Improving Eye Care in Rwanda
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Lessons from the field Improving eye care in Rwanda Agnes Binagwaho,a Kirstin Scott,b Thomas Rosewall,c Graeme Mackenzie,d Gweneth Rehnborg,c Sjoerd Hannema,c Max Presente,e Piet Noe,f Wanjiku Mathenge,g John Nkurikiye,h Francois Habiyaremyea & Theophile Dushimea Problem Visual impairment affects nearly 285 million people worldwide. Although there has been much progress in combating the burden of visual impairment through initiatives such as VISION 2020, barriers to progress, especially in African countries, remain high. Approach The Rwandan Ministry of Health has formed partnerships with several nongovernmental organizations and has worked to integrate their efforts to prevent and treat visual impairment, including presbyopia. Local setting Rwanda, an eastern African country of approximately 11 million people. Relevant changes The Rwandan Ministry of Health developed a single national plan that allows key partners in vision care to coordinate more effectively in measuring eye disease, developing eye care infrastructure, building capacity, controlling disease, and delivering and evaluating services. Lessons learnt Collaboration between stakeholders under a single national plan has ensured that resources and efforts are complementary, optimizing the ability to provide eye care. Improved access to primary eye care and insurance coverage has increased demand for services at secondary and tertiary levels. A comprehensive strategy that includes prevention as well as a supply chain for glasses and lenses is needed. Introduction the cost of equipment and treatment can be an obstacle.4,8 Chal- lenges with data collection and measurement of the burden Visual impairment – both preventable and treatable – affects of visual impairment complicate efforts to generate support an estimated 285 million people globally. Most of the people for effective health policy development.8 Here we summarize affected (87%) live in low- and middle-income settings.1,2 In ongoing efforts to overcome barriers to addressing the burden Africa, an estimated 32 700 people per million are visually im- of visual impairment in Rwanda. paired.3 A variety of eye disorders contribute to visual impair- ment, including cataract, glaucoma, trachoma and refractive Setting error.3 Nearly 80% of impairments are preventable or treatable.4 Presbyopia – difficulty focusing on nearby objects – is a com- Rwanda has 10.5 million inhabitants. Over the past two de- mon feature of ageing, as the ocular lens loses elasticity. The cades, mortality caused by infectious diseases has dropped, ageing population and the lack of national plans to address for instance, mortality related to acquired immunodeficiency the effect of visual impairment on people’s productivity and syndrome fell by 82% between 2000 and 2012. Consequently, quality of life, will likely increase the burden of eye disease in life expectancy has nearly doubled since the 1990s and is now many African countries.5 at 63 years of age.9 In the population older than 49 years, in Providing eye care services to mitigate visual impairment 2006, the overall prevalence of visual impairment was 5.3% is an important dimension of delivering comprehensive pri- (not including presbyopia) and the prevalence of blindness mary health care. It also contributes to economic growth and was 1.8%.10 In 2006, more than 80% of the eye conditions development by helping reduce injuries and by improving were considered preventable or treatable – including cataract, access to education and employment.6 Investment in eye care refractive error and trachoma.10 Other estimates suggest that services has a benefit-to-cost ratio of more than two to one.4,7 more than 65 000 people (0.6%) in Rwanda are blind in both While there is multilateral organizational support for eyes and 12% of the population – including those with pres- integrating eye care services into health systems – including byopia – have a correctable refractive error and are therefore the launch of the VISION 2020 Right to Sight Initiative – there in need of corrective lenses.11 are barriers to progress, especially in low-income settings.2 In While Rwanda has experienced substantial economic many African countries, there is a shortage of eye care person- growth, nearly 50% of the population still lives below the nel, a lack of standardized training, inadequate coordination poverty line, especially in rural areas. This means that most among eye care stakeholders and for those in need of eye care, people are not able to afford private eye care services.12 More- a Ministry of Health of Rwanda, PO Box 84, Kigali, Rwanda. b Interfaculty Initiative in Health Policy, Harvard University, Boston, United States of America (USA). c Vision