National Eye Care Strategy

Strategy for National Eye Care for Vision 2020 in Bangladesh

Prepared by Dr. A. M. Zakir Hussain

Dhaka, August 2014

TABLE OF CONTENTS

Acronym………………………………………………………………………………………...2

Background……..……………………………………………...... 4

The draft 2014-2020 strategic plan………………………...………….….………………..20

Policy statement……………………………………………………….… ……………...20

Results framework………………………………………………………………………...... 24

ACRONYM

BBS Bangladesh Bureau of Statistics BCPS Bangladesh College of Physicians and Surgeons BMDC Bangladesh Medical and Dental Council BNSB Bangladesh National Society for the Blind CBHC Community Based Health Care CC Community Clinic CDC Communicable Diseases Control CMSD Central Medical Stores Department DEC District Eye Health Coordinator DEHC District Eye Health Committee DGHS Directorate General Health Services DP Development Partners DSF Demand Side Financing ECHO Eye Care and Health Observatory ESD Essential Services Delivery FY Financial Year GDP Gross Domestic Product GOB Government of Bangladesh HEP Health Education and Promotion HIS-EH Health Information System-E Health HNPSP Health Nutrition and Population Sector Program HPNSDP Health Population and Nutrition Sector Development Program HRM Human Resource Management HSM Hospital Services Management IAPB International Agency for the Prevention of Blindness INGO International Non Governmental Organization JAG Joint Advisory Group KAP Knowledge Attitude and Practice M&E Monitoring and Evaluation MLEP Mid Level Eye Care Personnel MOHFW Ministry of Health and Family Welfare MOLGRDC Ministry of Local Government, Rural Development & Cooperatives NCD Non Communicable Diseases NEC National Eye Care NEH National Eye Health NEHC National Eye Health Committee NES Nursing Education and Services NGO Non Governmental Organization NIO National Institute of Ophthalmology NSAPR National Strategy for Accelerated Poverty Reduction NTDs Neglected Tropical Diseases OSB Ophthalmological Society of Bangladesh OP Operational Plan 3

OT Operation Theatre PHC Primary Health Care PIP Program Implementation Plan PIU Program Implementation Unit PPP Public Private Partnership RAAB Rapid Assessment of Avoidable Blindness SWAp Sector Wide Approach TK Taka UHC Upazila Health Complex USD US Dollar V2020 VISION 2020 WHO World Health Organization

BACKGROUND

1. Past activities

Vision 2020 – the Right to Sight, was launched by the World Health Organization (WHO) and International Agency for Prevention of Blindness (IAPB) in 1999 in Beijing to eliminate avoidable blindness by the year 2020. The 56th session of the World Health Assembly of WHO, which was chaired by the Honorable Minister, in- charge of the Ministry of Health and Family Welfare, Government of the People's Republic of Bangladesh, adopted the Vision 2020 formally.

To facilitate attainment of the Vision 2020 goals in Bangladesh a Bangladesh National Vision 2020 Advisory Committee was formed in 2007 with Director General of Health Services as its chairperson and the line director of the National Eye Care Program as its member secretary. The terms of reference of the Committee includes:

1. Provision of guidance and technical and advisory support to the line director;

2. Identification of national eye care priorities and program/research priorities and their implementation, operationalization of the national eye care plan included in the sector-wide perspective plan of the Ministry of Health & Family Welfare, Government of Bangladesh;

3. Promotion of and support to mobilize resources;

4. Pursuance for the formation of district Vision 2020 coordination committees;

5. Obtaining BNCB endorsement on policy and other issues relevant to attainment of Vision 2020 goals.

District Vision 2020 Committees were formed with support from international non- government organizations (INGOs). These committees draw members from upazila level public health officials, i.e., upazila health and family planning officers, Lions and Rotarians, representatives from education and religious sectors, from local bar councils and press clubs, local municipalities, NGOs, international NGOs (INGOs), private hospitals, local philanthropists, local public leaders and other stakeholders. These are headed by the head of the district health department, i.e., civil surgeons. The terms of reference of the District Vision 2020 Committees include:

1. identification of district eye care needs;

2. development of district eye care plans with targets;

3. Development of monitoring and evaluation plans and implementation strategies.

4. Rreviewing progress, achievements, challenges and lessons learnt to advise the district eye care managers;

5. Maintenance of a profile of the district eye care providers;

6. Facilitation of coordination to avoid duplications and overlaps; 7. Support for mobilization of resources;

8. Identification of needs and areas to improve infrastructure, human resources development and management, equipment and other supplies.

Bangladesh was also the first country in the South-East Asia Region of WHO to develop a plan in 1980 for a national program on prevention of blindness, which triggered a global concept of development of national programs on blindness prevention, supported technically by WHO. The program in Bangladesh was taken up under the aegis of the Bangladesh National Council on Blindness (BNCB), with support from the Royal Commonwealth Society for the Blind (RCSB), now known as the Sightsavers International.

This national eye care plan of 1980 was developed immediately after Bangladesh ratified the Vision 2020. This was subsequently incorporated in 2003 in the second sector-wide perspective plan of the Ministry of Health and Family Welfare, widely known as the Health, Nutrition and Population Sector Program (HNPSP) 2003-2011. Some of the activities of this plan were funded by the Sightsavers International.

In 2003 BNCB formed a review committee, which assessed eye care service capacity at the base nationally and drafted a new national eye care plan in 2005 (the second national eye care plan), after series of consultations and workshops across the country between 2003-2005 period, participated by the Ministry of Health & Family Welfare staff from national to the most fringe level, by national and international non-government organizations, eye care experts and the relevant auxiliary staff. These activities were supported by the Sightsavers International and ORBIS International.

The plan prioritized three eye care problems, namely, cataract, childhood blindness and low vision. Along with these three prioritized areas other problems that were focused were: cornea and retina related problems and glaucoma. This plan was followed by a ground breaking event- creation of a post of line director for National Eye Care in the 2011-2016 sector-wide five year plan of the Ministry of Health & Family Welfare, Government of Bangladesh.The 2005 national plan emphasized on capacity building for secondary care and on strengthening the primary health care infrastructure so that primary prevention and referral of medical cases may be institutionalized. The plan underscored the role of coordination, in particular at the district level. The plan also laid emphasis on public-private partnership including non- government organizations for effective attainment of the Vision 2020 goals.

The current sector-wide plan 2011-2016 of the Ministry of Health & Family Welfare, Govt. of Bangladesh, i.e., Health Population and Nutrition Sector Development Program (HPNSDP), has the following NEC relevant key objectives:

1. Awareness on blindness prevention;

2. Control of childhood blindness;

3. Strengthening of coordination between Government-NGO and private eye

care providers;

4. Building of capacity of eye care service providers;

5. Voucher scheme for eye care services;

6. increasing the country cataract surgical rate.

The 2011-2016 sector-wide plan underscored the importance of ocular trauma, due to agricultural and occupational accidents; ocular growth and malformations. A strategy was drawn for early detection and management of these problems, as these interventions provide appreciable social and economic dividend. A major thrust has been given to improvement of infrastructure and technology at secondary level service centers; establishment of vision centers at upazila level, for correction of refractive errors and identification of cataract and other ophthalmic problems for referral; introduction of child sight testing in primary schools; introduction of subspecialty services at tertiary level; demand side financing; management of information systems; and involvement of primary health care infrastructure for providing eye care. The other areas are: increase in awareness of the people on blindness prevention, strengthening coordination between government, NGOs and the private sector, introduction of vouchers to increase accessibility of the poor, elderly, women and children to cataract surgery. Some of the crucial activities completed under the plan are:

 SICS guideline;  Treatment protocol;  Examination protocol;  Eye care manual for primary health care workers;  Guideline for OT and ward management for nurses and paramedics;  Guideline for counseling in eye care;  Functioning district vision 2020 in 30 districts;  Age and gender specific cataract surgery reports on standard formats sent to IAPB and WHO regularly;  Cataract surgical outcome monitoring (CSOM);  Earmarking of community clinics as referral point to upazila health complexes (vision centers).

The World Health Assembly in May 2013 approved a Global Action Plan 2014- 2019-Towards Universal Eye Health. Its key elements are:

 To strengthen national efforts to prevent avoidable visual impairment including blindness, through inter alia, better integration of eye health into national health plans and health service delivery, as appropriate;

 To implement the proposed actions in the global action plan 2014-2019 on universal eye health in accordance with national priorities, including universal and equitable access to service.

