MS Case 19
MS Case 19
MS Case 19
chieving major public health impact requires that interventions reach a large share of those who need them and are effective and affordable. In many of the cases in this volume, the greatest challenge was to ensure access to a simple and cost-effective preventive technology or treatment that could be delivered or administered by basic health
workers. In the case of treating millions of cataract sufferers in India, the task was to both reach those in need and to ensure that the surgical treatment offered was of adequate quality to solve the problem, without needless complications. This represents a vast challenge, given major limitations in both the reach and the quality of health care delivery in India, but one that the govern-
ment, working with key partners and deploying low-cost technologies, has been able to accomplish to a remarkable degree. The cataract program in India, in its several phases, demonstrates some of the key features of scaling up: introducing better and affordable technologies when they become available, building demand for a service that was previously unavailable, and getting to low unit costs by serving large numbers of patients efficiently. Initially, the goal of a broad coverage of services to treat blindness and severe vision loss was achieved by public education to convince people that treatment was possible, and by the use of eye camps to bring screening and treatment services to remote and impoverished areas that had not previously been well served by either government or private providers. Services then needed to be reoriented and upgraded, focusing on quality as well as quantity. Achieving good outcomes from treatment required the systematic introduction of improved techniques, training and retraining, attention to monitoring, and partnership between government and a broad range of funding and service-provision organizations to achieve high-volume, low-cost surgery. Through those actions, more than 300,000 people have been saved from a lifetime of blindness each year.
hazards, infection, and poor nutrition. Because of environmental risks and limited access to care, women from low-income households are particularly affected by several blinding eye diseases, including trachoma and cataract. The household and social costs of blindness are high. About 3.1 percent of deaths worldwide are directly or indirectly due to cataract, glaucoma, trachoma, and onchocerciasis.3 Annual worldwide productivity loss associated with blindness is estimated at $168 billion (using 1993 data).4,a In India, the economic burden of blindness was estimated in 1997 to be about $4.4 billion annually.5
age incidence of cataract. Few extended families are untouched by the problem. In India in the early 1990s, it was estimated that more than 80 percent of blind people, or more than 10 million individuals, suffered from bilateral cataract, and another 10 million individuals had cataract in one eye. In India, the problem affects a broad swath of the population. Cataract hits people earlier in life than in most other parts of the world. Almost half (45 percent) of cataract cases in India occur before 60 years of age, and women appear to be particularly hard-hit, in part because exposure to smoke from indoor cooking represents a significant risk factor.7 Because of the relatively early onset, those affected with cataracts face many years of severe vision loss and/or blindness. In short, addressing the widespread problem of blindness in India requires dealing with cataractand dealing with cataract requires surgical intervention. Successful treatment of cataract can then have benefits over many years for individuals and their families.
Treatment for Cataract
ECCE, the lens is removed but the lens capsule is left partially intact; an intraocular lens is then implanted. In general, ECCE requires a very small incision, and the complication rate is quite low. In some cases, the correction is so good that patients do not require glasses or other corrective lenses. Although ECCE requires somewhat more skill by practitioners than ICCE, the outcomes confirm that the extra effort is worth it. The difference in efficacy between ICCE and ECCE is dramatic: In a study of outcomes after cataract surgery in India, covering about 3,600 operated eyes, researchers found that patients who had ECCE surgery had a 2.8 times higher chance of obtaining a good outcome after surgery, compared to those who had undergone an ICCE procedure. Among those who had obtained ECCE surgery, some 71 percent had a good outcome (vision >= 6/18 in the operated eye).8