for a nation, Kigali, Rwanda. d Adlens, Boston, USA. e Fred Hollows Foundation, Rosebery, Australia. f Christoffel Blinden Mission, Bensheim, Germany. g Rwanda International Institute of Ophthalmology, Kigali, Rwanda. h Dr Agarwal’s Eye Hospital, Kigali, Rwanda. Correspondence to Agnes Binagwaho (email: [email protected]). (Submitted: 19 June 2014 – Revised version received: 16 February 2015 – Accepted: 16 February 2015 – Published online: 30 April 2015 ) Bull World Health Organ 2015;93:429–434 | doi: http://dx.doi.org/10.2471/BLT.14.143149 429 430 Improving eye care inRwanda care eye Improving thefield from Lessons Table 1. Eye care in Rwanda: key functions of nongovernmental collaborators Partnering Start of partner- Description of partnership Support pillar organization ship Measurement of disease Infrastructure development Human resources development Disease control and service delivery burden and evaluation of services Vision for a Nation 2010 An NGO dedicated to Conducts on-going research Incorporated training curriculum Introduced affordable eye glasses at all nationwide primary eye care on the provision of eye in all eight national nursing 502 health centres; mobilizes district for rapid provision of vision glasses and productivity of schools; educates CHWs to enable level stakeholders and runs national assessments and affordable beneficiaries.13 Supports the public access of treatment at radio campaigns to promote services; eye glasses and referral monitoring of referrals and local health centres; has trained supports evaluations of the uptake of capabilities. The NGO works provision of eye glasses. primary eye care nurses in each of new primary eye care services; created in countries where there are the 502 health centres to provide a model for CHW training designed to limited or no such services vision assessments, to dispense raise awareness about new primary and products available to medications and eye glasses and eye care services. most of the population. to refer more complicated cases to hospital. Fred Hollows 2006 An NGO that seeks to Funded the first MoH rapid Built or refurbished three Proposed scholarship for 60 000 people received eye care Foundation eradicate avoidable assessment of avoidable district eye units. postgraduate studies in consultations in eye unit of health blindness in vulnerable blindness survey in 2006 in Supports 12 district eye ophthalmology for two practitioners centres supported by FHF. Bull World HealthOrgan Bull World populations and in resource- the western province.10 units for establishment per year. Supported 2930 cataract operations. poor settings around the Plans to fund the 2015 of referral and capacity Supported the training of 1855 Supports the maintenance of world. survey to update and building that links with the CHWs in eye care and blindness ophthalmic equipment across the compare to 2006 baseline primary level PEC services. prevention between 2007 and 2013. country. results. Donated ophthalmic Contributes funding to the College Evaluated primary eye care equipment to eight district of Health Sciences to train 20 new training in the western eye units. mid-level eye care workers each 2015;93:429–434 province. year. Funded the development of the primary eye care curriculum. Christoffel Blinden 1993 An international disability Financed a study on vernal Sponsors the Catholic Started the ophthalmic clinical Sponsors staff and materials needed | Mission and development keratoconjunctivitis in 2007. referral centre for eye health officers course at Kigali Health to perform most eye operations in doi:http://dx.doi.org/10.2471/BLT.14.143149 organization committed to located in Kabgayi District Institute. Rwanda. Since 2009, the Kabgayi team improve the quality of life Hospital in Muhanga district. Provides scholarships to train has provided approximately 4000 eye for persons with disability Constructed the eye unit Rwandan ophthalmologists abroad operations and 50 000 consultations and those at risk of disability in Kabgayi and provided and ophthalmic clinical officers at yearly. in low-and middle-income equipment. Kigali Health Institute. The Kabgayi Eye Unit sponsors countries. Kabgayi Eye Unit is a paediatric ophthalmology, etal. Binagwaho Agnes practical training centre for vitreoretinal surgery and ophthalmic clinical officers and retinoblastoma treatment. ophthalmologists in training. CHW: community health worker; FHF: Fred Hollows Foundation: MoH: Ministry of Health; NGO: nongovernmental organization; PEC: primary eye care. Note: This table summarizes key international non-profit partners involved in eye care in Rwanda and is not exhaustive of all stakeholders involved in providing eye care services in Rwanda. Lessons from the field Agnes Binagwaho et al. Improving eye care in Rwanda Fig.