Refractive Error EDITORIAL Uncorrected Refractive Error: the Major and Most Easily Avoidable Cause of Vision Loss

Community Eye Health

JournalVOLUME 20 | ISSUE 63 | SEPTEMBER 2007 Refractive error EDITORIAL Uncorrected refractive error: the major and most easily avoidable cause of vision loss

Brien A Holden Executive Chair, International Centre for Eyecare Education; Chair, WHO

Refractive Error Working Group; Ravilla Dhivya Scientia Professor, University of New South Wales, Sydney NSW 2052, Australia.

In the late 1990s, two papers from very different parts of the world, Australia and India, highlighted the fact that uncorrected refractive error was a significant cause of blindness and the major cause of impaired vision.1,2 Since then, the World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB), both separately and in their joint initiative, VISION 2020: The Right to Sight, A patient have worked very hard to put uncorrected undergoes refractive error on the blindness prevention refraction. agenda and to develop strategies for the INDIA elimination of this most simple avoidable cause of vision loss. They have been joined in these efforts by international non- governmental development organisations with expertise or programmes in this field, such as the International Centre for Eyecare Education (ICEE), Sightsavers International (SSI), Christian Blind Mission (CBM), Helen Keller International (HKI), and the World Council of Optometry (WCO). WHO revealed the magnitude of the Editorial continues over page ➤

In This Issue EDITORIAL 45 Making refractive error services HOW TO ... 37 Uncorrected refractive error: the major and sustainable: the International Eye 52 Test distance vision using a Snellen chart most easily avoidable cause of vision loss Foundation model Sue Stevens Brien A Holden Raheem Rahmathullah, John Barrows, 52 EXCHANGE and Victoria M Sheffield ARTICLES • Community perceptions on refractive errors in Pakistan 40 Presbyopia: prevalence, impact, and 47 Sourcing acceptable spectacles • Experiences with optical centres in West Africa Reshma Dabideen, Hasan Minto, and interventions • A public-private partnership to provide spectacles for Ilesh Patel and Sheila K West Kovin Naidoo Timor-Leste 42 Delivering refractive error services: 48 Training to meet the need for 55 USEFUL RESOURCES primary eye care centres and outreach refractive error services Kovin Naidoo and Dhivya Ravilla Hannah Faal and M Babar Qureshi 55 NEWS AND NOTICES

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Journal problem on World Sight Day, October 12, 2006, low vision). Supporting VISION 2020: The Right to Sight when it released its findings about the With regards to the new figures for uncorrected prevalence of uncorrected refractive error: refractive error released by WHO, it has been The journal is produced in 153 million people are either blind or estimated that, of the 153 million affected collaboration with the World Health Organization visually impaired due to uncorrected by uncorrected distance refractive error: distance refractive error. • 8 million are blind Commenting on the importance of uncor- Volume 20 | Issue 63 | September 2007 • 145 million have significant distance rected refractive error, the WHO Assistant Editor visual impairment. Elmien Wolvaardt Ellison Director General, Dr Catherine Le Gales- Camus, said: “These results reveal the In addition to the 153 million people with Editorial Committee Dr Nick Astbury enormity of the problem. vision loss due to distance Professor Allen Foster This common form of refractive error, there are Dr Clare Gilbert visual impairment can no ‘Refractive error hundreds of millions who Dr Murray McGavin longer be ignored as a have severe near vision Dr Ian Murdoch can no longer be Dr GVS Murthy target for urgent action.” impairment (near vision Dr Daksha Patel She also stressed the link ignored as a target equivalent to <6/18 in Dr Richard Wormald between uncorrected the better eye) due to Dr David Yorston refractive error and for urgent action’ uncorrected presbyopia. Regional Consultants poverty: “Without appro- Though no definitive Dr Grace Fobi (Cameroon) Professor Gordon Johnson (UK) priate optical correction, data are yet available Dr Susan Lewallen (Tanzania) millions of children are losing educational from WHO on global uncorrected Dr Wanjiku Mathenge (Kenya) opportunities and adults are excluded from presbyopia, estimates can be made of the Dr Joseph Enyegue Oye (Francophone Africa) productive working lives, with severe range and magnitude of the problem. For Dr Babar Qureshi (Pakistan) Dr Yuliya Semenova (Kazakhstan) economic and social consequences. example, papers published on uncorrected Dr BR Shamanna (India) Individuals and families are frequently presbyopia in Africa4 and Professor Hugh Taylor (Australia) pushed into a cycle of deepening poverty Asia5 show that in some countries up to Dr Andrea Zin (Brazil) because of their inability to see well.”3 94 per cent of people with presbyopia have Advisors Adding the number of people who are no vision correction at all. Those who Dr Liz Barnett (Teaching and Learning) blind and visually impaired due to uncor- cannot access an eye examination and Catherine Cross (Infrastructure and Technology) Dr Pak Sang Lee (Ophthalmic Equipment) rected refractive error to those blind and receive spectacles may therefore number Sue Stevens (Ophthalmic Nursing and Teaching visually impaired due to eye disease has well over 500 million people.6 For the Resources) virtually doubled the figures for the global moment, ICEE is using a conservative Administration burden of blindness and visual impairment planning figure of 150 million people with Anita Shah (Editorial/Administrative Assistant) (Table 1). significant near visual impairment due to Editorial Office The categorisation of Community Eye Health Journal overall blindness and International Centre for Eye Health London School of Hygiene and Tropical Medicine, visual impairment related Keppel Street, London, WC1E 7HT, UK. to eye disease into Tel: +44 (0)207 612 7964/72 treatable and permanent Fax: +44 (0)207 958 8317 vision loss is an important Email: [email protected] issue, but one for which Information Service definitive analyses and Jenni Sandford Email: [email protected] data are not yet available. Printing In the interim, however, Newman Thomson for planning purposes, it Online Edition (www.jceh.co.uk) is important to try to Sally Parsley estimate what might be Email: [email protected] the situation in each The Community Eye Health Journal is published four category. As outlined in times a year and sent free to developing Table 1, the estimates country applicants. French, Chinese, Spanish, are as follows: and Indian editions are also available. Please send details of your name, occupation, and postal address • 7 million people are to the Community Eye Health Journal, at the address above. Subscription rates for applicants totally blind, with no elsewhere: one year UK £50; three years UK £100. light perception Send credit card details or an international cheque/ • 30 million are blind, banker’s order made payable to London School of with vision ranging from Hygiene and Tropical Medicine to the address above. light perception to Website <3/60 in the better Back issues are available at eye; half of these cases www.jceh.co.uk may be treatable (e.g. Content can be downloaded in both HTML and PDF formats. cataract) © International Centre for Eye Health, London Articles may be photocopied, reproduced or translated provided these are • 124 million are visually not used for commercial or personal profit. Acknowledgements should be made to the author(s) and to Community Eye Health Journal. Graphics on impaired (vision <6/18 pages 40, 42 and 47 by Teresa Dodgson, all others by Victoria Francis. in the better eye) from Outreach clinic in ISSN 0953-6833 The journal is produced in collaboration with the World Health eye disease; approxi- Tongaat held the Organization. Signed articles are the responsibility of the named authors alone and do not necessarily reflect the policies of the World Health mately half of these day after the World Organization. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall cases may be Congress on not be liable for any damages incurred as a result of its use. The mention of specific companies or of certain manufacturers’ products does not imply treatable, while the rest Refractive Error. that they are endorsed or recommended by the World Health Organization suffer from permanent in preference to others of a similar nature that are not mentioned. SOUTH AFRICA visual impairment (i.e. Jeeva Rajgopaul, courtesy of ICEE

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CEHJ63_REVISE.indd 38 26/9/07 14:51:47 Table 1. Estimated number of blind and visually impaired people (including presbyopia) Number of people (millions) Permanent Correctable Total vision loss vision loss Vision loss due to eye disease Blind No light perception 7 - 7 Blind Vision from <3/60 to light perception in the better eye 15 15 30 Visually impaired Vision from <6/18 to 3/60 in the better eye 62 62 124

Subtotal 84 77 161b

Vision loss due to distance refractive error Blind Vision from <3/60 to light perception in the better eye - 8 8 Visually impaired Vision <6/18 to 3/60 in the better eye - 145 145

Subtotal - 153 153a

Vision loss due to near refractive error Visually impaired Near vision equivalent to <6/18 in the better eye - >150 >150b

Subtotal >150 >150b

Total 84 >380 >464b a WHO figures b Those with presbyopia who cannot get access to spectacles may number over 500 million people

Uncorrected refractive error causes serious • make refractive services a priority throughout the world into donating a visual problems for children trying to learn • support the development and deployment substantial part of the total cost of ‘giving and adults trying to work. The urgency of this of appropriate human resources, infra- sight’. This initiative has been successfully problem and its unacceptability in today’s structure, and technology for the effective launched in five countries thus far. world was partly the stimulus for the first delivery of refractive services within the The commitments needed to achieve World Congress on Refractive Error (WCRE) public sector the ultimate objective of VISION 2020: hosted by the ICEE in Durban, South Africa, • rationalise the tariffs, duties, and taxes The Right to Sight for those with uncorrected in March 2007. The congress attracted 650 imposed on spectacles, equipment for refractive error, as outlined in the Durban people from national and international refraction, and optical laboratory Declaration, include: quantifying vision loss government agencies, professional councils, equipment due to uncorrected presbyopia; undertaking and international non-governmental develop- • support and facilitate organisations the necessary advocacy, knowledge base ment organisations, who spent four days working towards the elimination of development, and research needed to discussing every aspect of the problem of avoidable blindness.” deliver best practice service in line with uncorrected refractive error, as well as cultural needs; coordination and cooperation The world must make every effort to meet potential solutions. to develop a supply of affordable spectacles the goals of VISION 2020 and eliminate The congress resulted in the Durban and the necessary human resources and uncorrected refractive error within the next Declaration,7 which was negotiated and infrastructure. 13 years. A tall order? Not really. ICEE has unanimously endorsed by the 650 delegates. If the world cannot eliminate blindness estimated (based on its own data from These included representatives of the World and visual impairment by delivering Africa, Timor-Leste, and Sri Lanka, as well Council of Optometry (WCO), The International spectacles to those in significant need, the as on data from the LV Prasad Eye Institute Council of Ophthalmology, IAPB, hosts ICEE, world is in a sorry state. For that reason in India) that it will cost US $1,500 million representatives of civil society, and regional alone, we must cooperate, mobilise our to give 300 million people access to an eye and national government ministries and resources, and make sure it happens – examination by a trained local eye care department representatives. The Director preferably before 2020. person and a pair of spectacles. General of the Department of Health for US $1,500 million for 300 million South Africa, the honourable Mr Thami References people to see by 2020 is a small price to Mseleku, said that he was proud that South 1 Dandona L et al. Burden of moderate visual impairment pay for eliminating the direct loss of oppor- in an urban population in southern India. Ophthalmol Africa was chosen as the site for the tunity and productivity due to uncorrected 1999;106: 487–504. inaugural WCRE and observed that the 2 Taylor HR et al. Visual impairment in Australia: distance refractive error. Better yet, it will also congress was “making the world realise that visual acuity, near vision, and visual field findings of the eliminate the indirect costs of having Melbourne Visual Impairment Project. Am J Ophthalmol this is a very important commitment to sighted children with uncorrected refractive 1997;123: 328–337. VISION 2020. The resolution shouldn’t just 3 WHO press release. Sight test and glasses could errors in programmes for the blind, of remain on paper – we should talk about how dramatically improve the lives of 150 million people uncorrected myopic children failing at with poor vision. Geneva. October 11, 2006. to take it forward.” 4 Patel I et al. Impact of presbyopia on quality of life in a school unnecessarily, and of the older And that, of course, is the key: it has rural African setting. Ophthalmol 2006;113(5): 728– needlessly blind and visually impaired 734. become essential to plan and fund the depending on society and the community. 5 Bourne RR et al. The Pakistan national blindness and solution to uncorrected refractive error. visual impairment survey: research design, eye exami- In total, a saving of many tens of billions In the words of the Durban Declaration7: nation methodology and results of the pilot study. of dollars. Ophthalmic Epidemiol 2005;12(5): 321–33. “We call upon governments, professional Optometry Giving Sight, a joint initiative 6 Holden B et al. Vision impairment due to uncorrected presbyopia (in preparation). bodies, manufacturers, suppliers, interna- of IAPB, WCO, and ICEE, is galvanising 7 The Durban Declaration: www.icee.org/pdf/Final_ tional organisations, and civil society to: optometry professionals and their patients FINAL_Declaration.pdf