The three strategic objectives of the WHO plan are:

1. Address the need for generating evidence on the magnitude and causes of visual impairment and eye care services and using it to advocate greater political and financial commitment by Member States to eye health;

2. Encourage the development and implementation of integrated national eye health policies, plans and programmes to enhance universal eye health with activities in line with WHO’s framework for action for strengthening health systems to improve health outcomes;

3. Address multi-sectoral engagement and effective partnerships to strengthen eye health.

The WHO plan of action has eight areas of focus which are:

1. Service delivery; 2. Medical products and technology; 3. Eye health work force; 4. Eye health information; 5. Eye health financing; 6. Leadership and governance; 7. Improving access and quality of care; and 8. Research in eye health.

The objectives of the WHO plan focus on: development/ strengthening of national policies, plans and programs for eye health and prevention of blindness and visual impairment; increase and expand research for the prevention of blindness and visual impairment; improve coordination between partnerships and stakeholders at national and stakeholders at national and international levels for the prevention of blindness and visual prevention of blindness and visual impairment; monitoring of progress in elimination of avoidable blindness at national, regional and global levels.

Activities of some of the international NGOs working in close proximity to the National Eye Care program are given below.

Orbis International has been working in Bangladesh since 1985. It started through Flying Eye Hospital program and established its long term program from 2000. Orbis works through partners to build capacity through training, quality enhancement, systems development, public education and evidence base advocacy. Orbis’s work focuses on the following six areas of eye care sector in Bangladesh.: (1) Disease Control – focusing childhood blindness including ROP, Diabetic Eye Diseases with an emphasis to Diabetic Retinopathy; (2) Human Resource Development in terms of fellowships and hands-on training in sub-specialties, clinical team approach and continued medical education using Orbis tools (Flying Eye Hospital, Hospital Based Program, long and short term fellowships, voluntary faculty and Cyber- Sight/Telehealth); (3) Facility strengthening by providing upgraded technology, appropriate equipment and accessories as well as renovating infrastructure, e.g., child friendly hospital facility; (4) Systems strengthening e.g., HMIS, integrated MIS

8 and reporting, management systems, adaptation of quality protocol and quality assurance; (5) Policy advocacy and research based evidence; and (6) Public education and awareness raising. Orbis aims at reaching 20 million people – children and adult diabetic population suffering from eye problems. One of its approaches is to work with all partners in eye health and its development NGO involved in eye care in order to establish a network of national programs with a focus to reduction of childhood blindness including ROP as well as comprehensive eye care in diabetic eye diseases with an emphasis to DR including VR surgery. Orbis for the first time introduced a rural DR project in 3 northern districts and developed a model for scaling up in partnership with BADAS (Bangladesh Diabetic Society). Under the childhood blindness reduction program 2 million children will be screened across Bangladesh. 0.8 million children will be treated medically and optically and 20,000 pediatric surgeries will be done. The aim of its research (clinical, operational system) is to develop innovative model and system in order to improve access and quality eye care services, evidence generation, adopt best practices and scaling up of successful model/approaches, For 2014, total annual budget of Orbis is about 2.3 million USD. Orbis currently works in 10 districts and in next five years from 2015 Orbis has a plan to work in 16 districts in all 7 divisions. The priority programs include: Childhood Blindness Reduction including ROP, Comprehensive Quality Eye care (Diabetic Eye Diseases including DR and integrated PEC). Orbis will work with international and national partners to develop a national coalition in eye health for sustainable impact in eye health.

Around 5% of total country budget of CBM contribute to eye health projects, which is BDT 36,68,700 for 2014. CBM also works with partners and its services include cataract surgeries, glaucoma and other surgeries, training of teachers, primary assessment of refractive error, staff training and capacity building on OT management and refraction. CBM supports Trusts and NGO hospitals to deliver quality eye care services (mainly cataract) to poor and marginalized communities, It works for Rights promotion and Rehabilitation of persons with visual impairment through advocacy, empowerment and community mobilization.

CBM supports direct eye care (cataract surgery) in 17 districts and has been implementing community based rehabilitation activities. In future CBM has a plan to support partners in establishing sub specialties like diabetic retinopathy, childhood blindness, glaucoma and low vision services; strengthening community outreach and school screening; promoting disability Inclusive practices in eye health; developing and integrating eye health services with CBR programs.

CBM (previously Christoffel-Blinden-Mission) is a German based international development organisation founded more than 100 years ago. It stepped into Bangladesh in 1972 to treat the disabled war veterans. In the subsequent years, CBM expanded its service coverage in partnership with local NGOs.

In the framework of global Vision 2020 Right to Sight, CBM is currently supporting 3 eye health partners in the districts of Tangail, Kushtia and Kishoreganj in Bangladesh. In 2013, a total of 112 851 persons were

9 screened for eye diseases and 10 797 received surgery support through partner hospitals.

The Fred Hollows Foundation, Bangladesh, has been working in Bangladesh since 2008. The timeline 2008-2012 marks its first phase in Bangladesh. The Foundation worked intensively with government in developing 10 district hospitals: Brahmanbaria, Satkhira, Jamalpur, Narail, Kishoreganj, Gazipur, Cox’s Bazar, Natore, Tangail and Kushtia (covering a population more than 23 million); that can provide standard eye care services. Infrastructure development, developing skilled human resources for better eye care services, creating demand at the community level, conducting RAAB (Rapid Assessment of Avoidable Blindness) & KAP (Knowledge Attitude and Practice) survey, establishing separate eye unit in district hospitals and raising community awareness are the highlights of the Foundation.

The Fred Hollows Foundation, Bangladesh, in its second phase (2013 to 2017), has been working with private partner NGOs in Barisal and Chittagong, specially focusing in remote rural places which are most underserved in terms of eye health care. It is also working alongside with its 10 government district hospitals. In addition some other district hospitals which will also come under a collaborative arrangement. These are: Comilla, Chandpur, Lakshmipur, Feni, Chittagong, Khagrachhari,Rangamati, Bandarban, Barisal, Bhola, Patuakhali, Barguna, and Pirojpur. The major focus of The Foundation in the second phase is to work strongly through public private partnership and effectively manage the cases of diabetic retinopathy.

FHF Bangladesh has for the first time taken DR services in a government district hospital, i.e., Brahmanbaria as a pilot project in 2012. In the year 2013, the number of DR patients treated with laser at the Brahmanbaria Sadar Hospital is 534. FHF also supported BIRDEM for renovation and training of ophthalmologists and paramedics at BIRDEM for DR. Alongside this, FHF has carried out communication campaign for people to actively seek DR services if they have diabetes for long. FHF Bangladesh has plans to continue its work in Barisal through Islamia (IIEI&H) and Chittagong through CEITC covering 14 districts. It will continue its work focusing on the most vulnerable and marginalized population, especially women and ethnic communities.

FHF has a budget of 1.87 million USD for 2014 for providing quality eye care services in10 district hospitals and in 14 districts of Chittagong and Barisal Division. This amount will be spent in the areas of skill development of service providers, renovation, refurbishment and up-gradation of service centers, conducting research and creating demand at the community level.

Helen Keller International has been implementing a DR action research on diabetic retinopathy and also vitamin A supplementation. The geographical areas covered are Chittagong and Feni districts. Under HKI supported DR services 20,519 patients were screened for diabetic retinopathy (DR); a total of 12,238 patients received information through BCC campaign, and 6,100 patients were referred, of who 3, 296 received treatment for DR.

Sightsavers International is supporting both government and non-government partners for reduction of avoidable blindness including cataract, childhood blindness, refractive error, and low vision. Its strategy is to integrate eye health with existing health systems and advocacy, supported by evidence, community development programs and disability movement through hands-on training, community mobilization, hospital based program, and health education with the help of local health care organizations. Sightsavers is working on system development through human resource and infrastructure development both in government and non- government organizations (national and international). Sightsavers plans to work for 34 million people of 11 districts in Bangladesh both in eye care and for social inclusion for education. Sightsavers aims at strengthening of cataract surgery, comprehensive PEC, community education and screening, care for refractive error and low vision; more community based activities (provision of awareness and screening, linking with nutrition and EPI program); advocacy for integrated HMIS for eye health; more emphasis for linking public and private sector for sharing information; Increased effort to build a sustainable referral network; and generation of evidence through research.

Sightsaver’s budget for 2014 is about BDT 34,312,956 which will be spent in few focused areas that include (i) Service delivery: primary eye treatment, refraction services including dispensing of spectacles, school screening program, community outreach program, cataract surgeries for both adult and child, other surgeries, (ii) Capacity development: orientate field level government and NGO staff, training technical staff, both from government and NGO sectors, training management staff both from government and NGO sectors, and (iii) Infrastructure development: establishment of vision centre in both government and NGO sector, secondary eye care centre at government district hospitals, evaluation and research and standard protocol and guideline development.

