and logistics 4. Disease prevention and health promotion 5. Quality of Care and supervision of systems 6. Research, Monitoring, Evaluation and Evidence-based approaches 7. Stewardship, Policy, Institutions and Systems 3. CHALLENGES 3.1 Major Constraints to Prevention of Blindness in Malawi Based on the situation analysis, the following are the problems that contribute to the inadequate delivery of eye care services; A critical shortage of eye care workers, i.e. Ophthalmologists, OCO s, Optometrists, Refractionists, Ophthalmic nurses, Low vision therapists; Inadequate supply of essential and specialist equipment, drugs and supplies; Lack of clear and relevant guiding protocols; Low profile of blindness and visual impairment as a public health problem; Low awareness and access to eye care services at community and district level; Inadequate funds and other resources for prevention of blindness services, e.g. eye camps, screenings, infrastructure development, etc.; Insufficient in-country data on prevalence and incidence of major causes of blindness on which to base planning; HMIS not capturing specific eye diseases; Unavailability of hospital based data; Insufficient eye health data at health facility level; 18

4. OBJECTIVES AND STRATEGIES OF THE MALAWI NATIONAL EYE CARE PLAN During 2011-2016 development partners and the health sector at all levels will work towards achievement of the following objectives 4.1 Objective To increase number of human resource for eye care at all levels of the health delivery system. Strategies.Integrate Eye Care training into the existing Human resource training plans.review curriculum for training and internship of cataract surgeons..to monitor deployment of trained human resource to ensure an even distribution throughout the country Table 2 : Planned numbers completing training per year Cadre Baseline 2011 2012 2013 2014 2015 2016 Total 2010 Ophthalmologist 7 2 0 0 0 4 13 OCOs 46 24 0 23 0 23 70 Ophthalmic Nurses 0 0 2 2 2 2 8 Cataract Surgeons 4 4 0 7 0 7 22 Optometrists 4 0 7 10 15 15 47 Optomettry 0 0 0 0 21 20 41 Technician Maintenance 2 0 3 0 0 0 5 Technician DCAs 10,500 Table 3: Table showing Planned Institutions and Cadres Trained Cadres Ophthalmologists Institution College of Medicine Award M. Med Ophthalmology OCOs Malawi College of Health Sciences Diploma in Ophthalmology Cataract Surgeons Malawi College of Health Sciences Advanced Diploma in Ophthalmology Optometrists Mzuzu University Bachelor of Science in Optometry Optometry Technicians Malawi College of Health Sciences Diploma in Optometry Technician 19

4.1 Objective To improve infrastructure, equipment and information technology for provision of eye care services Strategies Eye Care Infrastructure: Expansion of out patient space in the district hospitals Provision of space within existing hospital infrastructure for minor theatres for eye surgeries Renovation of existing infrastructure Construction of new facilities Health Care Technology: Standardization of equipment lists for all levels of hospitals Upgrading and updating existing tertiary and secondary eye canters with diagnostic and surgical equipment/instruments (maintenance and purchasing) Health Information Technology: Provision of IT equipment and software for data management Updating HMIS to include indicators for eye health 4.3 Objective To improve supply of eye care drugs, diagnostics and supplies to all hospitals. Strategies Strengthening the procurement, storage and distribution system for equipment, essential drugs and supplies Revise CMS drug catalogue to ensure that essential medicines for treatment of common eye problems are available at all levels of health care Improve drug supply chain management Existing Drug Revolving fund shall be strengthened to procure essential drugs for the treatment of common eye conditions at community level. 20

4.4 Objectives To reduce the burden of preventable and curable causes of blindness. Strategies Provision of cataract surgeries in all the district hospitals Institutionalise SAFE strategy in phased manner in the surveyed trachoma endemic districts. Mass drug Administration in the surveyed trachoma endemic districts. Promote behaviour change communications Promote good environmental sanitation. Strengthen services for the paediatric ophthalmology centre at the LSFEH Establish National Paediatric guidelines for referring children to Blantyre. Incorporate school screening of children into National School Health programme protocol. Establish vision centre in the districts for the provision of affordable spectacles at all eye departments. Strengthening referrals and coordination for low Vision services at the established centres. Year Table 5: Table showing CSR Objectives 2011-2016 Cataract Surgical Rate (CSR) (No. of op s/ million population / year) Number of Operations 2011 600 7,800 2012 700 9,800 2013 850 11,050 2014 1000 14,000 2015 1150 16,100 2016 1300 20,000 Total 70,950 Cost MK 39,000,000 49,000,000 55,250,000 70,000,000 80,500,000 100,000,000 354,750,000 21