Surgical treatment for cataract has been around since the mid-1700s, becoming more widely available, safer, and more effective through a series of major advances in technique. Age-related cataractsby far the most commoncan be treated well with a two-step surgery: all or part of the lens is removed, and then eyesight is corrected with eyeglasses or an intraocular corrective lens. Two approaches have been developed to remove the lens: With intracapsular cataract extraction, known as ICCE, the lens and surrounding lens capsule are removed in one piece. A plastic lens (an intraocular lens implant) is then placed, and remains permanently in the eye. This surgery requires a large incision and places significant pressure on a part of the eye known as the vitreous body. Because of these features, it has a relatively high rate of complications. ICCE also almost always requires patients to wear strong spectacles to correct for remaining refractive distortions. Traditionally, ICCE has been the procedure used in low-income environments because it is a relatively simple and quick surgery. The alternative, more technically sophisticated approach is called extracapsular cataract extraction, or ECCE. In
ment. In addition to the camps, the program included establishing regional institutions of ophthalmology, development of mobile eye units, recruitment of ophthalmologic professionals, and an increase in various eye care services. Help came from outside. In 1978, the National Program accepted assistance from DANIDA, the Danish International Development Assistance organization. This support primarily focused on nationwide expansion of infrastructure (equipment and mobile units) and for training of paramedical ophthalmic assistants. Funds were later added for central monitoring and evaluation. As the program expanded, the volume of surgeries in the camps was indeed impressive. The number of individuals screened in a day might be upwards of 600 in a camp, and the number of surgeries undertaken in a typical camp was 100 or more per day. Patients spent a very brief time recovering from surgery, and then were sent home with relatives. Once the screening and treatment were completed in a particular area, the team would pack up and move to the next, leaving few opportunities for postsurgical follow-up. Although the programs quantitative achievements were remarkable in those early years, the impact on health was disappointing; outcomes were relatively poor. According to at least one study of 24 villages, less than half of those operated had good visual outcomes.9 The reasons for this underperformance were many: First, the ICCE surgery itself had a significant failure rate, even under the best circumstances. And the camps were in no way the best circumstances. Surgeons were serving a rural population that did not always understand instructions for postsurgical care at home; it was difficult (and often impossible) to maintain a sterile field during the operation; and local doctors were either not present or not able to provide follow-up monitoring and care. And, while the program was increasingly successful at stimulating a demand for surgeries, it was unable to keep up with that demand. A backlog of people asking for treatment led to long lines and increased pressure to work quickly and move on. In part in response to the shortcomings of the public sector program, the private sectorand particularly nongovernmental organizationssought to fill the void.
4 TreaTing CaTaraCTs in india
Among those NGOs, the Aravind Eye Hospital, founded by a charismatic and committed leader, demonstrated a remarkable ability to reach poor communities with a range of quality eye care, including surgical treatment of cataract (see Box 191). In 1992, Aravind fostered a major innovation: the local manufacture of the previously imported intraocular lens, making surgery far more affordable. With this breakthrough in 1992, the path to large-scale use of superior surgical methods became possible.
Box 191
Beyond the mechanics of the business model was the leadership of dr. Venkataswamya surprising combination of marketing savvy and spirituality. if Coca-Cola can sell billions of sodas and Mcdonalds can sell billions of burgers, dr. Venkataswamy asked, why cant aravind sell millions of sight-restoring operations, and, eventually, the belief in human perfection? With sight, people could be freed from hunger, fear, and poverty. You could perfect the body, then perfect the mind and the soul, and raise peoples level of thinking and acting.10 With this approach, he attracted both financial and technical support from many organizations outside of india, from Lions Club to the World Health Organization to the seva Foundation, and inspired a generation of health professionals in south asia and beyond.
public sector collaboration by assigning geographic areas to NGOs and government hospitals to avoid duplication of effort and to help improve performance. Aravind was the leading partner, and ultimately provided a large share of the total services. Third, the program undertook specific actions to increase the coverage of eye care delivery among the underprivileged population groups including women and those in tribal areas and in geographically inaccessible and remote terrain. These actions included identification of patients blind in both eyes, who were given preferential access to services, and preparation of village registries of blind residents.