BRAC, with technical and financial support from Sightsavers. has planned to cover 11 city corporations and 37 upazilas under 4 districts of Sylhet division with its own fund. BRAC has started working towards 100,000 cataract surgeries up to December 2015 to reduce avoidable blindness from the above mentioned areas. This is a joint venture of NEC and BRAC where the technical supports are being providing by the NGO hospital partners. BRAC is carrying out community mobilization through its frontline health workers and staff. Besides, the NEC is providing the technical and advisory support for quality control to implement the program effectively and efficiently. This would leave municipalities in urban areas to be covered by the NEC office.

Other eye care NGOs Apart from the above mentioned NGOs, a number of eye care organizations have been implementing eye health services in the country such as BNSB chain eye care facilities and are partnering with all the above INGOs for a long time. With the emergence of new players in the eye field, a comprehensive directory has to be in place for planning and reviewing the coverage and quality of eye care services in Bangladesh.

2. Problems

2.1 Disease load

As per the Bangladesh National Blindness and Low Vision survey 20001 the age standardized blindness prevalence rate is 1.53%, which estimates 675 000 blind adults aged 30 years and above. The rate was 1.72% among females and 1.06% for males (more in manually laboring people). Bilateral blindness was highest in Borishal division (2.28%), followed by Khulna (1.97%). The rate is lower in Chittagong division (1.43%), Sylhet division (1.31%) and Rajshahi division (1.21%), with the lowest in Dhaka division (1.13%). These figures most probably are reflections of poor availability of service providers and low utilization of available services. Cataract was found to be the major cause (79.6%) of blindness. Cataract surgical coverage was found to be only 32.5% overall. It was lower among females in rural poor population. Cataract is also the major cause of visual disability among the poor people globally.

The income of individuals and families may itself be reduced due to blindness. There are, in addition, considerable amounts of opportunity costs lost to other family members, especially to the family care takers. Cataract surgery therefore can contribute to poverty alleviation and improve quality of life. Strong advocacy hence may be conducted among the policy makers and planners with necessary facts and figures to allocate enough resources to promote cataract services. The Bangladesh, national prevalence survey estimated 4,200 cataract cases per million population and an incidence rate of 840 per million. According to this survey there are 550 000 cataract blind in Bangladesh which are treatable. With a cataract surgery rate under the NEC program at present at 1,172 per million it is obvious that the present backlog in the prevalence of cataract will hardly be addressed adequately..

The survey1 also revealed that low vision prevalence is 0.56% among people aged 30 years and above. The main reason of this is retinal diseases (38.4%), corneal diseases (21.5%), glaucoma (15.4%) and optic atrophy (10.8%). It has been estimated that Bangladesh has a prevalence of about 250 000 low vision cases among adults aged 30 years and above. According to a WHO estimate globally 284 million people suffer from visual impairment; 39 million of who are blind and the remaining 245 million suffer from low vision. About 90 per cent of these people live in the developing world. WHO estimates that 80 per cent of these visual impairments can be avoided.

As per a Rapid Assessment of Avoidable Blindness, conducted in the 6 districts of Borishal division in Bangladesh2 the rate of blindness estimated among a population of 5,000 was 1.8 per cent. The prevalence of blindness between 2000 and 2013 therefore seems to have increased. This is not unusual since an increase in longevity in Bangladesh would tend to increase blindness and cataract, as these are more pronounced in advance age. The ongoing survey shows a staggered rate of blindness among the 10 districts studied, e.g., from a prevalence rate as low as 0.46 per cent in Brahmanbaria district to as high as 3.46 per cent in Natore, 3.02 per cent in Cox's Bazar and 2.72 per cent in Narail districts. Sixty four per cent to 85 per cent of these blindness are due to cataract; of which 72 per cent to 98 per cent were avoidable. On average while 0.55 per cent of the population in general was found to be blind, blindness among people aged 50 years and above was 0.75 per cent. On

12 average 83.87 per cent of these blindness were avoidable. The 2000 survey put this figure at 90%. This improvement between 2000 and 2013 may be an artifact, difference in the methodology of the two studies, due to a higher level of awareness among the masses or due to the effect of the government and the NGO driven services in the remote areas of the country. While the 2000 survey showed a cataract related blindness rate to be 80%. The 2013 study found that 76.66% of the blindness is due mainly to cataract and to a minor degree due to the squeal of cataract extraction combined. This condition has been seen to be particularly alarming in Natore, where it is 97 per cent. The rate of surgery with bilateral cataract at visual acuity of <3/60 and <6/18 is also lowest in Natore-53.1 per cent and 28.1 per cent respectively. On average in the eight districts that this data come from these rates respectively are 71 per cent and about 42 per cent.

Another estimate based on the 2000 survey rounds up the size of the blind people in Bangladesh to 750 000, among people aged 30 years and above3. If this absolute figure is applied to a rate of 1.8 per cent the absolute number of blind among the same age bracket would be more than 880,000 in 2013.

The Bangladesh National Blindness and Low Vision Survey 20034 estimates the following:

1. An age standardized prevalence rate of 1.53% blindness among adults 30 year and above;

2. 80% of the bilateral adult blindness due to cataract, followed by uncorrected aphak(6.2%) and macular degeneration (3.1%);

3. 650,000 blind people in the country;

4. Estimated low vision (among adults) 13.8%, mainly due to cataract (74.2%), refractive error (18.7%) and macular degeneration (1.9%).

According to the study the population blindness and cataract may be caused by old age and due to lack of nutrients and wrong medication. Surgery was correctly identified as the only corrective measure by the people for cataract. While people in general were found to believe that for cataract no voo-doo or faith healing works, many respondents thought that conjunctivitis is due to bad air and hence should be treated accordingly. For any eye problem people usually prefer the local allopathic and traditional healers. The cause of not seeking medical care in case of eye problems is poverty, lack of knowledge, distance, lack of social support, less than welcome attitude of providers, fear of surgery, belief on curse and attitude that in an advanced age there is hardly any use of operation etc.

As per the 2000 survey1 the country had about 40,000 childhood blindness, with an annual child cataract surgery rate of 2000 per year now. The size of the population has increased by 20 million between 2000 and 2013. The child population was about 47% in 2000, which is about 43% as of the latest figure available in 2011. Taking these figures into consideration the absolute number of child blindness should be about 42,000 in 2013. Estimated population in Bangladesh is about 160 million5. There are about 64 million children living in Bangladesh. Using the WHO global

13 estimate of Childhood blindness prevalence of 0.75/1,000 children, there are about 48,000 blind children in Bangladesh6. t is estimated that for every one million people in Bangladesh, there would be 300 blind children expected (total 48,000) of which around one third (100 children) are blind from cataract. Of the estimated 40 000 children suffering from cataract 12 000 are suffering from cataract which are due to un-operated cataract. Another 10 000 are blind due to preventable corneal scarring. For every million population 300 blind children are estimated. About one third of them are due to cataract. This would require 100 uniocular and 200 bilateral cataract surgeries per million population. Of the childhood blindness 25% would have to be prevented at community level as these are due to vitamin A deficiency, malnutrition, diarrhea and measles. Childhood eye care services are available in 16 centers in Bangladesh. Model child eye care centers will be established in 4 district hospitals as per recommendation of evaluation of BCCC (Bangladesh Childhood Cataract Campaign).

Childhood blindness in Bangladesh is 0.80 per thousand1. But there is a possibility that this figure in fact may be less than even 40,000 in absolute figure which needs to be evaluated or a comprehensive study would be required to plan address the situation., Due to recent improvement in child health care, reduction of U5 mortality and IMR and society's value attached to children new diseases like Retinopathy of Prematurity (ROP) has been emerging which also needs proper planning. Childhood blindness unfortunately is not to be seen in case of valuation of the elderly people in the family or in the society. Hence we would not project any lessening of the old age related blindness or cataract load, unless some targeted and coordinated interventions were taken for them in any defined geographical locations.

According to a Bureau of Statistics study in 20107 the overall prevalence of any type of disability for all levels of difficulty in Bangladesh is about 9.07%, The proportion for males is 8.13% whereas that for females is 10.00%. The proportion in rural area for both sexes is 9.63% whereas in urban area, the proportion is 7.49%. Individually, 14.01% suffer fro some kind of disability, but because one person may have more than one type of disability at the same time, the net percentage stands at 9.07%. Visual disability accounts for about 44% of all disabilities.

While globally uncorrected refractive error is the main problem in the mid-income and low-income countries cataract is the main cause of visual impairment. Although refractive services have been initiated in 32 district hospitals and 5 vision centers have been started at sub districts/upazila level. The Bangladesh National Blindness Survey1 found that the number of refractive error in Bangladesh is 27,250 adults and 9,925 children per million of population. This means that there are about 3.3 million adult refractive error cases with <6/12 visual acuity and 1.3 million children aged 5- 15 years, with refractive error at <6/18 visual acuity, at an estimated prevalence of 4%8. It is estimated that there are about 1,950 adults and 120 children per million of population who would be benefited from low vision related services. The 2000 survey1 suggests that Bangladesh had about five million people, including children, suffering from refractive errors.