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CEHJ63_REVISE.indd 39 26/9/07 14:51:48 PRESBYOPIA Presbyopia: prevalence, impact, and interventions

Ilesh Patel Sheila K West Research Fellow El-Maghraby Professor of Preventive Ophthalmology

Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, 600 N Wolfe St, Baltimore, MD, USA.

Presbyopia is an age-related loss of lens The degree of presbyopia was determined as accommodation that results in an inability to the minimum amount of plus lens needed to focus at near distances. It is the most achieve the maximum improvement in lines common physiological change occurring in read to the end point (N8). the adult eye and is thought to cause universal Using this definition, the prevalence of near vision impairment with advancing age. presbyopia in this population was found to People who become presbyopic may be 62 per cent, with prevalence increasing complain of headaches and eye strain, and with age.1 Age-adjusted data showed higher hold objects progressively further away from prevalence among women than men. In their eyes in order to be able to focus on multivariate analysis, women had 46 per them. However, while objects may then be cent higher odds (odds ratio of 1.46) of in focus, they may become too small to be being presbyopic. Women also had more identified. The length of the arm also limits severe presbyopia than men across all this compensatory mechanism. The most age groups. Secondary education and common remedy is the prescription of a pair residence in town (as opposed to a village) of reading spectacles. were also significantly associated with a It is now increasingly recognised that higher prevalence of presbyopia. Only six per presbyopia is an aspect of refractive error cent of the people with presbyopia in our are associated with earlier onset of that needs to be addressed. Good near vision study had the spectacles they needed. presbyopia.11,12,13 is important, even among populations who A survey of ocular morbidity in rural In summary, the studies to date of use it for tasks other than reading and writing. Ugandan adults found presbyopia to be the presbyopia in low- and middle-income most common cause of visual impairment in countries suggest the following: Prevalence that country for which treatment was sought. Patients with uncorrected • more than half of adults over the age of 30 The prevalence of presbyopia in low- and presbyopia accounted for 48 per cent of have presbyopia middle-income countries is not well known, as those presenting with visual impairment.2 • women have both a higher prevalence of, most studies of refractive error in these Morny, using hospital chart reviews, and more severe, presbyopia countries have been limited to distance vision. found a prevalence of presbyopia equal to • the majority of those with presbyopia do There are few presbyopia studies that have 65 per cent in Ghanaian women.3 not have corrective spectacles. used a population-based approach, making it In southern India, Nirmalan et al. used difficult to draw conclusions about the preva- the same definition for presbyopia. They Impact lence of presbyopia in the general population. found a prevalence of 55 per cent in people Presbyopia affects quality of life. This seems Another major problem with research in aged 30 years and older.4 As in our study, straightforward in high-income countries, this area is that there is no universally prevalence of presbyopia worsened with where reading and writing are the main near accepted definition of presbyopia and no increasing age. Female sex, rural residence vision tasks undertaken. For example, standardised technique to measure it. The (as opposed to urban), myopia, and McDonnell et al. showed that presbyopia prevalence of presbyopia will therefore hyperopia were associated with presbyopia. was associated with substantial negative depend on how it is defined, for example, A third of subjects with presbyopia were effects on health-related quality of life in a the end point chosen and the distance at currently using spectacles. US population.14 which near vision is tested. Duarte et al. in Brazil estimated the However, it is a misconception to think Some studies, however, including our own prevalence of presbyopia in 3,000 adults of that presbyopia has no impact on quality of study in rural Tanzania, can be used to construct 30 years and older at 55 per cent.5 Once life in populations where reading and a picture of the prevalence of presbyopia in again, age and female sex were associated writing are less a part of daily life, for low- and middle-income countries. with higher prevalence. In those who had example in the rural populations of low- For our study (of people aged 40 and near vision spectacles, 30 per cent had and middle-income countries. over), we used the N8 optotype (1M or corrections that were ineffective. A total of Our study in Tanzania showed that in rural 20/50 Snellen acuity) as the end point of 58 per cent of the sample reported requiring communities, where near vision tasks other near vision testing. This was selected as it near vision for their routine daily tasks. than reading and writing are predominant, matched the type size for newsprint in the Studies of hospital patients conducted uncorrected presbyopia had a substantial country. We measured near vision by in Africa showed a younger onset of impact on quality of life.15 We found that placing the near chart 40 cm away from presbyopia and more severe prebyopia than near vision was needed for winnowing grain, the subject. studies conducted in Europe and North sorting rice, weeding, sewing, cooking food, We defined people as presbyopic if both America.6,7,8,9 Pointer, in his clinic-based dressing children, and lighting and adjusting of the following were true: study, observed that presbyopia affected lamps. Almost 80 per cent of people with • they were unable to read the N8 optotype women earlier than men.10 In addition, presbyopia reported having problems with with distance correction in place, if needed several studies have correlated geographical near vision and 71 per cent were dissatisfied • they were able to read at least one more variations in the age at onset of presbyopia with their ability to do near work. line with the addition of a plus lens. with latitude and climate; hotter climates Good near vision is needed in many work-

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CEHJ63_REVISE.indd 40 26/9/07 14:51:51 Ilesh Patel Ilesh presbyopia require modest expertise and can be undertaken independently of fixed optical services. The ScoJo Foundation, which works in Africa, Latin America and Asia, has demonstrated a sustainable model to distribute high-quality, low-cost reading spectacles in rural areas. This organisation trains women to start their own small business to prescribe and dispense presbyopic spectacles at low prices. Such an approach can be an independent but integrated part of a comprehensive eye health solution, as it may be the first point of contact for those with other eye problems and could identify those in need of further eye care services (see box on page 44).

The future Further research should be conducted to determine why women and persons who live in urban environments have more presbyopia. As low- and middle-income Near vision countries undergo the demographic testing in a rural transition towards an ageing population, the community. number of people with presbyopia will TANZANIA increase. The impact on quality of life for older persons is now clear and presbyopia should be part of the WHO refractive error agenda. Clearly, presbyopia poses an important public health challenge, because related tasks. For example, research in India improvements in overall quality of life. An it affects older people’s ability to maintain showed that presbyopic factory workers were appreciation of the usefulness of having their economic independence. We need to less productive than their co-workers adequate near vision made subjects willing start working towards effective solutions. (personal communication with Praveen K to pay for spectacles and obtain replace- Nirmalan, LV Prasad Eye Institute, ments if the need arose. A high proportion References Hyderabad, India). After correction, their of people (69 per cent) were able to afford 1 Burke AG, Patel I, Munoz B, Kayongoya A, McHiwa W, Schwarzwalder AW, West SK. Prevalence of presbyopia productivity improved significantly, which spectacles at a price that covered the cost in rural Tanzania: a population-based study. made the investment in corrective spectacles and shipping of the spectacles. Men were Ophthalmology 2006;113: 723–7. very beneficial. Also, as more transactions more likely to be able to afford spectacles, 2 Kamali A, Whitworth JA, Ruberantwari A, Mulwanyi F, Acakara M, Dolin P, et al. Causes and prevalence of are done in writing, adults with poor reading whereas a higher proportion of women non-vision impairing ocular conditions among a rural vision will be at an economic disadvantage. needed to rely on another person to help adult population in SW Uganda. Ophthalmic Epidemiol Finally, uncorrected presbyopia can them afford spectacles. 1999;6: 41–8. 3 Morny FK. Correlation between presbyopia, age and hamper development. The World Health The majority of people in our study did not number of births of mothers in the Kumasi area of Organization (WHO) has placed increasing know where to get spectacles. Among those Ghana. Ophthalmic Physiol Opt 1995;15: 463–6. who knew where to go, ten per cent were 4 Nirmalan PK, Krishnaiah S, Shamanna BR, Rao GN, emphasis on adult literacy to improve Thomas R. A population-based assessment of attainment of development goals, but misinformed about where they were available presbyopia in the state of Andhra Pradesh, south India: people require good near vision to be able to and a third could not afford to travel to a the Andhra Pradesh Eye Disease Study. Invest location where spectacles could be obtained. Ophthalmol Vis Sci 2006;47: 2324–8. benefit from programmes to improve literacy. 5 Duarte WR, Barros AJ, Dias-da-Costa JS, Cattan JM. In general, lack of knowledge about refractive Prevalence of near vision deficiency and related factors: services, poor accessibility, and additional a population-based study. Cad Saude Publica Interventions costs (such as transport) raise further 2003;19: 551–9. While new treatments are being developed 6 Covell LL. Presbyopia. Am J Ophth 1950;33: 1275–6. challenges for intervention programmes. 7 Hofstetter HW. Further data on presbyopia in different for presbyopia, spectacles represent an Our experience in Tanzania also ethnic groups. Am J Optom Arch Am Acad Optom effective, economic option for low- and suggested that many subjects were not 1968;45: 522–7. middle-income countries. However, there is 8 Adefule AO and Valli NA. Presbyopia in Nigerians. East aware that correction could return adequate Afr Med J 1983;60: 766–72. little research on the determinants of, and near vision to them. Because presbyopia is 9 Kaimbo K, Maertens K, Missotten L. Study of barriers to, the use of near-vision a gradual process, others had forgotten the presbyopia in Zaire. Bull Soc Belge Ophthalmol spectacles. We are still awaiting data on the 1987;225: 149–56. value of having good near vision. Refractive 10 Pointer JS. The presbyopic add, II. Age-related trend availability and affordability of near-vision error correction programmes need to and a gender difference. Ophthalmic Physiol Opt refractive error services, including a system recognise this, and community awareness 1995;15: 241–8. 11 Weale RA. Epidemiology of refractive errors and for efficient dispensing of high-quality, of presbyopia needs to be promoted. presbyopia. Surv Ophthalmol 2003;48: 515–543. affordable spectacles. Our data suggest that it is very difficult to 12 Miranda MN. The geographic factor in the onset of In our study in Tanzania, 92 per cent of obtain reading spectacles for persons in presbyopia. Trans Am Ophthalmol Soc 1979;77: 603–621. 15 13 Rambo VC. Further notes on the varying ages at which people with presbyopia reported using the rural villages and small towns in Tanzania. different people develop presbyopia. Am J Ophthalmol near-vision spectacles we gave them. In southern India, Nirmalan et al. showed 1953;36: 709–710. Almost half of the people we studied were that a major proportion of people with 14 McDonnell PJ, Lee P, Spritzear K, Lindblad AS, Hays RD. Associations of presbyopia with vision-targeted health- using them a few times a week. This gave us presbyopia who had spectacles (93 per cent) related quality of life. Arch Ophthalmol 2003;121: an indication of the usefulness of adequate had obtained their spectacle prescriptions 1577–81. near vision in rural Tanzania, where many from ophthalmologists, who work primarily 15 Patel I, Munoz B, Burke AG, Kayongoya A, McHiwa W, 4 Schwarzwalder AW, West SK. Impact of presbyopia on subjects did not routinely read or write. in large cities. quality of life in a rural African setting. Ophthalmology Better near vision resulted in reported In general, assessment and correction of 2006;113: 728–34.