4.5 Objective To improve quality of eye care services. Strategies: Integrating eye care services into EHP service delivery Strengthen NPBC s capacity to coordinate and advocate for eye care services and supervision systems at all levels To develop and use standardized monitoring and supervision checklists 4.6 Objective To promote implementation of evidence based eye care practice. Strategies Conduct operational research on priority diseases, using VISION 2020 priority as a focus for research Establish evidence based information regarding eye diseases and services in Malawi Develop and collect reporting systems that will ensure that data regarding eye diseases are captured at all health facilities in Malawi Establish a National Inventory of eye equipment at tertiary and district levels Monitor deployment of trained human resource to ensure an even distribution throughout the country Integrate monitoring system into the wider HMIS : 4.7 Objective Medical Eye care interventions in Malawi are guided by Government policy, and Systems are developed for effective management and supervision of interventions carried out by the stakeholders in a coordinated approach. Strategies The policy framework of the Government of Malawi will continuously be further developed and revised in order to ensure incorporation of relevant objectives and strategies for Eye Care, informed by the NECP Strengthening of the integrated and coordinated eye care system of the Government, managed and supervised by the NPBC secretariat and NPBC committee of the MoH Participation and support of key stakeholders in the operations of the NPBC secretariat will be encouraged. 22

For corresponding targets, activities and budgetary requirements of the National Vision 2020 Eye Care Plan II (2011-2016), please compare the implementation framework (ANNEX 1). It is structured in line with health Sector Strategic Plan of the MoH, and its respective building blocks. 23

ANNEX: NECP Implementation Plan and Budget 2011-2016 Building Block 1: Adequate and appropriate trained and motivated Human Resources for Health to enable delivery of the EHP OBJECTIVES TARGETS / RESULTS ACTIVITIES BUDGET MK 3 1. Human resource for eye care are 1.1 Six (6) ophthalmologists 1.1.1 Training of six (6) ophthalmologists 67,200,000 available at all levels trained by 2015 1.2 20 Cataract surgeons trained by 2015 1.2.1 Training of 20 Cataract surgeons 70.000.000 1.3 70 Ophthalmic Clinical 1.3.1 Training of 70 Ophthalmic Clinical Officers 68.160.000 Officers trained 1.4 Eight (8) Ophthalmic nurses trained 1.4.1 Training of 8 Ophthalmic nurses 150.000.000 1.5 47 optometrists are trained 1.5.1 Training of 10-15 optometrists annually up to 2015. 345.600.000 by 2015 1.6 40 optometry technicians 1.6.1 Training of 40 optometry technicians. 288.000.000 trained by 2015 1.7 Three (3) Equipment 1.7.1 Training of 3 Equipment technicians 2.400.000 technicians trained by 2013 1.8 All DCAs (Disease 1.8.1 Orienting of Primary Eye Care Workers / DCAs (Disease 110.400.000 Controlled assistants) oriented in Controlled assistants) in eye care eye care by 2015 1.9 PAM personnel /technicians 1.9.1 Orienting of 3 PAM personnel/technicians in ophthalmic 2.500.000 oriented in ophthalmic equipment equipment maintenance 1.10 PEC incorporated in DCA 1.10.1 Lobby for inclusion of PEC in DCA training curriculum 2.500.000 training curriculum 1.11 Revised curriculum for 1.11.1 Revising of curriculum for training cataract surgery 3.000.000 cataract surgery 1.12 Continuous training 1.12.1 Conducting of career guidance on post basic and 15.000.000 programme established 1.13 A sustainable and comprehensive ophthalmology training programme established at CoM 1.14 A transparent recruitment system established in all training institutions postgraduate ophthalmology training. 1.13.1 Conducting capacity building for delivery of sustainable and comprehensive ophthalmology training at CoM 5.500.000 1.14.1 Ensuring proactive and transparent recruitment in all training institutions 3.000.000 TOTAL 1,133,260,000 3 Underlying exchange rate for calculation of USD costs in the NECP 2011-2016: 1 USD = 160 MK 24