The number of low vision, according to the 2000 survey1 was about three times that of blindness. Prevalence of low vision is 13.8% of among the people aged 30 years or more9. The rate of Low Vision in general is 0.56% (LD, NEC). In absolute figure

14 this should therefore have been 2,250,000 in 2000 and should be 2,640,000 in 2013. The 2013 estimates would hardly be different since no vigorous or unique efforts were taken to reduce these numbers so far. The Childhood Blindness Survey in Bangladesh estimates that 31% of blindness was due to problem with the lens (cataract) and 27% due to cornea (vitamin A deficiency) including glaucoma (4%) and aphakia (5%). 67% of childhood blindness thus can be prevented. The study also found that 90% of the childhood blindness developed within first five years of their age. For Low Vision 12 centers were established, most of which are under- utilized though due to lack of proper referral and un-availability of low vision devices.

In Bangladesh, according to the International Diabetes Federation, there are estimated 4.8% of people who are diabetic10. Based on the above prevalence of 4.8%, 7.4 million populations ought to be currently suffering from DM. About 25% to 27%11 or over all 23.7% to 36.2% of the diabetic population, i.e., about 1.85 million populations have Diabetic Retinopathy. Laser treatment can now prevent of many of the blindness caused by DR. Diabetic Retinopathy screening program has been initiated in 3 districts in Bangladesh. The 2000 survey also estimated 25 per cent of the diabetic patients suffering from diabetic retinopathy.

As life expectancy has been increasing and population aging, it is expected that ARMD will also be on rise in Bangladesh12

Glaucoma affects a significant number of people and is one of the leading causes of permanent blindness. According to the National Blindness and Low Vision Survey1 1.2% of all adult blindness is due to glaucoma. On the other hand, open angle glaucoma prevalence among Bangladeshis aged 35 years and above is 2.8% against a suspected rate of 11.2%. In absolute figure this is about one million13.The 2000 survey estimated the rate of glaucoma among the people 35 years of age or above to be 2.8 per cent.

For implementation of vision 2020,Bangladesh National Council for Blind (BNCB) of Ministry of Health and family Welfare, Government of the People's Republic of Bangladesh) and national Vision 2020 Committee has been formed. However, these committees’ needs to be activated and reformed (if required) to facilitate the planning and monitoring the achievements against the set target for Vision 2020 goal as well as set up and monitor the quality of services.

2,1 Quality of services

Although post-operative cataract complications are extremely negligible- 10 to 12 per 100,000 operations, quality assurance of the clinical services still leaves room for improvement. Although standard operating procedures are available, pre and post- operative follow up functions and their documentations need institutionalization. Public sector clinical staff have formidable role of undertaking these responsibilities for which they are yet to be ready. Past orientation interventions do not seem to have borne any fruit. Whatever complications are noted are mainly due to non-compliance of the post-operative measures by the patients, especially in case of diabetic retinopathy.

The proportion of IOL surgery is only about 59% in Bangladesh. While Dhaka and Rajshahi divisions accounted for 65% of IOL surgery, Borishal division had less than 1% and Khulna 6.6%.

The Bangladesh National Blindness and Low Vision survey 2000 showed that one quarter of intra-capsular cataract extracted eye was not corrected with a spectacle lens. This was more common among women, eye camp surgery recipients, illiterate people and rural inhabitants.

For regulating quality of eye care service Bangladesh does not have any accreditation system or overall standards of service procedures. The Bangladesh Medical and Dental Council, which is entrusted with regulation of medical care by professionals and the State Medical Faculty, which regulates mid-level non- professional cadre of service providers, have no eye care related specific regulations and functions.

2.3 Backlog of treatable cases and human resources for eye care situation

The level of skill and modern technology has brought in expediency in the time required for cataract operation. In skilled hands, if all the logistics and helping hands are available, should not take more than 3.5 minutes per operation. This would mean that conducting 100 cataract surgeries per day by an expert would not be a tall order. Unfortunately only 30% to 40% of a total of about 900 ophthalmologists available in the country are capable and willing to work at that pace, even when some incentives are provided to the service providers. This will be insufficient to remove the backlog that awaits surgical intervention, while new cases keep on piling up on the top of this backlog. The lack of philanthropy on part of the senior professionals is both attitudinal and monetary. Since in private chambers a cataract operation would fetch much handsome remuneration, so operation in public sector hospitals is sluggish. But the fact that most of the cataract cases occur among the poor, illiterate, elderly, non bread-earning rural population, who would not knock the door of these expensive service providers, do not get any attentive ears. Past orientation efforts to these elderly experts were not found to be useful. The cataract surgery rate is 1,172 on average per million population /year in Bangladesh. The total cataract surgeries in 2012 however, was slightly higher, i.e., 183,312, at a cataract surgical rate of 1,206 per million population /year (personal communication with the line director National Eye Care on 11 November 2013) the backlog of cataract patients waiting to be operated upon will only get longer. The present estimation for clearing this backlog is to raise this rate to at least 3,000 operations million/year.

There are only 2,800 mid-level eye care personnel available in the country (personal communication with line director of National Eye Care Prof. Deen Mohamad Nurul Haque, 11 November 2013). The number of ophthalmologists trained per year is about 50 (LD, NEC).in Bangladesh. At this rate the country needs more formal type of mid-level eye care providers. There are no optometrist or orthoptist in Bangladesh. It is imperative that physicians trained to be ophthalmologists are destined to work as specialists and services that may be provided by less trained mid-level personnel are inducted to cater those services. This is one answer to remove the backlog that has been heaping with time.

While younger ophthalmologists have been found to be more receptive to the concept of addressing the national curse of avoidable blindness the posts of ophthalmologists in the public sector is limited. Therefore collaboration between public and private sector for providing effective eye care in the country is important. Sadly though the investment cost for establishing an eye care service point runs into millions of taka. Maintenance of the eye care equipment and machines is also fraught with the non-availability of trained bio-medical engineers in the country.

One reason of the backlog is due to non-prioritization of eye care services at district level by the head of the district health office, i.e., civil surgeons. Past orientations have not brought in any considerable degree of success. The district Vision 2020 Committees are effectively functioning only in those districts where NGOs are providing active technical support. In many districts civil surgeons have to discourage hospitalization of the eye surgery patients as the available seats in district hospitals is inadequate even for more serious patients, albeit some other non- hospitalizable patients are found to occupy these scarce beds. Interestingly these officials have been said to discourage eye surgery even in private hospitals for some ill understood reasons. A collaboration between the line director of National Eye Care and the director of Hospital and Clinical Services, DGHS will be necessary to break this impasse.

Anone reason of the backlog may be a poor rate of eye care services including cataract surgeries provided at district level. District hospitals suffer from inadequacy of equipment, trained human resources and sub-specialty services.

Utilization of upazila health complexes, introduction of health vouchers and/or inclusion of most common eye care problems in the service package of universal health coverage may be useful in removing the backlog. To this end the cost for these services would be useful to know for ensuring an efficient service package in the universal health coverage system, when instituted in the country. Experience from Manikgonj and Kotalipara would be handy in this regard.

There are only four eye hospitals in Bangladesh with full-fledged pediatric ophthalmic units against a need of 16. Two eye hospitals have corneal sub-specialty units and two eye banks in the entire country, while six vitreo retinal units are functional in the country. Obviously these few service providing units in the country fall far short of needs,

2.4 Paucity of funding

Government allocation for the current five year plan period for eye care is a measly amount of Tk 18.12 crores-slightly more than 3.5 crores per year! On the contrary International NGOs, like Sightsavers, ORBIS, Helen Keller International, CBM , Fred Hollows and BRAC working in the area of eye care in Bangladesh spend ten times more than this. In contrast India allocated Rs. 2,500 crores in its current five year plan for eye care. Eighty per cent of this amount goes to private sector. This amount will be doubled to next five years. At present Govt. of India provides Rs. 1,000 through the district blindness committees for each cataract operation the private sector. To bring cataract patients for surgery BRAC in Bangladesh gives Tk. 50 to its field workers. According to a 2011 data the total expenditure on health per capita is

USD 67 per annum-combined from all sources. In terms of GDP it is 3.7% (http://www.who.int/countries/bgd/en/). 67% of this however, is paid from out of pocket by the service beneficiaries themselves.

2.5 Eye health service availability and utilization

According to the national eye care capacity assessment14, the country had 141 hospitals for eye care services. Of these 71 were in public sector (2 tertiary hospitals, 14 medical colleges and 55 district hospitals), 56 are NGO owned (53 secondary level and 3 tertiary level) hospitals and 14 in private sector (6 medical colleges). .