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CEHJ63_REVISE.indd 41 26/9/07 14:51:52 DELIVERY Delivering refractive error services: primary eye care centres and outreach

Kovin Naidoo Dhivya Ravilla Global Programme Director, International Center for Manager, Optical Section, Aravind Eye Hospital, 1, Eye Care Education (ICEE), 272 Umbilo Road Durban, Anna Nagar, Madurai 625 020, Tamil Nadu, India. South Africa. Email: [email protected] Email: [email protected]

Addressing refractive errors, the second major cause of preventable blindness, is now a Choosing a priority for eye care programmes. frame. INDIA Although a simple pair of spectacles will correct refractive error, there exists a high prevalence of uncorrected refractive error. This is due in large part to the cost and inaccessibility of refraction and spectacle dispensing services, which are usually offered only at secondary and tertiary eye care centres. The optometrists and ophthalmologists who provide these services are often kept very busy providing a range of other eye care services as well. This means that the number of refractions they have time for falls short of community needs. The distance to these secondary and tertiary eye care centres also hinders access. In addition, people who have been refracted and who have received a spectacle prescription need to have access to an affordable spectacle dispensing service. Since most spectacle retailers are concentrated in Ravillaa Dhivya bigger towns, accessibility is a major challenge for communities ‘People who have been refracted also need access to in rural areas. affordable spectacle dispensing services’ To solve the problem of uncorrected refractive error in low- and middle-income countries, it is contact, including the primary level, as is • refraction by a refractionist or optometrist therefore important to provide compre- done in India’s vision centres (primary using a simple Snellen chart and trial hensive services – both refraction and eye care centres). set to determine the best possible dispensing of spectacles – at the primary 2 Integrate refractive error services into correction and to issue a spectacle level of eye care, where they will be most outreach services, thereby bringing prescription accessible to the community. primary level eye care closer to • spectacle dispensing, which includes The delivery of comprehensive refractive communities. offering a range of frames from which error services at the primary level requires patients can choose. the following: Primary eye care Estimating demand • a trained person to refract and provide An important first step when planning a counselling about refractive error as part centres (vision centres) primary eye care centre is to estimate the of a general eye examination and service Dispensing spectacles in addition to potential demand for spectacles. • equipment for vision testing, refraction, providing refraction may improve the The prevalence of refractive error varies and spectacle dispensing sustainability of a refractive error service between age groups. Where reliable data • spectacles which are acceptable and and increase uptake by patients. The are available on the age distribution of the affordable to the patient. primary eye care centre or vision centre population at country and sub-country is a model that combines both these levels, the rate of refractive error in different There are two strategic options for improving components of refractive error services at age groups can be estimated (preferably access to comprehensive refractive error a single service point, close to where from studies done in that area, or from services at the primary level: communities live. personal experience) and the total demand 1 Integrate refractive error services at all Primary eye care centres serve popula- can be calculated, as shown in Table 1 levels of eye care delivery and patient tions of 50,000 and offer the following: (using data for India).

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CEHJ63_REVISE.indd 42 26/9/07 14:51:56 Table 1. Estimating demand for refractive error services for a population of 50,000 in India, using available data Aravind’s vision Age group Percentage Number of Percentage Number of of total people in with people with centres population each age refractive refractive Aravind Eye Hospital in South India has group error in each error in each developed an innovative approach to age group age group addressing all aspects of eye care in remote and rural areas. It has set up a Pre-school (0–5) 12% 6,000 Unknown Unknown network of special vision centres to serve (but low) (but low) rural areas around each of its secondary School (6–20) 34% 17,000 5% 850 and tertiary eye hospitals. Each Aravind vision centre covers a Adult (21–45) 37% 18,500 10% 1,850 population of about 40,000 to 50,000. The centres are equipped for refraction Adult >45 17% 8,500 90% 7,650 and the dispensing of spectacles. For (presbyopic age)* comprehensive diagnostics, they have a Total 100% 50,000 n/a 10,350 slit lamp fitted with a digital camera, * Many may also require correction for distance a glucometer, and a computer with webcam and internet connectivity (this In most situations, one can expect about 20 per cent of the population in total to require enables real-time interaction with refraction services. A primary eye care centre serving a population of 50,000 therefore has ophthalmologists at the base hospital). a big enough potential market to make it economically viable. The centres are run by well-trained ophthalmic assistants, who perform slit Marketing lamp examinations and refraction, treat Given the very low coverage and penetration of existing primary eye care services, a primary minor ailments, provide counselling, and eye care centre should not only cater for those who visit it, but it should also proactively seek so on. They are also trained to dispense out those who need correction. medicines and spectacles. Patients who Marketing strategies should be specific to each age group, as suggested in Table 2. require further investigation or advanced interventions are referred to Table 2. Marketing strategies for a population in India the base hospital. Age group Marketing strategy Field workers identify people with eye problems and refer them to the centre. Pre-school (0–5) General awareness about squint, amblyopia They conduct school screening camps Networking with paediatricians for early referral and awareness campaigns, and take School (6–20) School eye examinations care of the many marketing activities required. Field workers also provide Adult (21–45) Eye examinations in the workplace community-based rehabilitation for the Refraction services in comprehensive eye camps incurably blind. Adult >45 General awareness about the advantages of near vision correction At the vision centre, patients are (presbyopic age) Refraction services in comprehensive eye camps charged a nominal fee for the examination and pay for spectacles and Preliminary vision tests are conducted by trained field workers or teachers (in the case of medicines. Income from the sale of schools and colleges) to identify those with vision worse than 6/9 (or 6/12 for school spectacles is helping the centres to children). These people are then referred to the primary eye care centre for further investi- move towards financial sustainability. gation. When a large number of prescriptions are expected at a school, college or workplace, the complete range of refractive services, right up to dispensing of spectacles, Table 4. Statistics from five Aravind can be provided on the spot. vision centres during the year 2006 Outpatients 6,717 Table 3. Basic equipment required at the primary eye care centre for refraction services Total income US $23,402 Refraction equipment Spectacle dispensing equipment Number of spectacle 2,334 Snellen chart Marking pencil/pen prescriptions Near vision chart Lens chipper, cutter Number of spectacles 2,191 (94% of Trial lens set Lens edger ordered and dispensed total prescribed) Trial frame Screwdrivers Average sales price of US $6.70 Streak retinoscope (recommended) Frame warmer a pair of spectacles Jackson cross cylinder (recommended) Adjustment pliers Income from US $14,654 (63% Essential inventory items are: spectacles of total income) Frames. There should be a variety of frames available to reflect personal and local prefer- ences. As most people are willing to spend more on an attractive pair of spectacles, this can provide the required income to sustain the services of the vision centre. Smaller frames need to be available for children. Lenses. Only commonly required dioptre powers should be stocked – other lenses must be ordered. With proper inventory planning, on-the-spot dispensing of about 85 per cent of Lens orders can be achieved. However, this will require an inventory that is roughly ten times the edging. expected number of orders. The proportion of on-the-spot dispensing therefore depends on INDIA the inventory size that can be achieved.

Other accessories. Spectacle cases, cleaning materials. Ravilla Dhivya Continues over page ➤

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CEHJ63_REVISE.indd 43 26/9/07 14:51:58 DELIVERY Continued

does not make any profit. However, to programme, its pricing policy, and the type ensure that services are sustainable, ICEE of spectacles offered in different areas, as calculates what it costs them to provide the well as protocols to maintain standards of service and then charges patients accord- care. Convince other service providers to Jeeva Rajgopaul Jeeva ingly. Patient numbers are kept high by the adopt a similar approach. advocacy efforts of local clinics and Comprehensiveness. Refractive services department of health in the community; this makes services economically viable. should be linked to a comprehensive package of eye and health services, either Exit strategy. The ICEE exit strategy entails by direct delivery of services or through an handing over refractive services to local appropriate screening and referral network. health care providers. ICEE trains local personnel (ophthalmic nurses) in refraction It is important to fully exploit the potential services and advocates for optometrists to of refraction services in order to achieve the be employed. No optometrists were goals of VISION 2020: to bring sight to the millions of people who are blind or visually employed in the public sector when the ICEE Community members are screened for impaired due to refractive error. The income program started; currently there are 13 in refractive error in Tongaat, KwaZulu-Natal. generated by providing refractive error services employment. Out of 11 health districts SOUTH AFRICA to more people will in turn provide the required visited initially, ICEE is now serving only four. economy of scale for these services to This reflects the belief that outreach clinics Outreach clinics become sustainable – a win-win situation. Outreach refractive services can only be a are a short-term strategy: they help to show short-term strategy to meet needs. However, that there is a need for services, which then an outreach strategy can play a big role in prompts government and other providers to Refraction as a supporting permanent vision centres or health develop permanent services. centres, as well as enhancing the reputation Spectacles. Ready-made spectacles case-finding of the provider and reducing costs for patients (which have the same prescription in each by meeting their needs there and then. lens) are dispensed immediately. Custom- mechanism in The International Centre for Eye Care made spectacles are produced and sent to Education (ICEE) has been conducting the clinic where the patient was seen. With outreach outreach clinics in KwaZulu-Natal, a basic equipment and a small inventory of programmes province of South Africa. ICEE sent teams lenses and frames, some spectacles for to outlying and rural areas by road and by simple refractive errors can even be fitted Refractive error services provide an air, the latter in partnership with Red Cross and delivered there and then. opportunity to identify patients with other Air Mercy Services and the South African conditions, such as glaucoma, cataract, Case finding. Screening in schools and in Department of Health. and diabetic retinopathy, although they communities is critical to boost patient ICEE is acutely aware of the many are not often used in this way. numbers and to ensure that clinicians’ time problems that exist with outreach clinics and A service dispensing spectacles is in is used optimally. With funding from USAID, refractive error services in general, and it fact more likely to attract patients than a ICEE has trained 50 ‘vision screeners’ who structures its outreach clinics so as to surgical programme, as fear of surgery visit schools on a daily basis. The provincial minimise any possible negative impact. may prevent some patients from department of health has agreed to employ The problems include the following: attending. these screeners once the funding runs out; Developing refractive error as a • free spectacles create expectations and this will strengthen human resources screening strategy therefore becomes patients wait for the return of the free capacity in the long term. service, which in most cases never occurs an attractive option. Rather than • programmes run by non-governmental Volunteers. If necessary, volunteers should including the correction of refractive organisations (NGOs), independent of be incorporated into existing outreach error as just one of the services in an government services, negatively affect the programmes and function within that ethos. outreach programme, it may be more public sector. Patients wait for the NGOs to Changing the strategy when volunteers are useful to consider refractive error as the come back, instead of accessing the available and then reversing this later is not anchor of an outreach programme; it (possibly limited) services available in the best interests of the programme. has the potential to attract all patients • improperly matched recycled spectacles Outreach for advocacy. ICEE programmes with visual impairment. Patients often result in visual complications and target areas where there are no services needing eye care can then be identified poor cosmetic appearance (these should and the potential for a future eye clinic is from among those who need refractive only be used as a last resort). high. To do this, ICEE links up with the error services. government outreach clinics and adds This strategy is particularly relevant, Key components of the ICEE outreach refractive services to the package of existing given the fact that patients with strategy services. This demonstrates the value of presbyopia are usually at high risk of Relationship building. In order to ensure refractive services. age-related eye diseases as well. that there is cooperation and support (buy-in) However, it demands a coordinated and from the department of health, ICEE clinics Conclusion integrated approach to outreach clinics, are held in rural primary eye care centres or Outreach programmes have the potential to rather than having separate programmes rural hospitals. The service is advertised with serve as an advocacy tool and to meet short- which result in unnecessary duplication the help of local health centres. term needs in underserved areas. In order to of efforts. ensure the maximum is gained from these Equipment. Includes a trial case, trial In order to function as a screening programmes, there should be: frame, occluder, ophthalmoscope, retino- tool for other eye conditions, refractive scope, E chart, pupillary distance (PD) rule Caring. Ensure that outreach does not error programmes must ensure that they and tape measure. An autorefractor is imply lower standards of care; adopt clear include comprehensive eye examinations. carried by the Red Cross Air Mercy Services. management protocols. If they don’t, they will squander the opportunity to identify other eye Sustainability. In order to make these Consistency. Develop appropriate conditions that require intervention. services as affordable as possible, ICEE guidelines regarding the structure of the