Building Block 2: Adequate, standardized and functional infrastructures, healthcare technology and health information technology support service delivery OBJECTIVES TARGETS / RESULTS ACTIVITIES BUDGET MK 2. Improve infrastructure, equipment and information technology for provision of eye care services 2.1 Eye hospital at Kamuzu Central Hospital renovated by 2013 2.1.1 Renovation of Lilongwe Central Hospital Eye Department 20,000,000 2.2 Adequate space for OPD eye services are provided in 20 district hospitals by 2016 (incl. space for provision of refractive services) 2.3 Vision centres (1 per region) established by 2016 2.4 Minor theatres for eye surgeries established at 10 district hospitals by 2016 2.2.1 Construction of 5 District eye clinics, equipped with minor theatres 60,000,000 2.2.2 Expansion of out patient space in 15 district hospitals 30,000,000 2.3.1 Construction of three (3) vision centres (fully equipped) 30,000,000 2.4.1 Construction of 5 min. theatres 15,000,000 2.4.2 Constr. of 5 min. theatres (part of the 5 new distr. eye clinics) 15,000,000 2.5 100% district eye units equipped with basic instruments by 2016 2.6 All Central Hospitals with upgraded diagnostic and surgical equipment by 2016 2.7 Revised HMIS booklet, inclusive of comprehensive eye care indicators, by 2013 2.8 Central Hospital systems computerized by 2016 2.5.1 Develop standard list for equipments in district/central hosp. 3,000,000 2.5.2 Procurement of basic equipment for 28 district hospitals 140,000,000 2.6.1 Procurement and upgrading of equipment in 4 tertiary hospitals 160,000,000 2.7.1 Updating HMIS to include indicators for eye health 5,000,000 2.8.1 Procurement of 15 computers for 4 central hospital eye departments and National Eye Care Coordination Unit 3,000,000 2.8.2 Installation of computerized information systems in the 4 Central Hospitals and National Eye Care Coordination Unit for management of eye care data in Malawi 10,000,000 TOTAL 491,000,000 25

Building Block 3: Comprehensive and robust supply chain system and logistics backed by quality procurements of drugs, diagnostics and supplies enables delivery of the EHP OBJECTIVES TARGETS / RESULTS ACTIVITIES BUDGET MK 3. Improve supply of eye care drugs, 3.1 Revised drug catalogue which 3.1.1 Review CMS drug catalogue and include all essential drugs 2,000,000 diagnostics and supplies to all hospitals includes all required eye drugs by 2013 for eye health 3.2 90% of required eye drugs 3.2.1 Procurement of eye drugs and supplies for central and district 6,500,000,000 available at all levels by 2016 hospitals 3.2.2 Develop and implement a countrywide monitoring system for 20,000,000 supply and utilization of eye care drugs and supplies TOTAL 6,522,000,000 Building Block 4: Disease prevention and health promotion enabled through behavior change communication, demand creation, community mobilization, participation and civil society engagement OBJECTIVES TARGETS / RESULTS ACTIVITIES BUDGET MK 4. Reducing the burden of preventable 4.1 To increase national cataract 4.1.1 Strengthen surgical outreach to improve outputs and 354,750,000 and curable causes of blindness surgical rate from 500 to 1,300 CSR by 2016 (overall objective CSR 2000 for 2020) geographical coverage for cataract surgical services. 4.1.2 Improve the capacity of tertiary eye centres to perform high volume and specialist surgery. 4.1.3 To develop and reinforce guiding protocols to improve outcomes. (Budget 1.3 million for workshops) 4.2 To implement the SAFE strategy in Trachoma surveyed districts found to be endemic by 2015 4.1.4 Increase identification of cataract patients by CBR workers, DCA s, and volunteers in the community 4.1.5 To increase awareness through appropriate means (mass media, etc.) 4.1.6 To conduct cataract operations as per table 5 of NECP 2011-2016 4.2.1 Re-training/Training OCOs in TT surgery 562,240,000 4.2.2 Orientation of volunteers and DCA s in case identification and treatment 4.2.3 Training of general clinicians in trachoma case detection and referral 26

4.2.4 Development of IEC materials and conduct sensitisation of communities 4.2.5 Procure consumables and kits for TT surgery 4.2.6 Conduct mobile clinics for TT surgeries 4.2.7 Monitoring of quality of TTsurgery 4.3 Increasing access to eye care services through static and outreach facilities 4.4 Increase awareness of eye health issues to policy makers, development partners, private sectors and other stakeholders to increase support for the subsector 4.5 Increase community awareness on common eye conditions and the need to take up health services 4.2.7 Implement a national trachoma control plan and strategy which introduces use of oral azithromycin for treatment of active trachoma i.e.2 new countries every year. 4.2.8 To achieve at least 85%-90% annual mass distribution of Zithromax antibiotics in the surveyed districts 4.3.1 To strengthen services for the Paediatric ophthalmology centres at LSFEH in Blantyre by end of 2016 4.3.2 To establish National Pediatric guidelines for referring children to Blantyre by end of 2011 and start implementing them by 2012 4.3.3 To incorporate school screening of children into the National School Health programme protocol by 2013 4.3.4 To establish vision centre in the districts for provision of affordable spectacles at all eye departments by 2016 4.3.5 To strengthen referrals and coordination for Low Vision services at established centres by 2012 16,000,000 80,000,000 16,000,000 20,000,000 16,000,000 4.4.1 Conduct stakeholder meetings/forums 2,500,000 4.4.2 Conduct national World Sight events 10,000,000 4.4.3 Participation in national health forums (eg Health Sector reviews) 2,500,000 4.1.1 Design IEC materials for eye health 3,000,000 4.1.2 Develop and distribute IEC materials 10,000,000 4.1.3 Conducting of community sensitization 72,000,000 TOTAL 1,164,990,000 27