According to a study conducted in 200515, only 8% of the rural people are able to obtain health care services from government facilities and 2% of mothers seek care for their sick children from UHFWCs. Most of the people in rural areas (about 57%) prefer health services from Palli Chikitshoks, a village practitioner etc. In urban areas this is about 31%. Almost half of the rural women are not aware of the existence of a satellite clinic close to their homestead. The study found that less than one percent of the surveyed respondents have used the services of the union level public health facilities, who usually come within half a kilometer distance. Even at this poor rate of utilization an estimated 70% of the eye surgeries in Bangladesh is due to cataract.

Most of the cataract surgeries are conducted in urban areas with Sylhet city topping the list8. Eighty six percent of these surgeries are done in NGO clinics, 10% in government facilities and 4% in private hospitals. Out of 626 ophthalmologists 350 were found to be serving in Dhak city. Rajshahi city had 103 and the other cities had less than 100 ophthalmologists each. Borishal was found to have only 16. Mid-level eye care providers (618) were also distributed similarly. In this case Chittagong city however, had a slight edge over Rajshahi- 134 to 73. Borishal again was at the bottom with only 7.

Forty seven percent of the ophthalmologists were found to be located in NGO hospitals, 40% in government hospitals and 13% in private hospitals. Sixty eight percent of the mid-level health care providers were found in NGO hospitals, 23% in government hospitals and 9% in private hospitals. Given this distribution, it is clear that personnel working in the government hospitals are conducting fewer operations than the NGO hospital based staff. However without having a system of regular updating on national level information appropriate planning is almost impossible. The following are the areas which will be collected through a concerted effort of Public- private-NGO partnership effort.

 Number of general hospitals with eye department in public sector;  Number of general hospitals with eye department in private sector and NGO sector;  Number of beds for eye services in public sector hospitals: 2 822 (National Eye Care Capacity Assessment 2003);  Number of beds for eye services in private and NGO sectors:  Number of ophthalmologists;  Total cataract surgeries at district level per year in last three years. .

VISION AND MISSION STATEMENTS

Vision

“A world in which no one is needlessly blind and where those with unavoidable vision loss can achieve their full potential”.

Mission

To “eliminate the main causes of avoidable blindness by the 2020 by facilitating the planning, development and implementation of sustainable national eye care programme based on the three core strategies of disease control, human resources development and infrastructure and technology, incorporating the principles of primary health care.”

Goal

Reduction of blindness by 50%, from 1.53% to 0.7% by 2020.

Purpose

Strengthen management and technical aspects of the eye care program for reducing preventable blindness including removal of cataract backlog in Bangladesh and for ensuring adequate availability of major eye care services at all nodal levels.

The targets for the 2011-2016 period

Indicator Baseline Projected target Mid-2014 Mid-2016 No. of adult cataract patients undergone 1,164 (2009 NEC) 1500 1600 surgery per million

No. of cataract patients received cash NA 6000 10000 voucher

No. of diabetic retinopathy cases received NA 2000 3000 service

No. of hospitals following standard protocols 150 (2009 NEC) 200 250

No. of child cataract surgery performed 4,000 (2009 NEC) 5000 5000 annually

The targets for the 2014-2020 period

1. 70% removal of cataract surgery backlog by 2017 and 100% by 2020;

2. >3 community health care providers per union in GO/NGO/private sector are capable to identify and refer cases of refractive error, cataract and suspected cases of glaucoma by 2020; 3. 20% of the primary schools by 2020 have teachers who identify students with refractive error, and cataract manually and refer them; 4. Creation and posting of mid-level ophthalmic personnel (optometrists and orthoptists) in 70% of the upazila health complexes by 2017 and in 100% upazila health complexes by 2020; 5. Identified physicians at all the upazila health complexes in the country by 2017 to diagnose and refer low vision, glaucoma, diabetic retinopathy and cataract cases to district hospital; 6. All district hospitals manage cataract (including in children above 10 years of age), low vision, glaucoma, diabetic retinopathy and follow up of all cases of cataract surgery by 2020; 7. All the poor (under safety net) children will get spectacles at all the upazila health complexes free of cost by 2020; 8. 50% of the identified poor people are covered under demand side financing for cataract surgery by 2020; 9. Sixteen adequately equipped pediatric tertiary facilities (one per ten million population) established to provide referral care including adult sub- specialties and pediatric surgical services (at least one per division). 10. National HMIS data base created to inform the NEC for planning, decision making, resource allocation and reporting

STRATEGIC PLAN

1. Expected outputs

2. Responsive and skilled eye health workforce available at nodal levels; 3. Management related information is available for assessing performance and for management decision; 4. Adequate medical products, facilities and technology are available at all levels of health care infrastructure for eye care; 5. Effective leadership and governance system has been developed for eye care and for developing plans and financing the plans at all levels; 6. Standards and required measures are available and implemented for improving and assessing quality and quantity of care; 7. Research in eye care conducted to generate evidence and for assessing attainment of objectives and targets; 8. Community participates in planning, implementation and program review; 9. Access to eye care services improved at all levels and more specialized services are available at lower levels; 10. People are more aware of the eye care problems, their causes, how to prevent those and where to get treatment for the different types of eye care diseases.

2. Prioritized actions

1. Strengthen management and clinical skill at all levels for eye care; 2. Strengthen management information systems for monitoring and supervision; 3. Procure medical products, facilities and technology; 4. Build/strengthen effective leadership and governance system; 5. Improve quality of care; 6. Conduct health systems and population related research; 7. Conduct advocacy and awareness raising among policy makers, managers, farmers and industrial workers on prevention of ocular injuries; 8. Ensure community participation in planning and implementation of population based programs; 9. Establish, expand and enhance access of sub-specialty services at lower levels.

3. Strategic actions

Strengthen management and clinical skill at all levels for eye care: (i) strengthen and activate BNCB, national and district Vision 2020 Committees; (ii) Form functioning of upazila Vision 2020 committees; (iii) strengthen project management at national and district levels; (iv) integrate national eye health program with primary health care structure and with urban health care structure, and establish vision centers at upazila health complexes; (v) establish subspecialty services (paediatric ophthalmology, vitreo-retina, cornea, oculoplasty, ocular trauma, glaucoma and low vision care) at teaching/ tertiary and divisional hospitals; (vi) Establishment of pediatric eye care facilities as per WHO recommendations including ROP service introduction in

21 coordination with Neonatal Intensive care Units; (vii) establish a National Center for Allied Eye Health Professionals at NIO&H for training of allied eye health professionals and ophthalmic nurses; (viii) develop effective continuous professional development (CPD) program for ophthalmologists especially in updating surgical skills; (ix) assign eye care services to one of the existing medical officers and nurses at upazila and district levels for indoor and operation theater; (ix) create posts and deploy eye care counselors and coordinators at district hospitals; (x) develop mid- level professionals for attaining the prioritized national and Vision 2020 goals (optometrists and orthoptists); (xi) strengthen human resources development process; (xii) ensure efficient utilization of all available resources, in particular the infrastructures, equipment and human resources in public, private and NGO sectors (at all nodal levels), with special focus on primary health care level (up to the community clinic level); (xiii) formulate a human resource development policy to maintain a balanced supply of trained personnel for ophthalmic services in the country; (xvi) pool and encourage private-NGO-public partnership resources to plan and manage implementation of the activities for eye health as per relative advantage of the partners; (xiv) develop national and local plans: (xv) strengthen monitoring framework; (xvi) orientate and train the available ophthalmologists and ensure that all of them perform cataract surgeries as per a given target; (xvii) orientate and train peripheral public sector and NGO workers for diagnosing and referring cases of cataract and other blindness and blinding conditions, i.e., glaucoma and diabetic retinopathy cases,

Management information systems for monitoring and supervision: (i) In collaboration with MIS, DGHS establish key eye health indicators (gender disaggregated where feasible) and data management formats for the national eye health programs; (ii) train personnel bestowed with the responsibilities of HMIS at different levels on the format; (iii) Facilitate data recording and reporting on eye care from all levels to HMIS; (iv) provide logistics support where necessary.

Procurement of medical products, facilities and technology (i) conduct assessment of logistics strength (and weakness) at each level in light of the available standard per level; (ii) provide logistical support, and operational and system maintenance costs at all nodal levels; (iii) make biomedical engineers available, if not available locally in the private sector at these levels for repair and maintenance of the standard sets of logistics; (iv) support from development partners.

Effective leadership and governance system development: (i) strengthen leadership and governance including supervision, monitoring and evaluation functions to support better quality of performance, coverage and service outcome; (ii) develop or support development of plans for national to local levels of eye care infrastructure; (ii) provide necessary logistics at all levels for strengthening management and leadership positions; (iii) recruit coordinators at district level for eye care; (iv) recruit consultants. (iv) conduct advocacy for resource mobilization among policy makers, planners, development partners and philanthropists.