44 Community Eye Health Journal | Vol 20 ISSUE 63 | SEPTEMBER 2007

CEHJ63_REVISE.indd 44 26/9/07 14:52:00 SUSTAINABILITY Making refractive error services sustainable: the International Eye Foundation model

Raheem Rahmathullah John Barrows Victoria M Sheffield Sustainability Specialist Director of Programmes President and CEO Email: [email protected]

International Eye Foundation, 10801 Connecticut Avenue, Kensington, MD 20708, USA.

The International Eye Foundation (IEF) lishes professional optical businesses that patients, including the poorest). believes that the most effective strategy for can be accessed by anyone, regardless of It is also essential that everyone involved making spectacles affordable and acces- socioeconomic background. Net profits agree beforehand about the control and sible is to integrate refractive error services then go toward improving quality, expanding management of the business and, into ophthalmic services and to run the services, and subsidising in particular, the refractive error service as a business – ophthalmic care in the eye unit. ‘The customer management of thereby making it sustainable. An optical This combined approach increases human and financial service should be able to deal with high the number of patients accessing must be satisfied resources. volumes of patients and generate enough ophthalmic as well as optometric It is important to revenue – not just to cover its own costs, services and earns revenue to with the service, determine before- but also to contribute to ophthalmic clinical support both types of services. hand the capacity of services. This article discusses some the product, and the optical service IEF assists public and private eye important aspects of the IEF the result’ (the number of hospitals in low- and middle-income model. people it can serve) countries to build sustainable refractive and its market (the error services, both by helping them estimated number of people who need or reorganise their management processes, Planning want optical services). It is also important to and by improving their infrastructure When designing an optical service, it is establish relationships with relevant stake- through sub-grants and technical important to clearly formulate its purpose holders, for example, with local businesses assistance. With this model, the IEF estab- (for example, to offer services to all Continues over page ➤

The optical sales showroom at Penya Optical. MALAWI

Penya Optical, Malawi

Penya Optical was established within the government eye unit in Blantyre, Malawi, one of the world’s ten poorest countries. IEF’s initial investment was US $42,000; Penya Optical broke even after seven months. Now in its third year, Penya Optical’s assets are US $65,800 and it has US $47,766 cash in the bank. The estimated return on investment is 156%. Penya Optical contributes 15% of its gross monthly sales to the Blantyre Eye Unit’s sustainability fund. Victoria M Sheffield M Victoria

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Financial considerations It is important to establish clear policies governing the use of revenues. In general, IEF recommends that 70 per cent of Victoria M Sheffield M Victoria revenue be reinvested into the spectacle inventory, with revenue equal to three to four months’ operational costs retained in the bank. It is also important to agree on a strategy to manage the devaluation of funds, especially where customs and taxes are high. IEF’s hospital partners include the refraction fee as a fixed amount in the general outpatient fee. Patients requiring additional services such as spectacles are charged separately for frames and lenses. Building an optical service from scratch requires between US $40,000 and US $50,000 for equipment, inventory, supplies, furniture, and staffing. This is usually provided by a grant or donor initially, and does not include the indirect costs to IEF of providing support. In IEF partner hospitals, the percentage of total hospital earnings generated by revenue from the refractive error service ranges from 12 per cent in northern India and 18–30 per cent in Central America to 98 per cent in Malawi, where most other services are provided free of charge (Figure 1). IEF believes in having an exit strategy: this involves handing over assets and The optical workshop at the Lions SightFirst optical centre at the Kimuzu Central management responsibilities to local Hospital in Lilongwe. MALAWI hospitals/charities eventually and maintaining only a monitoring and and community leaders. The resulting some in the latest designs, to satisfy advisory role. business plan should define the market patients’ individual needs and tastes. In conclusion, combining a high-quality potential, evaluate the competition, and Monitoring the quality of refraction, the optometric business with ophthalmic describe the range of products offered, the craftsmanship of spectacles, and turna- services helps to reduce rates of uncorrected procurement and inventory requirements, round time is critical. The customer must be refractive error and contributes to the pricing, and revenue projections. satisfied with the service, the product, and financial health of the entire eye care the result: improved vision. Quality counts! service. Procurement and implementation Figure 1: Relative contribution of optical and non-optical services to total revenue Before establishing an optical service, the 900,000 team must ensure that the location is Non-optical convenient, is prominently visible to the 800,000 public, is close to an optical workshop, and Optical (refractive error) allows for efficient patient flow (with space 700,000 for patients to wait, enough examination rooms, and a space where patients can try 600,000 on new frames). Optometrists skilled in objective and subjective refraction should

(US $) (US 500,000

be used, rather than automated equipment. In addition, having basic workshop equipment on-site will minimise 400,000

downtime due to maintenance and repair. Income Strong management is critical: lines of 300,000 authority and accountability should be clear. 200,000 Finally, efficient procurement practices must be adopted to ensure lower costs. The following points are important: 100,000 • order large volumes to lower costs, but 0 avoid being overstocked Malawi El Salvador India Guatemala • look for the most cost-effective source Blantyre ClaraVision Gomabai Visualiza of spectacles LSFEU/Penya Nethralaya and (two units) • stock a wide choice of frames and lenses, Optical Research Centre

46 Community Eye Health Journal | Vol 20 ISSUE 63 | SEPTEMBER 2007

CEHJ63_REVISE.indd 46 26/9/07 14:52:04 PROCUREMENT ICEH Sourcing acceptable spectacles

Reshma Dabideen purchasing trends. This knowledge Programmes Director (Africa), can then be used to make informed International Centre for Eyecare decisions. Education (ICEE), 272 Umbilo Road, In order to gain better knowledge of Durban 4001, South Africa. the market and to understand Email: [email protected] dispensing challenges, the International Centre for Eyecare Hasan Minto Refractive Error and Low Vision Advisor, Education (ICEE) analysed data from Sightsavers International, House No 2, their project with the KwaZulu-Natal Street No 10, F-7/3, Islamabad, Pakistan. Red Cross Air Mercy Service and Email: [email protected] conducted a market analysis. In this project, a total of 4,458 patients were Spectacles should be cosmetically appealing. Kovin Naidoo examined between 2005 and 2006 JAMAICA Global Programme Director, ICEE and 1,981 pairs of spectacles were Email: [email protected] dispensed. The dispensing patterns are • eliminate the duplication of effort and depicted in Figure 1. resources between NGOs The need Other factors, such as the age of the • promote the tracking of worldwide trends Spectacles are the simplest and most patient and what the target market could to inform purchasing decisions and inexpensive way to correct refractive errors. afford, were also used to determine purchasing resource allocations Sadly, the cost of a pair of spectacles is out trends. Consultations with partner organisa- • be a single contact for the procurement of of the reach of most people in low- and tions resulted in a wealth of knowledge devices and equipment from multiple middle-income countries. This is true even about current ordering volumes and prices. suppliers in countries with the capacity to manufacture • give both large and small customers and distribute spectacles. The response access to spectacles at the same low One solution is for hospitals or govern- As a result of this analysis, ICEE decided prices ments to provide spectacles free of charge to create a system that would have the • ensure quality checks or at a minimal fee. However, this can use up potential to address both African and global • promote easy ordering of products via the available funds very quickly, which means needs: the Global Resource Centre web. fewer people can be helped. (www.iceegrc.org). The Global Resource In addition, most spectacles available Centre (GRC) aims to act as a centralised commercially are expensive and access to Key lessons purchasing and shipping centre which them is limited. On the other hand, cheaper Pilot projects were conducted to test the allows like-minded organisations to pool spectacles can often be of very poor quality. GRC system. The key lessons learnt were: their buying power. The GRC is a collaborative Ensuring that spectacles are both acces- endeavour; it is supported by Sightsavers 1 It is imperative to have offices and a sible and affordable is therefore one of the International (SSI) and Christian Blind distribution network in the country from key challenges facing any programme Mission (CBM), and it is managed by ICEE. which one is sourcing. This forms a aiming to deliver refractive error services. The GRC aims to: critical part of the supply chain. Prior The non-governmental organisation to the dispatch of every order, the (NGO) sector is a major consumer of • use large volumes to drive down unit costs products supplied can be scrutinised spectacles. This offers a possible solution to • use large volumes to drive down shipping to assure quality. New trends in the problem of sourcing acceptable costs products can be adequately assessed spectacles: organisations can pool their and exploited to the benefit of the spectacle orders and buy spectacles in bulk, Figure 1. Analysis of dispensing patterns thereby lowering their costs significantly. programme. 600 2 Transportation, shipping, and other costs need to be kept to a minimum, as The challenge 514 an inexpensive product could become Purchasing affordable and acceptable 500 very costly by the time it reaches the 447 spectacles requires the following: 434 purchaser. months 3 A huge stock (inventory) is required, • knowledge of the market (knowing your 400 five

which requires sufficient funds and environment and the trends that exist therein) 325 space as well as stringent stock control. • ensuring that the product is cosmetically over 300 ICEE, CBM, and SSI are assisting with appealing 261 funding to address this issue.