Building Block 5: Quality of care, supervision of systems enables effective delivery of the EHP OBJECTIVES TARGETS / RESULTS ACTIVITIES BUDGET MK 5. Development of Medical Eye care in Malawi is informed by research based evidence, and continuous Monitoring and Evaluation of implemented 5.1 Eye care services are integrated into DIPs and NTD Programme at District level by 2013 5.1.1 Sensitazation and awareness building of DHMT through monitoring visits and follow up by NPBC 4,884,000 activities. 5.2 NPBC s capacity to 5.2.1 Awareness building campaigns in newspapers, TV and radios 2,400,000 coordinate and advocate for eye care services and 5.2.2 Inspection visits to eye care facilities 1,200,000 supervision systems at all levels is increased by 2013 5.2.3 Participation at International meetings related to Eye care 3,000,000 5.3 Standardized monitoring and supervision checklists are developed and used by NPBC by 2012 systems development 5.3.1 To develop and use standardized monitoring and supervision checklists 0 Building Block 6: Research, Monitoring, Evaluation and Evidence-Based approaches facilitate delivery of the EHP TOTAL 11,484,000 OBJECTIVES TARGETS / RESULTS ACTIVITIES BUDGET MK 6. Development of Medical Eye care in Malawi is informed by research based evidence, and continuous 6.1 Through health system analysis eye patient care i improved in Malawi by 2015 6.1.1 In country health system research to improve eye patient care 2,000,000 Monitoring and Evaluation of 6.2 Evidence based knowledge 6.2.1 Mapping of prevalence of trachoma in a total of 12 implemented activities. on Trachoma prevalence in districts in Malawi 30,000,000 12 districts is available by 2016 6.3 Evidence based knowledge on Cataract outcomes is available by 2013 6.4 Evidence based knowledge on Glaucoma in Malawi is available by 2013 6.3.1 Conduct research on outcomes of cataract operations in Malawi 6.4.1 Study Glaucoma as a VISION 2020 priority disease in Malawi 8,000,000 3,200,000 28

6.5 Evidence based knowledge on Conjunctiva tumour is available by 2013 6.6 Prevalence of avoidable blinding diseases in south west zone of Malawi is available by 2012 6.5.1 Map up incidence and prevalence of conjunctiva tumours in Malawi 6.6.1 Rapid assessment (RAAB) of avoidable blindness in S-W zone 1,600,000 3,200,000 6.7 National inventory established by 2013 6.8 HMIS form starts reporting more detailed eye data by 2013 6.9 Implementation of the NECP is constantly monitored and lessons learnt are applied 6.7.1 Monitoring of list of hospital eye equipment from physical asset management (inventory) 6.8.1 Review the HMIS form and add more eye indicators for reporting at National Level 0 3,000,000 6.9.1 Annual review meeting of the implementing plan. 2,000,000 6.9.2 Mid term evaluation in 2013 carried out 1,500,000 6.9.3 Final implementation review by 2016 and development of NECP 2017-2020. 4,000,000 TOTAL 57,800,000 Building Block 7: Stewardship, Policy, National and Central Institutions, and Systems development and effective management enable the delivery of quality care OBJECTIVES TARGETS / RESULTS ACTIVITIES BUDGET MK Medical Eye care interventions in Malawi are guided by Government policy, and Systems are developed for effective management and supervision of interventions carried out by the stakeholders in a coordinated approach NPBC to meet twice Organize NPBC meetings twice yearly 600,000 7.1.2 Policy Guidelines 7.1.2.1 Develop and Distribute Policy Guidelines 5,000,000 established and distributed by 2016 7.1.3 National Eye Care Plan 2011-2016 adopted by all stakeholders by 2016 7.1.3.1 Distribute, raise awareness and facilitate adoption of National Eye Care Plan 2011-2016 to all stakeholders 9,000,000 29