Improvement of clinical service quality: (i) establish and strengthen quality assurance system of hospital care especially for cataract surgery; (ii) develop minimum service delivery standards and standard operating procedures; (iii) develop quality manuals and guidelines; (iv) develop standard post operation follow up protocols and utilize

22 those (v) review and update job description of relevant staff; (vi) conduct competency based training (vii) develop total quality improvement and management protocols and implement those; (viii) ensure appropriate and adequate logistics and maintenance systems (ix) institute continuous education seminars and symposia; (x) arrange public hearing of service outcomes; (xi) coordination and collaboration between government, private sector, non-government organizations, international NGOs and development partners; (xii) strengthen and effectuate referral pathways through development of standard memorandum of understanding between the referring and referred facilities and ensure timely referral, treatment and rehabilitation services

Health systems and population related research: (i) conduction of situation analysis to determine the prevalence of eye care problems by type and magnitude and utilization of eye care services and facilities; (ii) eye health workforce situation; and clinical protocols, guidelines and quality improvement protocols and their use at all levels of care; (iii) availability of service delivery standards; and gaps in priority actions; (iii) conduction of periodic research to assess strength and weakness of program activities and management, their impacts on the prevalence of eye problems and the remedies.

Design and implement awareness and communication interventions for: (i) improve demand creation for service utilization; (ii) conduct advocacy and awareness raising among policy makers, managers, farmers and industrial workers on prevention of ocular injuries and availability of services; (iii) improve knowledge of the people on the common eye problems, their causes, prevention and management services and availability of these services; (iv) sensitize people to participate in public hearings and to involve them in local level program management

Ensure community participation for: (i) planning, review and monitoring of eye care program (ii) coordination at operational levels between stakeholders; (iii) local resource generation. (iv) public hearing; (v) sustainability of the local Vision2020 activities; (vi) school based programs; (vii) management of eye camps.

Establishment, expansion and accessibility of eye care services: (i) strengthen program management (ii) develop and establish sub-specialty services (address problems of low vision by referral from all possible levels and strengthening of nodal infrastructures, address eye problems that are due to diabetic retinopathy and glaucoma through: (a) developing capacity to diagnose, counsel, prevent complication and refer cases from upazila level and also from private vision centers by development of a mid-level cadre of service providers for and through early identification of common blinding condition (e.g., cataract, refractive errors, diabetic retinopathy and glaucoma) , (b) break the barrier and opposition to developing a mid- level cadre of eye care providers by intensive orientation of the graduate and expert eye care providers and encouraging and supporting institutionalization of the suggested mid-level cadre of eye care providers, (iii) manage cases at secondary and tertiary levels by providing training to the ophthalmologists, (iv) providing required logistics at all the nodal levels); (v) hold community based screening camps for refractive error, low vision and cataract, (vi) institute primary school based screening for refractive error and low vision; (vii) facilitate adequate infrastructure development at all levels for catering eye care (viii) conduct awareness programs;

(ix) correct refractive error among primary school aged children through: (a) orientation of the teachers to suspect refractive problem among students, (b) orientation of the community clinic staff and NGO field workers to identify and refer visual acuity problems among primary school aged children during home visits and during those children attending community clinics for whatever reason by using Snellen’s Chart, (c) development of a cadre of optometrists to diagnose and prescribe for correction of refractive error (x) health education of family care takers at every level of health care infrastructure to suspect refractive problems among primary school aged children in their families, (xi) provision of spectacles among poor children;(xii) continue to keep vitamin A administration rate among children less than five years of age about 90 per cent and above and ensure administration of high potency vitamin A capsule to all post-partum women; (xii) Coordination and collaboration between government, non-government organizations, international NGOs and development partners.

4. RESULT FRAMEWORK Expected result 1: Responsive and skilled eye health workforce available at nodal levels

Activity Indicator Baseline Target 2020 Means of verification

1) Orientate and conduct refresher Number of district Not Available 64 Independent survey training for ophthalmologists on hospitals providing adult and pediatric cataract, low pediatric cataract vision, glaucoma and diabetic services effectively retinopathy

2) Train ophthalmologists on diabetic Number of district Not 64 Independent survey retinopathy and glaucoma hospitals providing Available? diabetic retinopathy and glaucoma related services effectively

3) Train mid-level auxiliaries Number of (i) upazila 0 (i) 50% (ii) 64 Independent survey (optometrists/ and (ii) district orthoptists/ophthalmic technicians hospitals where and nurses) for: optometrists/ (i) diagnosing and referring cataract orthoptists are and low vision cases providing standard (ii) prescription of eye glasses to services effectively refractive error cases (iii) diagnosing and referring diabetic retinopathy and glaucoma cases (iv) counselling

4) Train identified clinicians at upazila Number of upazila 0 481 Independent survey health complexes for: health complexes

(i) diagnosing and referring cataract where standard eye and low vision cases care services are (ii) prescription of eye glasses to being given refractive error cases effectively (iii) diagnosing and referring diabetic retinopathy and glaucoma

5) Train community clinic staff with Number of 0 100% of Independent survey the help of UHC clinician trained community clinics community on eye care services for: providing standard clinics (i) diagnosing and referring cataract eye care services (ii) diagnosing and referring refractive error and low vision cases (iii) suspecting and referring glaucoma cases (iv) referring diabetic cases with visual complaints

6) Train private and NGO service Number of private 0 33% of the Independent survey providers at community level with and NGO service eligible the help of UHC clinician trained providers working at on care services for: community level who (i) diagnosing and referring cataract are providing cases standard eye care (ii) diagnosing and referring refractive services effectively error and low vision cases (iii) suspecting and referring glaucoma and diabetic retinopathy cases

7) Train primary school teachers with Number of schools 0 25% of the Independent survey the help of the UHC trained which referred primary physician for suspecting and refractive error, low schools

referring refractive error, low vision vision and cataract and cataract cases cases

8) Develop, in collaboration with the Number of nurses Not Available 100% Progam management Bangladesh Nursing Council, its trained as graduate and report course curriculums for bachelor/ optometrist/ post-graduate master degrees and for mid level orthoptist nurses eye care personnel, i.e., orthoptist/ optometrist and technicians in/low vision/ posterior segment related diplomas

Expected result 2: Management related information is available for assessing performance and for management decision

Activity Indicator Baseline Target Means of verification

1) Update HMIS reporting format DGHS reporting format 0 01 Program management to include cataract, glaucoma provides space for report and diabetic retinopathy cases reporting eye care services and problems as per the requirement of the program management

2) Orientate MIS related staff of Percentage of eligible 0 >70% Independent survey tertiary, secondary and primary staff trained health care level staff including the CC staff on reporting selected eye diseases to HMIS

3) Report selected eye diseases (i) Percentage of (a) Not Available (i) >60% of Independent survey from different levels of health tertiary hospitals (b) facilities from care infrastructure secondary hospitals, each level (c) UHCs and (iv) CCs (ii) >80 of which report selected cases from eye diseases each primary (ii) Number of cataract health care cases reported from level and community clinics, and 100% from from NGO and private upper levels sector health care providers (iii) Number of cataract cases referred from population screening programs

4) Reports from institutions on (1) Percent of ? (i) 64 Program and cataract surgery and low vision estimated (a) cataract (ii) 10 district management report operated/ managed/treated, by and (b) low vision and 10 and Independent age category to the HMIS of problems managed at tertiary survey DGHS district hospitals hospitals (ii) Percent of (iii) NIO estimated diabetic retinopathy and glaucoma cases managed at identified district/tertiary hospitals

5) Update program and Program management 0 One every Program and management reporting format of report provides useful month management report

the line director (e.g., human information resources recruited and trained, allocations made and expended, documents prepared etc.)

