CASE STUDY South West Province Eye Care Programme,

Joseph Enyegue Oye the Ministry of Public Health (MoPH) health centre which will, in turn, refer to the Ophthalmologist, Coordinator national and provincial level, SSI, churches, nearest eye unit. However, there is no of the South West Eye Care professionals and the community were paediatric ophthalmology centre in Project, Cameroon. represented. Cameroon at present. Children needing Situation analysis WHO projections, demographic and surgery are referred to tertiary hospitals MoPH primary health care (PHC) data were where services are out of reach for the The South West Province of Cameroon is used for needs assessment and planning. A majority of families. one of two English speaking provinces, mapping exercise was conducted to ensure much of which is situated in the equatorial comprehensive geographical coverage of the Research rainforest. Most of the estimated 1.2 million entire province. During the mapping exercise, A survey was conducted in the rural area of inhabitants live in rural areas. The main it became known that the Baptist Church the province in 20041. A similar survey is occupation is agriculture for subsistence had advanced plans to establish an eye unit planned for the urban area to complete the and employment in agro-industrial estates. in Mutengene, about 10km (15 minutes picture of the prevalence and causes of drive) away frm the Limbe eye unit. Figure 1. The Provinces blindness and visual impairment, and of of Cameroon A five-year VISION 2020 plan (2001– cataract surgical services in the province. 2006) was developed and is being implemented by the Government with SSI Human resource development support, based on a Memorandum of The programme has trained two ophthal- Far North Understanding between the two parties. mologists for and AFRICA respectively. The project coordinator works as an ophthalmologist at the Limbe eye Cameroon What is in the plan? Disease control unit and has been joined by another Cataract, refractive errors and childhood ophthalmologist posted by the North blindness are the main priorities for government. The Baptist Church Health Km disease control, alongside onchocerciasis, Centre in Mutengene recruited an ophthal- 0 100 200 which is addressed through the Community mologist to run their centre. In total, there Adamawa Directed Treatment with Ivermectin are five ophthalmologists in the province, North Programme (CDTI). Trachoma is not one of whom also acts as project coordi- West endemic in the area. nator. Five ophthalmologists for this population size, a luxury by African South West The two functioning government eye units West and the Baptist Eye Unit all perform cataract standards, was facilitated by the Centre surgery. The eye unit in Kumba will perform appointment of an ophthalmologist by the Littoral Baptist Church Health Centre in East cataract surgery when fully operational by late 2005. However, the Cataract Surgical Mutengene, and the government’s Rate (CSR) remains very low. In 2004 only decision to transfer another ophthalmol- South about 261 cataract operations were ogist to the provincial hospital in Limbe. performed by the Baptist and Limbe Eye A full time optometrist was contracted by Unit, giving a CSR of 218. A study conducted the Provincial Delegation of Health to 1 develop the refractive services. A contract Human resources for eye care in a rural area of the province found a refractionist, trained at a Train-The-Trainers Before the South West Provincial Eye Care Cataract Surgical Coverage (CSC) of 15.5% Course run by the International Centre for Programme (SWPECP) started in July 2001, for eyes and 21.7% for persons. The same Eye Care Education (ICEE) in South Africa, there was no resident ophthalmologist or study found that 33.3% of people did not assists him. A two-month refractionist specialist eye care worker in government have their cataract operated because they training course was started in the hospitals. The eye unit in the provincial lacked awareness and 30.8% because of programme in April 2005 to meet the need hospital in Limbe, which had obsolete cost. In order to increase the CSR, we plan for refraction personnel in all eye units. equipment, was visited weekly by a part- to train Community Directed Distributors of Eleven people have been trained as time optometrist and subsequently a Ivermectin (CDDs) in case-finding and ophthalmic nurses and are working in the part-time ophthalmologist. Surgical eye referral, intensify Information Education and government eye units. They were trained in care services were delivered by itinerant eye Communication (IEC) and reduce transport West Africa as there is no in-country training care teams based in Mission Hospitals costs to patients from remote areas. for specialised eye workers. Four additional (Mbingo Baptist Hospital and Acha Tugi Refractive error services are delivered ophthalmic nurses, each paired with a Presbyterian Hospital) in the neighbouring through refraction at base hospital and on outreach. School screening is a routine refractionist, will be trained and posted in North Province. The teams referred all the activity. In 2005, two optical workshops will the most remote health districts. The surgical cases to their base hospitals over be set up in Mamfe and Limbe eye units, posting of ophthalmic nurses and refrac- 300 km away (about seven hours drive). No and a third one later in Kumba. There was tionists in remote government district national or provincial survey on blindness little information and expertise on optical hospitals was not in the initial plan but it had been conducted. There was no national services at the time the plan was drawn up was realised that some remote areas would prevention of blindness plan or coordinator. so the optical services component was not not feel the impact of the project unless originally included. A new proposal for there were eye nurses posted closer to the Planning stage optical services (annexed to the original) population there. Funds for this were In November 2000 a meeting was organised was developed. identified from the existing plan’s budget, to draw up a VISION 2020 compliant CDDs have been trained to detect blind thanks to budget flexibility. Over 150 provincial eye care plan. Stakeholders from children and refer them to the nearest integrated eye workers (general doctors,