• knowledge about what customers can afford sold

• an easy-to-use and accessible procurement 200

system units Conclusion

• coordination of efforts (because higher There are two key aspects to sourcing 100 volumes drive prices down) Total affordable spectacles. The first is to have a • warehousing and stock control one-stop system that addresses the issues • open communication and networking. 0 of affordability, accessibility, and accepta- Ready- Single Single Bifocal Bifocal bility. The second is to know the patterns The ICEE experience made vision vision plastic metal and trends within the target market, as this Analysing the data from various projects can plastic metal influences the financial outlay, the type of provide us with significant information on Categories of spectacles stock carried, and stock levels.

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CEHJ63_REVISE.indd 47 26/9/07 14:52:07 TRAINING Training to meet the need for refractive error services

Hannah Faal M Babar Qureshi Senior Eye Care Programme Consultant, West Senior Regional Office Advisor: West Asia, North Africa and Eastern Europe, Christian Africa, Sightsavers International, PO Box 18190, Blind Mission (CBM). CEO and Executive Director, CHEF International, 10 E1 Abadara 58 Patrice Lumumba, Airport, Accra, Ghana. Road, University Town, Peshawar, Pakistan. Email: [email protected] In many low- and middle-income countries, cosmetic appearance of spectacles, and we Step 3: Determining the there are inadequate refractive error found that it was of more importance to the services for the many people who are urban population. tasks, skills, and human currently either blind or visually impaired resources needed for because they lack a pair of spectacles. Step 2: Analysing existing refractive error services The prioritisation of refractive error and low vision services within VISION 2020: The resources and services First, we considered what tasks would Right to Sight has provided an impetus and In The Gambia, a country with a population have to be carried out, and what compe- framework for the development of refractive of just over one million, the national eye tencies and skills were needed for each of error programmes to meet this need for care programme had already achieved full these. We then identified different types of services. national coverage. In this country, therefore, eye health practitioners who would be To ensure the success of a refractive our approach to meeting refractive error needed to carry out these tasks in the error programme, there have to be enough needs was to incorporate refractive error different service delivery areas of the people with the right skills in order to provide services within the national programme, national eye care programme. This ensured refraction services throughout the programme. which could easily be done. that the refractive error service programme Therefore, careful thought should be given We found that refractive error services in would be integrated into existing services to setting up an appropriate training The Gambia were being provided by a single (Table 1). programme that will support the human private practice shop in the main capital and We identified existing staff in the national resource needs of a refractive error an optical service centre in the tertiary eye eye care programme who could receive programme. unit of the main teaching hospital. additional training and expanded their The following steps are generally The eye care resources, human and duties to include refractive error tasks. We advisable: material, of the existing national eye care also identified gaps where new practitioners programme were also analysed. and workers would be needed. • Step 1: Estimate the need for services • Step 2: Analyse existing resources and services • Step 3: Determine the tasks, skills, and

human resources needed for refractive Bah Momodou error services • Step 4: Devise a training plan. This article shows how two countries, The Gambia and Pakistan, approached the training and integration of refraction personnel in their respective eye care programmes. The Gambia Step 1: Estimating the need for services We estimated the need for refractive error and low vision services by looking at population trends in different age bands (e.g. 10–15 years or >45 years), patient volumes and patterns of diagnosis in hospitals (who is diagnosed as having what refractive error), and trends in spectacle and lens prescriptions. In the rural population of The Gambia, the people needing refractive error services are mostly literate adults (such as teachers and religious leaders), men, and school children. The urban population needing refractive error services presented a similar profile, with the addition of civil servants in the public sector and workers in the private sector. We also investigated the importance A community member tests her own vision at an outdoor ‘vision corridor’, a component attached by different populations to the of the national refractive error programme at community level. THE GAMBIA

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CEHJ63_REVISE.indd 48 26/9/07 14:52:09 Table 1. The various service delivery areas of The Gambia’s refractive error programme (within the existing national eye care programme)

Service delivery area Tasks Team Community (urban and rural) • Dissemination of information/health education on near vision, Community-based vision and eye- the benefit and use of spectacles, and where best to obtain them oriented workers, e.g. ‘friends of • Counselling on the use of spectacles and low vision aids the eye’1 (usually non-health • Making near vision spectacles available service personnel, selected by the • The use of vision corridors for self-testing of distance and near community and covering a vision and for raising awareness, particularly in urban areas population of 250) School eye health programme All the above, plus: Teachers, school nurses, (this covers all primary schools, • Vision screening using Snellen E chart and occlusion community ophthalmic nurses but the refractive error • Identification of children (11–15 years) with visual problems component is extended to • Keeping records and tracking children referred for refraction secondary schools as well) and for their annual or bi-annual follow-up visits as required General health facilities, e.g. • Self-check for distance and near vision Integrated eye workers health centres (frontline health • Proper care of own spectacles facilities) Primary health facilities, where • Training and supportive supervision of community-level workers Community ophthalmic nurse as a community ophthalmic nurse • Holding stock of near vision spectacles part of community health facility serves a population of • Tracking referrals, especially of school children, for spectacle staff 10,000–30,000 wearing and offering support for repairs or replacements • Data management of refractive error and low vision as part of comprehensive eye care Secondary eye unit • Screening for presbyopia and refractive errors in government Refractionist* within a secondary covering a population of ministries, industries, and other work places (in urban areas only) eye unit team, which is led by a 100,000–150,000 • Eye health education cataract surgeon • Basic refraction • Basic dispensing of simple and near spectacles (following strict referral criteria) • Tracking, counselling, and supporting patients needing low vision services Tertiary eye unit covering a All of the tasks assigned to the secondary eye unit, plus: Optical sub-unit of the eye care population of about 1,000,000 • Basic and complex refractions for walk-in patients and referrals team made up of: • Low vision services • Optometrist* • Optical workshop services • Refractionist/optical technician* • Investigations: visual field tests, keratometry, etc. • Receptionist or display shop • Training assistants* • Supportive supervision • Optical stores keeper* • Accounts clerk* * New staff (not part of the existing national eye care programme)

Certain new staff, such as the receptionist presbyopic spectacles, and eye health nurses, medical students, and other or display shop assistant, the optical stores education) health workers were reviewed and keeper, and the accounts clerk, could be • referral of non-refractive error visual loss improved to include refractive error and recruited from the existing human resource and eye problems, as well as complex low vision components. pool in The Gambia, while an optometrist refractive errors, to the ophthalmologist 3 In-service training: The existing eye could be recruited from another country in and the optometrist, respectively. care programme staff, service delivery the sub-region. staff, and faculty received customised However, customised training would be Step 4: Devising a training to consolidate their skills in required to meet the need for refractionists, refractive error services and training. also known as optical technicians. These training plan eye health practitioners would be based in Based on the task and skill analysis (Step 3), Training refractionists/ the secondary and tertiary units, but they a training programme was developed and optical technicians would offer specific intermittent population- implemented. The tertiary unit was made responsible for based services. the training course for refractionists/optical The refractionist/optical technician would Existing staff technicians. An optometrist was recruited perform the following tasks: The skills of existing staff in the national eye from Nigeria to join the eye team at the care programme needed to be updated. In • refraction services (including simple tertiary unit and, with the help of the eye addition, existing training programmes had subjective and retinoscopic refraction) programme senior staff, to develop the to be expanded to include refractive error • low vision services (including assessment training modules. components. and prescription of low vision aids) This new course trained refractionists/ The following steps were taken: • optical workshop services (including optical technicians to provide services glazing lenses of all kinds into frames) 1 Community-level eye care training where there are no optometrists in the • investigations (including visual field tests, was expanded to include refractive community. Their role would also include colour vision tests, and keratometry) error components. This was at most assisting the optometrist or ophthalmologist • community services (including screening 1–2 hours. where there was one. for refractive errors and presbyopia, 2 The pre-service training modules for Community eye health, primary eye care, prescription and dispensing of simple general nurses, community ophthalmic Continues over page ➤

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and optical dispensing components were coverage of population needs, as well as travel to ophthalmologists in the city for included in the module in order to equip the enable the further training of the smaller refractive error services. refractionists to provide optical and primary number of refractionists who could eye care at an affordable price. It was progress to other aspects of service Step 3: Determining the decided that the refractionists would work as delivery, such as that provided by tasks, skills, and human members of an eye care team and at the ophthalmic technologists or optometrists following service delivery points: refraction • it is essential to maintain quality assurance resources needed for clinics, low vision clinics, optical workshops, by providing full, supportive supervision to the refractive error services and secondary and tertiary units. refractionist and any allied health practitioner It was determined that refractive services had The criteria for enrolment were: • in many countries in West Africa, it may be to be integrated at the district level. Therefore, necessary to advocate and work with the • twelve years of schooling (general certif- the National Committee for the Prevention of ministry of health to establish a council for icate of education or equivalent) Blindness decided to train ophthalmic techni- allied health practitioners, as only the tradi- • passes in English, mathematics, physics cians and refractionists who could serve in the tional medical and nursing councils exist. and/or biology or equivalent. districts and have clear career pathways. Optometrists, orthoptists, and ophthalmic Practical experience in an eye unit was technologists would be trained to assist considered to be an advantage. Pakistan ophthalmologists in tertiary eye care institu- Candidates for this training programme tions and to meet the need for eye care were nominated by a supervising optometrist Step 1: Estimating the teaching, training, and research in Pakistan. or ophthalmologist and sponsored by need for services The role of refractionists, in particular, government and non-government agencies. Pakistan has a high prevalence of refractive was considered to be very important. At To accept a candidate from the private sector error: 63.5 per cent in adults, according to district or secondary level, they could carry would be an exception. (For improved the national blindness survey of 2002. out simple and complex refraction, as well as integration, absorption and career growth, In addition, four per cent of children provide support to the ophthalmologists. the programme is currently recruiting from below the age of 15 have refractive errors. They could also take part in school screening the now sizeable pool of community Given that 40 per cent of the population programmes and outreach clinics, providing ophthalmic nurses who already work in rural is younger than 15 and 34 per cent is refraction to those being screened. areas at the secondary eye units.) older than thirty, we calculated that a The duration of the course was six minimum of 230,200 people per million Step 4: Devising a months, consisting of three months of population would need refractive error intensive studying and practical experience training plan services (the figures for the age group at the base hospital and three months of The National Committee for the Prevention 15–30 are not yet known). This figure practical experience in the community. of Blindness approved job descriptions and excludes those with presbyopia. Continuous assessment was carried out tasks for ophthalmic technicians, refrac- and logbooks were used to track the skills the tionists, optometrists, orthoptists, and candidates had learnt. This was followed by a Step 2: Analysing existing ophthalmic technologists (Table 2). final written and practical exam. Certification resources and services In order to train these practitioners, it was was done by the Regional Ophthalmic There were few existing optometrists in decided to upgrade the ophthalmic Training Programme, which conducts all mid- Pakistan, and they were practising only in technician course offered at the Pakistan level eye care training in The Gambia. cities. Most of the optometrists were trained Institute of Community Ophthalmology into a Existing faculty and staff, such as optome- abroad and worked in tertiary eye care insti- four-year, multi-tiered curriculum. The trists, ophthalmologists, residents, and tutions. There were no institutions in content of the curriculum was based both on cataract surgeons, as well as existing tertiary Pakistan that ran accredited and certified the tasks the practitioners would be required unit facilities, were used to conduct training. training programmes for optometrists. Most to perform and on the needs of the The practical experience component included people in need of refraction saw opticians in community at different levels. The multi- work in secondary units, schools, community the local market place. Few of these tiered approach allowed human resources to screening, and eye camps. This practical work opticians had received any certified training be produced for each level of eye care. was mainly supervised by the optometrist. in Pakistan; they were mostly operating as At present, three additional institutions Each student received a kit and textbooks, family businesses. Other patients had to are offering this four-year programme. which would become part of the equipment at their posts on graduation and not the Students practising PICO personal property of the students. Graduates refraction on a model also received extensive post-training support of an eye. PAKISTAN for at least six months in order to help them set up services, to ensure these are of the required standard and quality, and to help the graduates integrate their work into existing services. The following lessons were learnt: • having a community-oriented optometrist with excellent training and management skills is absolutely essential for successful management of such a training programme • the training has to be competency-based and intensely practical, with continuous emphasis on quality assurance • to ensure the continued job satisfaction of the refractionists/optical technicians, it would be necessary to provide opportunities for further training. A multi-entry and multi-exit scheme would allow for the