6) Establish National Eye Care National Eye Care 0 >80% data Independent survey Observatory Observatory has available required data

7) Develop and operationalize a A monthly updated eye 0 Website is Independent survey website of the national eye care care website is appreciated program available by >70% of the users

8) Prepare and disseminate annual Annual state of the eye 0 One per year Direct observation state of the eye health report health report available

Expected result 3: Adequate medical products, facilities and technology are available at all levels of health care infrastructure for eye care

Activity Indicator Baseline Target Means of verification

1. Provision of equipment as per Number of (i) (i) 0 (ii) ? (i) 481 (ii) 64 Independent survey standard for cataract diagnosis/ upazila health surgery at: complexes (i) upazila health complex diagnosing (ii) district hospitals cataract with (iii) tertiary hospitals equipment and (ii) number of district hospitals conducting cataract surgery

2. Provision of medicines and Number of 0 481 Independent survey equipment as per standard for upazila health diagnosing and calibrating complexes refractive error and low vision at diagnosing (i) (i) upazila health complexes refractive error (ii) district hospitals and (ii) low vision (iii) tertiary hospitals by using equipment

3. Provision of eye glasses at: Number of (i) (i) 0 (ii) 0 (i) 240 (ii) 64 Independent survey (i) upazila health complexes upazila health (ii) district hospitals complexes and (iii) tertiary hospitals (ii) district hospitals providing eye glasses through DSF

4. Provision of Snellen’s chart at: Number of (i) (i) 0 (ii) 0 (i) 13500 (ii) Independent survey (i) community clinics, NGO and community clinics 33% private clinics (ii) district level and (ii) NGO public and private hospitals (iii) clinics using tertiary level public hospitals Snellen’s chart

5. Provision of appropriate Number of (i) (i) 0 (ii) ? (i) 481 (ii) 64 Independent survey equipment as per standard for upazila health diagnosing/ managing glaucoma complexes at diagnosing (i) upazila health glaucoma with (ii) district hospitals equipment and (iii) tertiary hospitals (ii) district hospitals with

medicine and equipment providing glaucoma related interventions

6. Provision of (i) medicine and (ii) Number of (i) (i) 0 (ii) 0 (iii) 3 (i) 481 (ii) 64 Independent survey equipment as per standard for upazila health (iii) 21 (iv) 5 diagnosing/ managing diabetic complexes (ii) retinopathy at and district (i) upzila health complex hospitals (ii) selected district hospitals diagnosing (iii) tertiary hospitals diabetic retinopathy with equipment, and selected (iii) district and (iv) tertiary hospitals; managing diabetic retinopathy

Expected result 4: Effective leadership and governance system has been developed for eye care and for developing plans and financing the plans at all levels

Activity Indicator Baseline Target Means of verification

1) Establish project Management Line director’s 1 1 Program and Unit at the office of the line office implements management report director, NEC for providing activities as per technical support in work plans implementing the action plan

2014-2020

2) Form an advisory body for the An advisory body 0 3 per year Program and line director and held meetings to the LD meets management report quarterly

1. Develop efficient joint Availability of 0 At 100% level Program and perspective plans, annual plans plans at every every year management report and work plans level developed by the stakeholders jointly

2. Mobilize development partners Percentage of ? >80% Program and and ensure availability of required fund management report required fund obtained

3. Ensure effective and efficient Percentage of ? >80% of Program and expenditure of budget and planned planned management report implementation of program as expenditure on expenditure per plan at all nodal levels on yearly basis at yearly basis each nodal level

4. Develop an M&E framework and Findings of mid- 0 > 80% of Independent survey conduct annual performance term and end- activities review, mid-term and end-term term evaluations completed evaluation efficiently

5. Develop necessary tools for a Participation by (i) 0 (ii) ? (iii) ? At (i) >240 Independent survey sector-wide unified monitoring all stakeholders UHCs (ii) 64 system at every level at (i) upazila districts (iii) level, (ii) district national level

level and (iii) national level in program monitoring

6. Develop an eye health workforce A health 0 01 Health master plan master plan as a part of the workforce master overall human resources for plan which health master plan, based on a includes eye situation analysis health care providers is available b. Recruit district eye health Each civil 0 64 Program and coordinators, as the secretary of surgeon’s office management report the district Vision 2020 has an effectively functioning district eye care coordinator c. Arrange yearly workshop for Availability of the Nil One per year Workshop report sharing experiences, study report of the findings, reviewing goal and workshop target attainment d. Conduct biyearly situation Availability of the Nil One every two Situation analysis analysis on knowledge, attitude report of the years report and practice of the people; situation analysis availability, access, quality and satisfaction of people and patients

33 e. Update the annual operational Updated annual 02 07 Annual operational plan as per study findings and operational plan plan annual workshop generated that is based on recommendations. Include policy activity 1 and 2 makers, planners and project under expected implementers in the annual result 12 workshops f. Include the 2014-2020 NEC Sector-wide plan One plan with One plan with Program and program in the overall sector-wide of the MoHFW insufficient fund sufficient fund management report plan and ensure enough budget includes eye care allocation in the plan for the as a program and management of human allocates resources, logistics including sufficient fund physical infrastructures (renovation and new constructions as per the need to suit the demands for quality services), maintenance and operational costs

Expected result 5: Access to eye care services improved at all levels and more specialized services are available at lower levels

Activity Indicator Baseline Target Means of verification

1. (i) Establish vision centers with (i) Number of (i) 0 (ii) 0 (iii) ? (i) and (ii) >60% Program report necessary equipment at UHC UHCs with of 481 UHCs OPDs (ii) ensure/ facilitate identified eye (iii) >80% of 64 availability of identified MOs and care trained MOs district hospitals counsellors in UHCs (iii) (ii) Number of (iii) in all 10 ophthalmologists, MOs- district hospitals selected tertiary

ophthalmology, optometrists/ with full fledged hospitals orthoptists, counsellors, at staff- district and tertiary hospitals in ophthalmologists, existing positions and in posts to ophthalmic MOs, be created for priority eye care optometrist/ortho services at: ptists, counsellors (iii) Number of tertiary hospitals with full fledged staff- ophthalmologists, ophthalmic MOs, orthoptists/ optometrists. Counsellors

2. In light of the eye health (i) One dedicated (i) 0 (ii) 0 (iii) 0 (i) 64 (ii) 481 Program and workforce master plan (i) modify counsellor for eye (iii) (a) 128 (b) management report job description of (a) one of the care is serving in 20 upazila health complex nurses each district (b) two of the district hospital hospital (ii) One nurses and (c) two of the tertiary of the nurses in hospital nurses to function as a each UHC is counsellor for eye care in serving as a addition to their usual functions counsellor (iii) (ii) modify job description of two two nurses are of the district and selected working in the tertiary hospitals nurses each to eye OT and serve in the eye OT and indoor ophthalmic indoor each at (a)

district and (b) tertiary hospitals

3. Conduct follow-up home visits No. of follow-up 0 100% of Independent survey for glaucoma and diabetic home visits made complicated retinopathy related services cases

4. Establish sub-specialty services (i) Selected 0 (i) 10 (ii) 10 Program and in 10 selected public sector district hospitals management report tertiary hospitals and 10 with specialists selected district hospitals, i.e., who manage low paediatric ophthalmology, vision, DR, diabetic retinopathy, glaucoma, glaucoma, low vision, posterior segment posterior and corneal/ oculoplasty clinics segment and pediatric ophthalmology cases and (ii) selected tertiary hospitals which also provide, corneal/ oculoplasty services

5. Institute universal health (i) Eye glasses (i) 0 (ii) ? (i) >80% of the Independent survey coverage/ demand side are available to ultra-poor in financing to cover travel costs, ultra-poor free of 481 UHCs (ii) costs of eye glasses, medicine, cost from UHCs, >80% of the follow up visits and for incentive (ii) Cataract ultra-poor in 64 for cataract surgery for the surgical cases district hospitals eligible patients (under safety are covered for

net) travel cost, follow up visits, medicines, surgery and other paraphernalia

6. Develop communication Communication (i) 0 (ii) 0 At (i) 481 Independent survey materials on availability and materials are upazilas and (ii) benefit of services, demand side adequately and 64 districts financing, free glasses etc. appropriately used at (i) UHCs (ii) district hospitals

7. Create upazila based Vision Number of 0 481 upazilas Program and 2020 Committees and orientate upazilas with management report the members annually functional Vision 2020 Committees 8. Orientate members for ensuring Number of ? 64 district Program and effective functioning of Vision districts with hospitals management report 2020 Committees at district functional Vision level annually 2020 Committees

9. Conduct population screening Biyearly camps ? 481 UHCs Program and programs after effective per upazila twice per year management report information disseminated in the catchment area

10. Conduct mass media based Percentage of 0 >70% Independent survey awareness programs planned interventions

conducted

11. Conduct inter-personal IPC conducted in ? 100% Independent survey communications (IPC) at all the every public health facilities health facility at all level

12. Provide counselling services for Counselling given 0 >100 (i) district Independent survey low vision, refractive error, in (i) tertiary and and (ii) tertiary diabetic retinopathy and (ii) district hospitals and cataract hospitals and (iii) >90% UHCs UHCs

13. Strengthen and effectuate All the 0 (i) >361 (ii) 64 Independent survey coordination and collaboration stakeholders between public sector, participate in joint community based organization, review and private sector and non- evaluation at (i) government organizations at the upazaila and (ii) district, upazila and community district level clinic levels.