92 COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 54 | JUNE 2005 general nurses, a paediatrician, midwives At the planning stage, the VISION 2020 which meets twice a year, includes repre- and health managers) have been trained in standard list of equipment had not been sentatives of all stakeholders in eye care, eye care by ophthalmologists and developed. There was a list of minimum rehabilitation and education in the province. ophthalmic nurses. necessary equipment proposed by the West It is the forum for planning and coordination African College of Surgeons. This list was of all provincial eye services. There is a Infrastructure adapted to the programme’s needs. VISION 2020 task force that is a smaller The Cameroon health structure divides the Each of the eye units (except ) has sub-set of the committee in charge of country into health provinces (e.g. South a full range of equipment, instruments, technical issues. The task force meets four West Province) which are sub-divided into consumables and drugs to deliver times a year. The project coordinator is the health districts (e.g. Kumba, Mamfe). Each secondary eye care services. They have one executive secretary of both the committee health district has a district hospital. The slit lamp each, one operating microscope, a and the task force. province has a provincial hospital that is the dedicated theatre, at least three cataract referral hospital for district hospitals. In the surgical sets each, and diagnosis and South West Province, a second provincial Challenges, constraints refraction instruments. None of the eye hospital was created recently in Buea. The units has a working visual field analyser and lessons learnt eye units in the provincial hospital Limbe, (other than the Bjerrum’s Screen), or The low CSR in the province is the main the Baptist Church Health Centre in biometry equipment. Limbe, Mamfe and challenge. The programme is working to Mutengene, the district hospital in Mamfe Kumba will have vehicles for outreach by the bridge the gap between the cataract and the district hospital in Kumba (to start end of the year. There are teaching services provided by health facilities and later in the year) provide secondary level eye materials (teaching aids, slides and cataract patients in the community. Key care services. Tertiary eye services (retinal manuals) in Limbe, Mamfe and Kumba. detachment surgery, diabetic retinopathy learning points from our experience are Sight Savers International provided laser photocoagulation, paediatric surgery, summarised in the box below. equipment and initial stocks of drugs and etc) are not provided by any of the eye units consumables. SSI also supported infra- in the South West Province. The eye unit in structure development (refurbishment of Key learning points from the the provincial hospital Annex Buea (newly existing building in MoH facilities to created) will also provide secondary level eye district level VISION 2020 transform them into eye units), training of care, but not major ocular surgery (cataract, experience in Cameroon all cadres of staff and running of the eye etc.) because it is staffed with an eye nurse care project office. Additionally, SSI only. All eye units are in existing health facil- • Early mapping and early involvement supports monitoring/supervision and ities providing general health care. Apart of all the stakeholders avoids dupli- coordination meetings. The MoH from the Mutengene Eye Unit, which is cation of effort. VISION 2020 contributes to infrastructure, personnel a Baptist Church institution, all committees are a good avenue for salaries, furniture and utility costs. other eye units are within coordination of all eye care activities. government health facilities. The project is integrated in the MoH structure at all levels. • Optical services should be part of all VISION 2020 plans from the outset. Figure 2. Eye units in Community approach Needs for optical services constitute a Cameroon’s South There is a Community Directed substantial part of the eye care needs West Province Treatment with Ivermectin programme of the population. Furthermore, (May 2005) in the South West Province, with which optical services generate funds that the eye care programme is integrated at health district level. In 2003, can be used to sustain eye care Mamfe 434 Community Directed services in general. Eyumojock Distributors of Ivermectin LEGEND • It takes more than human resources, DH Mamfe and other community infrastructure and technology to make members were trained to Health Districts an impact on the eye health of a measure visual acuity. Over population. Potential barriers to 1,800 CDDs were trained in the Fontem service uptake and strategies to Main Roads first quarter of 2005 to identify overcome them deserve equal consid- and refer cases of blindness in Nguti eration at the planning stage. Eye Care Unit their community. Teachers have been trained to screen over 18,000 • It is feasible to train general health school children. These practitioners and community community-based eye workers members to deliver eye health sensitise and mobilise the services. More people could be effec- Konye population. During World Sight Day tively reached in a limited period of celebrations, radio interviews, DH Kumba time and with little additional input. Ekondo Titi quizzes, round table discussions, and phone-in programmes inform and Kumba mobilise the community. Health education messages are also sent to churches and References KEY mosques to be delivered during religious 1. Enyegue Oye J. Prevalence and causes of blindness DH = and visual impairment in , a rural health district District Hospital Muyuka services. The message contents vary from of the South West Province, Cameroon. MSc CEH Dissertation, London School of Hygiene and Tropical HC = year to year. Last year, the focus was on PHA Buea cataract and eye diseases in the elderly. Medicine, 2004. Health Centre Buea PH = Limbe Baptist HC Acknowledgements Provincial Hospital PH Limbe Mutengene Planning and coordinating Sight Savers International and their country represent- PHA = mechanisms ative in Cameroon, Dr Rosa Befidi-Mengue, have been Provincial Hospital Annex The VISION 2020 committee became instrumental to the programme development. The government, through the Ministry of Public Health, took Km functional in 2004, after most programme the necessary actions to implement a VISION 2020 plan 0 10 20 30 40 elements were in place. The committee, at provincial level.

COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 54 | JUNE 2005 93