50 Community Eye Health Journal | Vol 20 ISSUE 63 | SEPTEMBER 2007

CEHJ63_REVISE.indd 50 26/9/07 14:52:11 Table 2. Tasks and areas of work for different eye care personnel

Qualification Tasks Level Ophthalmic • Detection and referral Primary and technician • Providing vitamin A capsules and tetracycline at primary eye care level secondary eye care • Providing services for simple refraction • Using mydriatics and local anaesthetics cautiously and responsibly • Removing superficial conjunctival/corneal foreign bodies • Providing health education and counselling Refractionist All the functions of ophthalmic technicians, plus: Secondary eye care • Using cycloplegics (district level: vision • Undertaking advanced refraction centres and district • Prescribing contact lenses and contact lens solutions (depending on infrastructure available) hospitals) • Prescribing simple low vision aids (depending on infrastructure available) Optometrist All the functions of ophthalmic technicians and refractionists, plus: Tertiary eye care • Assisting ophthalmologists at tertiary level with simple and complex refractions (hospital) • Carrying out low vision assessments and prescribing low vision devices • Running a contact lens practice • Assisting in data entry and analysis using computers • Acting as faculty members (teaching others) Orthoptist All the functions of ophthalmic technicians and refractionists, plus: Tertiary eye care • Assisting ophthalmologists at tertiary level with assessment and management of advanced (hospital) visual functions • Carrying out squint assessment and optical management (the management of squint by providing optical devices, spectacles, or patches) • Assisting in data entry and analysis using computers • Acting as faculty members (teaching others) Ophthalmic All the functions of ophthalmic technicians and refractionists, plus: Tertiary eye care technologist • Assisting ophthalmologists at tertiary level with sophisticated ophthalmic diagnostic and (hospital) therapeutic procedures • Assisting in data entry and analysis using computers • Acting as faculty members (teaching others)

The four tiers of the training programme are Figure 1. Pakistan’s four-tier training programme as follows (Figure 1): Exit with Bachelor’s Degree Tier 4 Tier 1. A one-year ophthalmic technician One-year internship in Vision Sciences (in one of the three sub-specialities) course. Entry requirement: 12 years of schooling (with science subjects). After one year, students can exit with an ophthalmic Tier 3 Optometrist Ophthalmic technologists Orthoptist technician diploma. They may come back within five years to continue to the next tier. Those attaining marks of 70 per cent or Exit with refractionist Tier 2 Refractionist more overall and wishing to continue can go diploma on to the next level.

Tier 2. A one-year refractionist course. Entry Exit with opthalmic Tier 1 Opthalmic technician requirement: 12 years of schooling (with technician diploma science subjects) and successful completion of the one-year ophthalmic technician For these graduates to successfully deliver Table 3. Professional kit provided on exit course. After one year, students can exit with services, there has to be a sense of from the course for different qualifications an ophthalmic technician diploma. They may ownership; candidates must be well come back within five years to continue to Ophthalmic Ophthalmoscope, Snellen equipped to put in practice the skills they technician charts, torch, and Binomag the next tier. Those attaining marks of 70 per have learnt. Therefore, a kit is provided to cent or more overall and wishing to continue ophthalmic technicians, refractionists, and Refractionist • Refraction box can go on to the next level. optometrists on their exit (Table 3), so that • Retinoscope they can start to practise what they have • Cross cylinders Tier 3. A choice of one-year courses in one • Trial frame of the following sub-specialities: optometrist, learnt. (Orthoptists and ophthalmic technologists don’t receive a kit – their • The practise of refraction ophthalmic technologist, or orthoptist. Entry by Steward Duke-Elder requirement: 12 years of schooling (with specialised equipment is provided by the hospital where they will work.) • The ophthalmic assistant science subjects) with the successful by Harold A Stein completion of both the one-year ophthalmic There is also a refresher course every Optometrist Same kit as for refractionist, technician course and the one-year refrac- five years, which allows graduates to come plus low vision assessment tionist course. back and share their experiences, and to receive any new knowledge in the field. The and contact lens kit Tier 4. A one-year internship that would give institute continues to provide graduates Reference students training under supervision and entitle with whatever institutional support they 1 Kanyi S. Evaluation of the impact of Nyateros “Friends of them to receive a Bachelor’s Degree in Vision the eye” in the delivery of eye care services after one year may require, including sending them the of its implementation in Lower River Division, The Gambia. Sciences in one of the three sub-specialities. Community Eye Health Journal. Community Eye Health J 2005;18(56): 131.

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CEHJ63_REVISE.indd 51 26/9/07 14:52:11 HOW TO ... EXCHANGE Test distance vision using a Community perceptions of refractive errors in Snellen chart Pakistan Sue Stevens Sumrana Yasmin Nurse Advisor to the Community Eye Health Journal, International Project Officer Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Hasan Minto Indications Refractive Error and Low Vision Advisor • To provide a baseline recording of visual acuity (VA) • To aid examination and diagnosis of eye disease or refractive error Sightsavers International, House No 2, Street No • For medico-legal reasons 10, F-7/3, Islamabad, Pakistan.

Equipment Pakistan’s national survey of blindness and • Multi-letter Snellen chart visual impairment in 2002–2004 reported • E or C Snellen chart or a chart with illustrations the prevalence of blindness to be 0.9 per cent. for patients who cannot read or speak Of this total, 3 per cent can be attributed to • Plain occluder (not essential) uncorrected refractive errors. As Pakistan has • Pinhole occluder a population of 150 million, this is equivalent • Torch or flashlight A multi-letter Snellen chart (left) to just over 40,000 people. Given these • Patient’s documentation and a chart with illustrations figures, there is an urgent need to increase refraction services in a comprehensive Procedure manner. • Ensure good natural light or illumination on the chart Whereas many studies have been • Explain the procedure to the patient conducted on the scientific and program- • Wash and dry the occluder and pinhole. If no plain occluder is available, ask the patient to matic aspects of refractive error services, wash his/her hands as they will use a hand to cover one eye at a time there is insufficient data available about the • Test each eye separately – the ‘bad’ eye first consumer’s perspective and possible • Position the patient, sitting or standing, at a distance of 6 metres from the chart reasons for the low uptake of services. • Ask the patient to wear any current distance spectacles, to cover one eye with his/her We designed a study to investigate hand (or with a plain occluder), and to start reading from the top of the chart communities’ perceptions of refractive errors, • The smallest line he/she can read (the VA) will be expressed as a fraction, e.g. 6/18 or to assess sociocultural patterns, practices, 6/24 (usually written on the chart). The upper number refers to the distance the chart is and attitudes towards the use of spectacles, from the patient (6 metres) and the lower number is the distance in metres at which a and to investigate issues related to the person with no impairment should be able to see the chart affordability and availability of spectacles in • In the patient’s documentation, record the VA for each eye, stating whether it is with or rural and urban communities. without correction (spectacles), for example: Focus group discussions and participatory Right VA = 6/18 with correction Left VA = 6/24 with correction rapid appraisal techniques were used to • If the patient cannot read the largest (top) letter at 6 metres, move him/her closer, one collect information from the community. A metre at a time, until the top letter can be seen – the VA will then be recorded as 5/60 or structured questionnaire was developed and 4/60, etc. field-tested to ensure validity. A team of two • If the top letter cannot be read at 1 metre (1/60), hold up your fingers at varying distances female and three male interviewers carried of less than 1 metre and check whether the patient can count them. This is recorded as out the field research and 479 questionnaires counting fingers (CF). Record as:VA = CF were completed. Participants were members • If the patient cannot count fingers, wave your hand and check if he/she can see this. This of different communities, chosen from is recorded as hand movements (HM). Record as: VA = HM 11 clusters representing urban, semi-urban, • If the patient cannot see hand movements, shine a flashlight toward his/her eye from four and rural settings. Each cluster contained directions of a quadrant. Record this in the documentation, in the relevant quadrant, as perception of light (PL or √), or no perception of light (NPL or X). Record as: from 15–25 participants. We did not encounter any substantial refusals to partic- NPL NPL PL NPL Right VA = Left VA = ipate. The quantitative data was cleaned and NPL NPL PL NPL then analysed using the SPSS statistical package, version 11. or Out of the total sample interviewed, X X √ X Right VA = Left VA = 41 per cent were female and 59 per cent X X √ X were male. The age breakdown of the participants was as follows: 1–15 years, 41 per cent; • If 6/6 (normal vision) is not achieved, test one eye at a time with a pinhole occluder (plus 16–30 years, 27 per cent; 31–40 years, any current spectacles) and repeat the above procedure at 6 metres only. The use of the 18 per cent; and 41 and above, 14 per cent. pinhole enables assessment of central vision • If the vision improves, it indicates the visual impairment is due to a refractive error, which Many of the respondents (44 per cent) were is correctable with spectacles or a new prescription married, 32 per cent attended school, and all • Repeat the whole procedure for the second eye ethnic groups were represented. • Summarise the VA of both eyes in the documentation, for example: Many people did not understand what Right VA = 6/24 with specs, 6/6 with pinhole Left VA = NPL refractive error services were offered and did not consider themselves as having refractive If using the E or C chart: errors. Affordability was the major reason • Point to each letter on each line and ask the patient to point in the direction toward which given by people for not purchasing the the open end of the letter is facing spectacles they had been prescribed. • Follow the same procedure and recording methods as above. Cosmetic factors were important for all