The program included significant resources for the provision of information to the general population about the potential to cure cataracts through a relatively simple surgical procedure. Individuals affected by cataract and their families were informed through both public and NGO outreach that services were available and that full recovery of sight was possible. This aspect of the program built directly on the Aravind experiences, which had demonstrated that even very poor patients in rural areas valued effective treatment for cataracts. As researchers and clinicians from Aravind had found, The magnitude of intraocular lens (IOL) acceptance among these patients has surpassed even our expectations and projections. Since this change seems to occur from within the community, there is every reason to expect the demand to increase in an exponential fashion. This clearly indicates that the rural patient is prepared to meet the cost of an IOL provided the visual results are convincing.12
Tracking the Data
A simple management information system was devised for use at the state, district, and central levels. Data from the cataract surgery records provided detailed information for every person operated on for cataract, as well as financial status for all districts. Funds were released based on information from this system. At a district level, the system could be used for evaluating the monthly performance of the District Blindness Control Society, the ophthalmic surgeon, and the civil surgeon (or chief medical officer) against a fixed target. The data provided a good leading indicator of trends and needs. Tracking studies developed by the Indian Institute of Health Management Research and by the National Program for Control of Blindness were carefully designed to build a benchmark against which to measure progress with established survey elements for statistical analysis. A combination of measures attempted to capture both the number of individuals treated and the outcomes of the surgeries.
Strengthening Institutional Capacity
Training of eye care professionals was an imperative of CBCP. A 16-week train-the-trainer program was delivered through medical colleges across India, ultimately training 100 faculty in ophthalmic hospitals. This was followed by two months of instruction for eye surgeons on the latest surgical techniques, such as intraocular lens and sutureless surgeries. More than 800 eye surgeons received this training. Education programs also included health workers and teachers, covering issues such as types of eye disease, treatments, and advantages and disadvantages of available surgical methods.
Based on the experiences of previous blindness control programs, the Cataract Blindness Control Project committed to the decentralization of eye care services
in the seven participating states. Toward that end, district blindness control societies were established, each headed by a district program manager. Each district was assigned eye surgeons and paramedical ophthalmic assistants to diagnose patients, conduct surgeries, and perform follow-up care.
Expanding the Role of International NGOs
Major Achievements
Although the achievements of the program were not subject to a rigorous impact evaluation, there is little doubt that much was accomplished: many more people obtained surgical treatment; that treatment was, on average, much more effective than earlier methods; and the move from performing surgeries in the camps to fixed facilities greatly reduced the postsurgical risks. In short, better outcomes for more people. At the most basic level, the program was successful in increasing access to services, improving the quality of care provided, and the health outcomes achieved. A rapid assessment conducted in 20012002 found that the program had expanded accessa cumulative total of 15.35 million cataract operations were performed within the seven years of the World Bank-funded program and during that period 69 percent of those requiring cataract surgery received it. By the end of the program, which included a major communications effort, some 90 percent of the population the area included in the program was aware of the availability of a treatment for cataract blindness. The appropriate surgeries are now being done: According to the rapid assessment, the number of surgeries using the recommended IOL technique increased from 3 percent before 1994 to about 42 percent (cumulative) between 19992002. Although exceptions do exist, today eye surgeons have moved their operating theaters to safe and more sterile locations, away from the mobile camps. By 2001, only about 8 percent of conventional surgeries were taking place in camps. The remainder are done in fixed facilities, where better outcomes can be expected; 17 percent of those are in government facilities; 37 percent in NGOs; and about 38 percent in private facilities.13 The camps have continued to play a crucial role as the locus for screening and follow-up care, as well as the provision of public information. Surgical outcomes have improved with the introduction of improved procedures, well-equipped surgical facilities, and trained personnel: Postoperative visual
In addition to the many Indian NGOs participating in the CBCP, significant organizational, professional, and financial contributions have been made by the following international NGOs: Sight Savers International, based in the United Kingdom, is active in more than 50 countries worldwide. India is one of its oldest programs. Sight Savers supported (and continues to support) NGOs and eye hospitals throughout India. It funds training courses, such as the intraocular lens training course in the Aravind Eye Hospital and programs for rehabilitation of incurably blind persons. Christoffel Blinden Mission (CBM), based in Germany, is the largest NGO working on blindness control and rehabilitation in 105 countries in Asia, Africa, Latin America, and Europe. The CBM total budget for 1994 was over US$100 million. Eventually, CBM has come to support 127 eye care projects in India; these are mainly Christian NGO eye hospitals in rural and underserved areas. Lions International SightFirst program activities have been implemented through local Lions Clubs all over India. SightFirst funds cataract surgeries performed by local NGOs. They have constructed eye hospitals and funded a training institute for community ophthalmologyLions Aravind Institute for Community Ophthalmology at the Aravind Eye Hospital in Madurai. DANIDA supported the NPCB starting in 1978 and the CBCP through 1996, with emphasis on equipment and training including the development of local education programs such as school vision screening programs.
acuity to an acceptable level (> 3/60) following surgery improved from 75 percent before 1994 to 82 percent between 19992002. Based on an estimated 3.5 million cataract surgeries each year in India (2000 figure), about 320,000 people were saved from blindness annually. Overall population prevalence of cataract blindness declined by 26 percent, from 1.5 percent at baseline to 1.1 percent, during the program period.13
cataract blindness in the country would have required 9 million high-quality cataract surgeries annually between 20012005, and would require another 14 million between 20162020, given population growth and demographic change. This requires twice the current number of surgeries. Second, because the program funded by the World Bank was focused entirely on reducing the prevalence of cataract blindness, no provisions were made to treat individuals who came to the screening camps with other types of eye problems. Thus, there has been a steadyand ever more obviousneglect of other causes of blindness.
Remaining Challenges
Despite the achievements of the program in the participating states, major challenges remain. First, the states that did not participate in the program have much catching up to do. It is estimated that eliminating
8 TreaTing CaTaraCTs in india
force behind the VISION 2020: The Right to Sight initiative of the WHO and the International Agency for the Prevention of Blindness. This international initiative is a multinational effort to generate and share accurate data on distribution and determinants of vision loss; the development and introduction of cost-effective ways to prevent and treat eye problems; and partnerships among governments, communities, and NGOs. With the advances in control of onchocerciasis and trachoma, prevention of xerophthalmia due to vitamin A deficiency, and treatment of cataract, the successes of those who work on eye care are among the most impressive in global health.
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Bachani D, Gupta SK, Murthy GVS, Jose R. Visual outcomes after cataract surgery cataract surgical coverage in India. Int Ophthalmol. 1999; 23(1):49 56. Anand R, Gupta A, Ram J, Singh U, Kumar R. Visual outcome following cataract surgery in rural Punjab. Indian J of Ophthalmol. 2000; 48(2):153 158.
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10. Rubin H. The perfect vision of Dr. V. Fast Company. 2001;43:146. Available at: http://www.fastcompany. com/online/43/drv.html. Accessed January 12, 2007. 11. Sommer A. Toward affordable, sustainable eye care. Int Ophthalmol. 1994;18:287292. 12. Venkatesh PN, Raheem R. Changing trends in the intraocular lens acceptance in rural Tamil Nadu. Indian J of Opthalmol. 1995; 43(4):177179. 13. World Bank. Cataract Blindness Control Project Implementation Completion Report. Washington, DC: World Bank; 2002. 14. Javitt J, Venkataswamy G, Sommer A. The economic and social aspect of restoring sight. In: Henkind P, ed. ACTA: 24th Int Congress of Ophthalmol. New York, NY: JP Lippincott; 1983:13081312. 15. Baltussen R, Sylla M, Mariotti SP. Cataract surgery: a global and regional cost-effectiveness analysis. Bull WHO. 2004;82(5):338344. 16. Debas HT, Gosselin R, McCord C, Thind A. Surgery. In: Jamison DT, Breman JG, Measham AR, et al, eds. Disease Control Priorities in Developing Countries. 2nd ed. New York, NY: Oxford University Press; 2006:12451260.
References
1. World Health Organization. Global Initiative for the Prevention of Avoidable Blindness. Geneva, Switzerland: World Health Organization; 1997. WHO/ PBL/97.61. Frick K, Foster A. The magnitude and cost of global blindness: A problem that can be alleviated. Am J of Ophthalmol. 2003; 135(4):471-476. Murray CJL, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet. 1997;349:14361442. Smith AF, Smith JG. The economic burden of global blindness: a price too high! Brit J Ophthalmol. 1996;80:276277. Shamanna BR, Dandona L, Rao GN. Economic burden of blindness in India. Indian J Ophthalmol. 1998;46:169172. Foster A. Cataracta global perspective: output, outcome and outlay. Eye. 1999;13:6570. Pokhrel AK, Smith KR, Khalakdina A, Deuja A, Bates MN. Case-control study of indoor cooking smoke exposure and cataract in Nepal and India. Int J Epidemiol. 2005;34(3):702708.
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