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CEHJ63_REVISE.indd 52 26/9/07 14:52:14 communities surveyed. The main reason for part of the centres’ remit). discontinuation of spectacle wear in women Experiences with optical Staffing was a delicate issue, as optical was given as community pressure and centres often do not fit into existing cosmetic factors. The stigma attached to centres in West Africa government salary and employment struc- spectacle use was apparent in women, who Trent Huon tures. This is an area that requires extensive were keen to know about the other options Optometrist and Advisor to Sightsavers advocacy by NGOs and private providers to available, such as contact lenses and International, West Africa Regional Office, improve the acceptance of optical providers refractive surgery. These women reported PO Box 18190, Airport, Accra, Ghana. within the public system. Optical and low that they often had to face social pressure, vision service provision is further complicated not only in terms of appearance, but also While working for Sightsavers International in by the lack of training facilities available. because of the perception that their children 2003, I took over the management of an Our experiences in Ghana suggested that may inherit their visual impairment. optical centre in Hohoe, Ghana (established we needed a strong outline of procedures in In rural areas, 69 per cent of people in 1999), with the view to making it the optical centres. This led to the devel- thought that using spectacles would cause sustainable by improving profitability. opment of an extensive handbook that is their vision to deteriorate; they therefore tried The basic changes we made were to run used in day-to-day operations. to avoid it. However, the perception of most of the centre more like a business. The handbook outlined the records to be the respondents was positive with regards to However, after two years, the model kept, operational guidelines, storeroom the use of spectacles by children. Respondents proved to be unsustainable because of cost procedures, outreach guidelines, staff job said that it helped children to continue their issues (the expense of running outreach trips, descriptions, administrative requirements, education and improved their quality of life. too many staff members), as well as a lack of and a monitoring checklist. However, they also felt that spectacle wear community ownership, staff commitment, A generic version of this document was hindered children’s participation in sport and and patronage in the local area. developed as the basis for organising the other extracurricular activities. The lessons learnt in Ghana were subse- new optical centres. However, it was heavily The majority of respondents countrywide quently applied to the setting up of optical adapted to suit local circumstances; the reported accessing refractive error services in centres within existing Sightsavers International- organisational structure, in particular, was the private, rather than public, sector. They sponsored eye care facilities in hospitals in adapted to fit within existing eye clinic and said this was because, in the private sector, Cameroon, Nigeria, Mali, and Guinea. These hospital procedures. they could access both refraction and lessons were also put in practice when reorgan- Another lesson we learnt was to treat our spectacle dispensing services at the same ising two existing facilities in Sierra Leone. patients as customers: we are aiming for location. They were also not satisfied with the In order to avoid the problems we experi- profit and independence, and frames are as attitudes of service providers in the public enced in Ghana, such as lack of patronage in much about style as they are about function. sector. the local area, we undertook an assessment Frame styles and lens types should be The average amount paid for spectacles of the potential centres. We considered considered with the local population in mind. in poorer communities ranged from US $1.5 several factors beforehand: available space The centres have only been operating to US $4. In most instances, refraction was at the clinics, local private and public optical since the beginning of 2007, and reports are included in the price. The average amount suppliers, local population numbers, the now coming in. The biggest issues are with spent by middle-class families on spectacles proximity of the optical centre to the main record keeping (store room procedures, ranged from US $6 to US $10. Throughout population centres, patronage at the current recording payments, taking patient details) Pakistan, a range of affordable spectacle clinic, existing facilities available at the clinic, and improving the refraction and dispensing frames were available; however, there was a available staff or training institutions, hospital skills of staff. The focus now is also on gener- clear lack of high-quality, modern spectacle administration and local government ating awareness of refractive errors within frames in the smaller towns. commitment, the influence of other stake- the local communities. In summary, this study suggests that there holders, current memoranda of understanding, In my opinion, the long-term success of are currently a number of barriers to the and so on. the centres is dependent on the close effective correction of refractive errors: After this assessment, we compiled monitoring of their operations, particularly orders for equipment and materials. The proper stock keeping, financial accounta- • lack of awareness and recognition of stock for the centres included fashionable bility, and quality of service. This can indeed refractive error as a correctable cause of frames, lenses (single vision and bifocal), be accomplished if we train staff and set up visual impairment, compounded by the readers, cases, cords, and low vision appropriate systems. non-availability of affordable services Exchange continues over page ➤ • cultural factors which lead to discontinu- supplies (providing low vision services forms ation of the use of spectacles, especially in women • lack of awareness among providers that good quality, attractive, and comfortable spectacles are essential to ensure continued use of spectacles. When designing refractive error programmes, consumers’ perspectives are often ignored. However, we feel strongly that community studies should form part of the planning process.

References 1 Holden BA, Sulaiman S, Knox KBA. Challenges of providing spectacles in the developing world. Comm Eye Health J 2000;13(33): 9–10 2 Ali SM, Johnson GJ, Bourne RRA, Dineen BP, Huq DMN. Correction of refractive errors in the adult population of Participants in a Bangladesh: meeting the unmet need. Invest staff training Ophthalmol & Vis Sci 2004;45(2): 410–417 3 Situation analysis of refractive services in Pakistan. workshop. GUINEA

Unpublished data. Huon Trent

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The programme involves a three-way public- A public-private private partnership between: the ministry of A Palagyi A health; a local non-governmental organisation, partnership to provide Fo Naroman Timor-Leste; and an international spectacles for non-governmental development organisation, the Fred Hollows Foundation New Zealand. Timor-Leste Each partner brings particular expertise and makes complementary contributions: J Ramkea, C Williamsa, L Ximenesb, D Ximenesc, A Palagyia, R du Toita, and G Briana Performing a • the ministry of health is responsible for a The Fred Hollows Foundation, New Zealand, refraction. TIMOR-LESTE regulation: it brings political, regulatory, and Private Bag 56908, Dominion Road, Auckland staff support capacity (including active partici- b 1446, New Zealand; Fo Naroman Timor-Leste; pation by ministry of health eye nurses) c Timor-Leste Ministry of Health. • the local non-governmental organisation, Fo Refractive error is a leading cause of low cannot afford to pay even US $1 for them.5 Naroman Timor-Leste, has an understanding of vision in low-resource settings1,2 and its Permanent refraction services are the social setting and is able to work effectively correction is now a priority of VISION 2020. available within some government facilities – within the constraints of the country. It is respon- However, spectacles are not included on the referral hospital in Dili, the capital, and sible for the implementation of the project: most essential medicines and supplies lists, four rural eye clinics. In Dili, private optical management, service delivery, and supply and schemes to make them available do not shops provide spectacles at a price • the international non-governmental devel- generally receive government support. unaffordable to most. Various government opment organisation, the Fred Hollows Additionally, in many countries in the Pacific and private community health centres offer Foundation New Zealand, supplies ready- region, legislation and regulation prohibit the spectacles, usually donated ‘recycled’ made and custom-made spectacles to the sale of spectacles from public health facil- spectacles selected by potential users on a government eye clinics. It also undertakes its ities or by government-employed health trial and error basis, or handed out by health own refraction and spectacle dispensing workers. This is based on the belief that workers with no training in dispensing. Visiting activities. This organisation has experience in health services should be provided free of expatriate teams provide brief, intermittent systems to address refractive error, quality charge. Where spectacles are available from refraction and dispensing services (mostly control, and transparent management, so it private suppliers, these are mainly in urban ready-made spectacles) in Dili and elsewhere. provides capacity building and systems areas and are too expensive for most people. To address the identified need for development. Timor-Leste is one of the poorest countries sustainable refraction services and spectacles, in the world; 40 per cent of its people live on Timor-Leste has set up a national spectacle All partners have agreed beforehand on activities, less than US $0.55/day. There are many programme as part of its National Eye Health stock management, pricing, subsidisation, barriers to the use of health services, Strategy.6 It aims to provide equitable access collection and use of funds, data collection and especially for rural inhabitants. As in other to good quality refractive services and analysis, reporting requirements, and countries,3,4 there is a large unmet need for affordable spectacles through a financially governance. spectacles. An estimated 87,500 Timorese self-sustaining scheme that uses cross- Already, despite the civil unrest in Timor- aged ≥40 years need spectacles, but half subsidisation to help those unable to pay. Leste and just 12 months since the partnership commenced, the number of spectacles Table 1. Aims and activities of the national spectacle programme dispensed has increased by 40 per cent (from Aim of the Activities for 2006/7 2,050 pairs in 2005/6 to 2,880 in 2006/7), as partnership have the proportion dispensed in rural areas (from 36 per cent in 2005/6 to 45 per cent in Increase • Conduct outreach refraction services in rural areas 2006/7) and the number dispensed to the poor equity • Use information, education and communication (IEC), and social at subsidised prices (from 12 per cent in marketing strategies to raise awareness of gender and equity issues in eye health service utilisation 2005/6 to 38 per cent in 2006/7). The public-private partnership and its Increase • Undertake a willingness-to-pay survey to investigate the feasibility of a affordability subsidised price of US $0.10 for spectacles in rural areas excellent working relationships make the Timor- • Develop a strategy for self-selection of ready-made spectacles at Leste national spectacle programme innovative. US $0.10, US $1.00 and US $3.00 Once its cost-effectiveness and adaptability • Develop a subsidisation protocol for those unable to pay US $0.10 for have been assessed, this partnership may be spectacles suitable as a template for a sustainable Improve • Apply quality standards to ready-made and custom-made spectacles approach to the provision of a complete quality • Implement and monitor a rational system for prescribing and dispensing refraction service in other low-resource settings. spectacles References Improve • Integrate with existing ministry of health systems (e.g. distribution system) 1 Garap JN, Sheeladevi S, Shamanna B, Nirmalan PK, Brian efficiency • Network with other agencies active in health care, with the aim of G, Williams C. Blindness and vision impairment in the elderly sharing resources of Papua New Guinea. Clin Experiment Ophthalmol 2006;34: 335–41. • Facilitate support and incentives for motivated ministry of health staff to 2 Ramke J, Palagyi A, Naduvilath T, du Toit R, Brian G. dispense spectacles Prevalence and causes of blindness and low vision in Timor- Improve • Measure patient satisfaction Leste. Br J Ophthalmol 2007;91: 1117–1121 3 Bourne RR, Dineen BP, Huq DM, Ali SM, Johnson GJ. satisfaction/ • Implement improvements to services Correction of refractive error in the adult population of acceptability Bangladesh: meeting the unmet need. Invest Ophthalmol Maintain • Maintain and improve accurate financial management systems Vis Sci 2004;45: 410–7. 4 Fotouhi A, Hashemi H, Raissi B, Mohammad K. Uncorrected financial • Undertake an annual audit refractive errors and spectacle utilisation rate in Tehran: the accountability unmet need. Br J Ophthalmol 2006;90: 534–7. Ensure • Develop a business plan to ensure there are enough funds (and income 5 Ramke J, du Toit R, Palagyi A, Brian G, Naduvilath T. Correction of refractive error and presbyopia in Timor-Leste. sustainability diversification) for restocking and for cross-subsidisation of the poor Br J Ophthalmol 2007;91: 860–866. • Establish staff motivation and incentive schemes to minimise staff attrition 6 Ramke J, Ximenes D, Williams C, du Toit R, Palagyi A, Brian Evaluation • Evaluate the partnership annually and implement identified G. An eye health strategy for Timor-Leste: the result of INGDO-Government partnership and a consultative process. modifications to the project Clin Experiment Ophthalmol 2007;35: 394.

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News Useful resources: World Sight Day World Sight Day 2007 will highlight blindness and visual refractive error impairment in children as a major public health issue around Optical suppliers Dandona R, Dandona L, Srinivas M, the world. For more information, Sahare P, Narsaiah S, Muñoz SR, go to www.v2020.org ICEE Global Resource Centre. The Pokharel GP, Ellwein LB. Refractive error International Centre for Eyecare Education’s in children in a rural population in India. Global Resource Centre provides low-cost Technology Invest Ophthalmol Vis Sci 2002;43: 615– publications available spectacles, frames, lenses, and low vision 622. aids to organisations working in disadvantaged The Standard List for a communities. Prices start from US $1.00 for a Du Toit R. How to prescribe spectacles VISION 2020 Eye Care Service Unit spectacle frame. Visit www.iceegrc.org, for presbyopia. Community Eye Health J contains information about the medicines, email [email protected] or write to 2006;19(57): 12–13. equipment, instruments, optical supplies, ICEE Global Resource Centre, 272 Umbilo Limburg H, Kansara HT, D’Souza S. Results and educational resources needed to set up road, Durban 4001, South Africa. of school eye screening of 5.4 million a VISION 2020 service delivery unit, typically children in India – a five-year follow-up serving a population of 500,000 to 1 million. VISION 2020 Low Vision Resource study. Acta Ophthalmol Scand 1999;77: For each item listed, it gives guidance on Centre. The centre provides low vision 310–4. price and the contact details of the suppliers. devices and assessment materials at low cost. Write to The Low Vision Resource Maul E, Barroso S, Muñoz SR, Sperduto The Technology Guidelines for a District Centre, 2nd Floor, East Wing, Headquarters RD, Ellwein LB. Refractive error study in Eye Care Programme builds on the infor- Building, 248 Nam Cheong Street, children: results from La Florida, Chile. mation in the Standard List to provide Shamshuipo, Kowloon, Hong Kong, email Am J Ophthalmol 2000;129: 445–454. guidance on the quantities of equipment, [email protected] or visit www.hksb.org. Négrel AD, Maul E, Pokharel GP, Zhao J, pharmaceuticals, etc., needed at each level hk/VH/hksb/lvrc/LVRC%20Front.htm Ellwein LB. Refractive error study in of a district programme. The guidelines are children: sampling and measurement also available in French. Websites methods for a multi-country survey. Am J These publications can be downloaded from The International Centre for Eyecare Ophthalmol 2000;129(4):421–6. www.iceh.org.uk and www.v2020.org. Education (ICEE). Look in ‘Publications’ on Nottle HR, McCarty CA, Hassell JB, Keeffe CD-ROMs and print versions can be obtained the website for free ICEE research articles on JE. Detection of vision impairment in from the International Centre for Eye Health, a range of topics. www.icee.org people admitted to aged care assessment London School of Hygiene and Tropical The ScoJo Foundation. The ScoJo centres. Clin Experiment Ophthalmol Medicine, Keppel Street, London WC1E 7HT, Foundation improves access to reading 2000;28(3): 162–4. UK. Fax: +44 20 7958 8325. spectacles in low- and middle-income Dandona R and Dandona L. Refractive World Congress on Refractive Error countries by training and equipping local error blindness. Bulletin of the World presentations entrepreneurs to establish businesses that sell Health Organization 2001, 79: 237–243. The presentations given at the first World these spectacles. www.scojofoundation.org www.who.int/ncd/vision2020_actionplan/ Congress on Refractive Error, held in Durban documents/vol79.no.3.237-243.pdf in March this year, have recently been made Books Wedner SH, Ross DA, Todd J, Anemona A, available online. www.icee.org/events/ Mayer S. Refraction training course manual. Balira R, Foster A. Myopia in secondary congress_video/index.asp Available from the International Centre for school students in Mwanza City, Tanzania: Eye Health. UK £5 plus post and packing. the need for a national screening VISION 2020 workshop held in London programme. Br J Ophthalmol 2002;86: A total of 27 participants from 13 countries Schwab L. Eye care in developing 1200–1206. attended the annual ‘Planning for nations. 4th ed. Manson Publishing, 2007 VISION 2020’ workshop held by the Wedner SH, Ross D, Balirab R, Kajic L, (Chapter 13: Refractive Errors). Available International Centre for Eye Health at the Foster A. Prevalence of eye diseases in London School of Hygiene and Tropical from the International Centre for Eye Health. primary school children in a rural area of Medicine in July. The main aim of the UK £12 plus post and packing. Tanzania. Br J Ophthalmol 2000;84: 1291– workshop was to familiarise participants 1297. Reports with the goals and objectives of VISION WHO. Elimination of avoidable visual Zhao J, Pan X, Sui R, Muñoz SR, Sperduto 2020: The Right to Sight and the planning RD, Ellwein LB. Refractive error study in disability due to refractive errors. Geneva, principles involved in establishing community children: results from Shunyi District, 2000. Available from WHO or online at eye health China. Am J Ophthalmol 2000;129: 427– programmes. In www.who.int/ncd/vision2020_actionplan/ 435. documents/WHO_PBL_00.79.pdf addition to lectures about Community Eye Health eye diseases

Articles Sydenham Emma Bourne RRA, Dineen BP, Ali SM, Noorul Journal back issues and programme Huq DM, Johnson GJ. Prevalence of Volume 13, Issue 33, 2000 Refractive errors planning, the refractive error in Bangladeshi adults. Volume 15, Issue 43, 2002 The role of participants Ophthalmol 2004;111: 1150–1160. optometry in VISION 2020 worked in teams to develop a Bourne RRA, Dineen BP, Ali SM, Noorul Suppliers’ addresses model for eye Huq DM, Johnson GJ. Correction of care interven- refractive error in the adult population of International Centre for Eye Health, tions in their Bangladesh: meeting the unmet need. London School of Hygiene and Tropical selected Invest Ophthalmol Vis Sci 2004;45: 410–417. Medicine, Keppel Street, London WC1E 7HT, regions. To apply Chou S, Misajon R, Gallo J, Keeffe JE. UK. Fax: +44 20 7958 8325. for future short Measurement of indirect costs for WHO: World Health Organization, WHO courses, email: The participants in the people with vision Impairment. Clin Exp Press, CH-1211 Geneva 27, Switzerland. shortcourses@ ‘Planning for VISION 2020’ Ophthalmol 2003;31: 336–340. Email: [email protected] Lshtm.ac.uk workshop, July 2007. UK

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Meetings sionals with knowledge of the major blinding Short course in Tropical eye diseases and the VISION 2020 initiative. All India Ophthalmological Society Ophthalmology Target audience: Eye care professionals 66th Annual Conference, 31 January to Date: 9–11 April, 2008. Objectives: The who want to receive training in community 3 February, 2008, Bangalore, India. For more primary purpose of the course will be to eye health, but cannot be away from their information, email santhangopal@gmail. familiarise participants with the main place of work for a longer training course. com or write to KS Santhan Gopal, #81, causes of blindness in the world, with Scholarships: Contact Emma Sydenham first floor, 7th Cross, 4th Block Koramangala, emphasis on the tropics. Target audience: ([email protected]) for Near BDA complex , Bangalore 560 034, India. Ophthalmologists from high-income information. Information and admission countries. More information: Visit www. procedures: Visit www.Lshtm.ac.uk/ World Congress on Optometric Lshtm.ac.uk/prospectus/short/sto.html prospectus/short/sdceh.html or email Globalisation, 11–13 April, 2008, London, [email protected] UK. For more information, email the World Planning for VISION 2020 Council of Optometry at [email protected] or Date: July 2008. Objectives: The main aim fax +1 (0)215 780-1325. of the workshop is to familiarise participants Kilimanjaro Centre for with the goals and objectives of VISION 2020: Unite For Sight Fifth Annual International Community Ophthalmology The Right to Sight and the planning principles Health & Eye Care Conference, 12–13 April, (KCCO), Tanzania involved in establishing community eye 2008, Connecticut, USA. For more information, health programmes at regional or national For information and admission procedures, visit www.uniteforsight.org/conference/2008 level. Target audience: Ophthalmologists visit the KCCO website (www.kcco.net) or or write to Unite For Sight, 31 Brookwood and eye health charity programme contact Genes Mng’anya, KCCO Course Drive, Newtown, CT 06470, USA. managers. More information: Visit Administrator. Email: [email protected] www.lshtm.ac.uk/prospectus/short/spv World Ophthalmology Congress, Bridging communities and eye care 28 June–2 July, 2008, Hong Kong. For more MSc in Community Eye Health providers to achieve VISION 2020 in information, visit www.woc2008hongkong. Africa org or write to Angela Cho, Department of Date: 29 September, 2008 to 18 September, 2009. Objectives: To equip eye health Date: 12–16 November, 2007. Objective: Ophthalmology & Visual Sciences, The To provide eye care programme managers Chinese University of Hong Kong, 3/F, Hong professionals with the knowledge and skills to reduce blindness and visual disability in with the skills necessary to develop, Kong Eye Hospital, 147K Argyle Street, implement, and monitor strategies for Kowloon, Hong Kong. their own country. Target audience: Eye care professionals who have, or could have, increasing utilisation of services by the population in need. Target audience: Eye IAPB General Assembly, 25–28 August, leadership roles either within their govern- care programme managers (from 2008, Buenos Aires, Argentina. For more infor- ments or in the NGO sector. This course is government, NGOs, or service groups), mation, write to Louis Pizzarello, Secretary not appropriate for people wanting training trainers, and key decision makers of national General, International Agency for the in clinical ophthalmology. Scholarships: prevention of blindness programmes. Prevention of Blindness, IAPB Central Office, Contact Emma Sydenham (emma. LV Prasad Eye Institute, LV Prasad Marg, [email protected]) for information. Management for VISION 2020 Banjara Hills, Hyderabad 500 034, India. Please apply in October 2007 to ensure you are accepted before the scholarship closing Programme Managers dates in December 2007. Information and Date: 19–30 November, 2007. Objective: Training admission procedures: Visit www.Lshtm. To provide practical (African-tested) strategies International Centre for ac.uk/prospectus/masters/msceh.html for either developing or strengthening or email [email protected] management systems to facilitate increased Eye Health, London, UK efficiency, coverage, and satisfaction with For application information, email Diploma in Community Eye Health eye care services. Target audience: Heads [email protected] or write to Registry, Date: 13 February to 23 May, 2008. and key decision makers of VISION 2020 50 Bedford Square, London WC1E 7HT, UK. Objectives: To equip eye health profes- planning areas.

Community Eye Health Next issue Supported by:

Journal Kuper Hannah

The late Christian Blind Mission (CBM) Sightsavers Dr Hans Hirsch International

The next issue of the Community Eye ORBIS Conrad N. Hilton Foundation Dark & Light Blind Care Health Journal will be on the theme Advocacy Journal design by Lance Bellers Lance by design Journal

56 Community Eye Health Journal | Vol 20 ISSUE 63 | SEPTEMBER 2007

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