16. Establish physical facilities for (i) Well equipped (i) ? (ii) 0 (iii) 0 (i) 64 (ii) 20 (iii) Independent survey efficiently functioning (i) eye eye units with >361 care unit in all district hospitals independent OT with dedicated full fledged are functional at operation theatres, (ii) district hospitals, subspecialty units (pediatric (ii) Vision centers ophthalmology, low vision, DR are functional at and oculoplasty etc.) in selected UHCs district and tertiary hospitals and (iii) vision centres in UHCs

Expected result 6: Standards and required measures are available and implemented for improving and assessing quality and quantity of care

Activity Indicator Baseline Target Means of verification

1. Prepare a standard list of A standard list of 0 1 Program and equipment/ tool for: equipment/ tools management report (i) community clinics is available for a. upazila health complex eye care at: b. district hospital (i) CCs c. tertiary hospitals (ii) UHCs (iii) district hospital (iv) tertiary hospitals

g. Prepare a standard list of A standard list of 0 1 Program and medicine for eye care at: medicine is management report i. community clinics available for eye ii. upazila health complex care at: iii. district hospital (i) CCs (ii) UHCs iv. tertiary hospitals (iii) district hospital (iv) tertiary hospitals

h. Develop a standard list of the eye A standard list of 0 1 Program and care services to be given at: eye care services management report (i) community clinics available for: (ii) upazila health complex (i) CCs

(iii) district hospital (ii) UHCs (iv) tertiary hospitals (iii) district hospital (iv) tertiary hospitals

3) Develop a standard list of A standard list of 0 1 Program and designated health workforce with workforce is management report job description for eye care at: available with (i) community clinics their job (ii) upazila health complex description for: (iii) district hospital (i) CCs (iv) tertiary hospitals (ii) UHCs (iii) district hospital (iv) tertiary hospitals

4) Update standard operating SOPs are ? (i) >80% Independent survey procedures (SOPs) practiced at (i) district hospitals district and (ii) and (ii) 100% tertiary hospitals tertiary hospitals

5) Develop a quality care manual A quality care 0 1 Program and with standard operating manual is management report procedures and include the available for: standard list of eye care services, (i) CCs workforce, equipment, tools, and (ii) UHCs medicine for: (iii) district (i) community clinics hospital (ii) upazila health complex (iv) tertiary

(iii) district hospital hospitals (iv) tertiary hospitals

6) Develop standard training Standard training 0 1 Program and materials for: materials are management report (i) community clinics available for: (ii) upazila health complex (i) CCs (iii) district hospital (ii) UHCs (iv) tertiary hospitals (iii) district hospital (iv) tertiary hospitals

7) Develop standard communication Standardized 0 As required Program and materials for (i) mass media and communication management report (ii) inter-personal communication materials are (IPC) to be used on prevention available for (i) and management of eye mass media, and problems at: (ii) IPC for (i) community clinics (i) CCs (ii) community based NGO and (ii) UHCs private clinics (iii) district (iii) upazila health complexes hospital (iv) district hospitals (iv) tertiary (v) tertiary hospitals hospitals

8) Develop (i) clinical guidelines, (ii) Percentage (i) 0 (ii) 0 (iii) ? (i) >100% at Independent survey good practice protocols, (iii) compliance by tertiary and quality care indices and standards eye department/ secondary for clinical service and unit staff of best hospitals and management for all levels of eye practice (ii) >80% in care infrastructure in addition to protocols/ quality other health

clinical SOPs care indices/ facilities standards

9) Establish monitoring of Percentage of Not available >80% Program and compliance of quality protocols planned reviews management report and guidelines at secondary and of monitoring tertiary hospitals held on practicing of quality protocol and guidelines at each hospital

10) Conduct monthly continuous Percentage of ? (i) >80% in Program and professional development and planned tertiary management report education sessions at secondary continuous hospitals and and tertiary hospitals education (ii) >60% in sessions held at district hospitals each hospitals

11) Establish national center for eye Number of (i) (i) ? (ii) 0 (iii) 0 (i) 100% (ii) health professionals at NIO&H for ophthalmologists 50% (iii) 25% training and surgical and trained (ii) MOs, microsurgical skill development of optometrists/ ophthalmologists, pediatric orthoptists and anesthetist, ophthalmic nurses other allied eye with particular attention to health pediatric eye are nursing, allied professionals eye health professionals in trained, (iii) particular pediatric refractionist, ophthalmic pediatric technician nurses trained

12) Conduct pre and post surgical Percentage of ? Review made Independent survey reviews of cataract surgery eye care for > 70%

departments/ cataract units achieving surgery note post operative sheets visual acuity >6/18

13) Ensure effective two way referral No. of home visits 0 50% of Independent survey system for diabetic retinopathy made for diabetic identified cases cases retinopathy

14) Arrange periodic clinical audit at No. of clinical ? Two per month Independent survey tertiary and secondary hospitals audits conducted in >80% hospitals

Expected result 7: Research in eye care conducted to generate evidence and for assessing attainment of objectives and targets

Activity Indicator Baseline Target Means of verification i. Conduct assessment on quality A comprehensive Not available One in 2015 Assessment report and appropriateness of current assessment report and one in residency programs and and identification 2019 institutional assessment of gaps and areas for standardization ( international ) ii. Conduct research on eye health A research report Not available One in 2014 Research report seeking behaviour of the people is available with and one in in general and for the children in good 2019 particular recommendations

iii. Conduct research on improving A research report Not available One in 2015 Research report management efficiency in eye is available with and one in care services at district and good 2020 tertiary hospitals recommendations

iv. Conduct prevalence study on (i) Prevalence rates Two One in 2017 Research report cataract (ii) low vision, (iii) are known for the and one in refractive error (iv) diabetic most common eye 2020 retinopathy and (v) glaucoma by problems gender and economic status

v. Conduct survey on people’s A research report Not Available One in 2014 Survey report knowledge, attitude and practice, is available with and one in specially for children by gender, good 2019 economy for eye problem recommendations vi. Conduct study on the availability A study report is 0 One in 2014 Study report of infrastructure, logistics, human available with and one in resources and fund for eye care good 2020 at: recommendations (i) community clinics (ii) upazila health complex (iii) district hospital (iv) tertiary hospitals vii. Conduct baseline survey on A survey report is 0 One in 2014 Survey report prevalence of diabetic retinopathy available with and other issues related to it good including its precipitating factors recommendations by gender and economic status on how to improve the results of treating diabetic retinopathy

44 viii. Conduct survey on the A survey report is 0 One in 2014 Survey report satisfaction of the people with available with regard to eye care services by recommendations gender and economic status on utilization of eye care services

ix. Strengthen knowledge Number of Not Available 33% increase in Program management management capacity of the research papers published report ophthalmologists published in peer papers in peer reviewed journals reviewed journals

Expected result 8: Community participates in planning, implementation and program review

Activity Indicator Baseline Target Means of verification

i. Plan, review and monitor eye Proof of 0 In 100% Program management care program participation of districts by report people in local 2016 and 100% level management upazilas by of eye care 2020 program

ii. Coordinate stakeholders at Participation of all 0 In 100% Program management operational levels stakeholders in districts by report local level review 2016 and 100% process upazilas by 2020 iii. Generate resource locally Percentage 0 15% at each Program management increase in locally nodal level by report arranged funding 2017 and 35% for eye care by 2020

program

iv. Arrange public hearing Public hearing 0 In 100% Program management held periodically districts by report on goal attainment 2016 and in every upazila by 2020

v. Keep local Vision2020 activities Planned number 10? In 100% Program management alive and kicking of meetings of districta by report Visions2020 held 2016 and in at each nodal 100% upazilas level by 2020

vi. Participate in school based Percentage of 0 20% of schools Program management programs planned school by 2016 and report based program, 50% by 2020 that were participated by the community vii. Participate In management of Percentage of ? 100% by 2018 Program management eye camps planned report

Expected result 9: People are more aware of the eye care problems, their causes, how to prevent those and where to get treatment for the different types of eye care diseases review

Activity Indicator Baseline Target Means of verification

i. Develop standard communication Number of ? 3 each type for Survey report messages for mass media and messages IPC (posters, interpersonal communication produced fliers and

stickers) 2 for mass media ii. Produce training plans and train Percentage of 0 100% districts Program report potential communicators in public relevant staff by 2016 and and private sector/ NGOs trained at nodal 100% upazilas levels by 2020

iii. Develop plan and procure and Percentage of 0 100% per Survey report produce communication planned materials planned year materials used or available for use iv. Develop plan and conduct mass Percentage of 0 In >80% Survey report media and interpersonal planned mass districts and communication at all nodal levels media and IPC >35% of conducted upazilas and the rest by 2019

CONCLUSION

The NEC program, in collaboration with other development partners will conduct 3,000 cataract surgeries/ million population per year. 80% of the Ophthalmologists are working in public sector, whose current performance is equivalent to 20%. If the performance level increases significantly and if the private and NGO providers also further increase their performance, e.g., in cataract surgery, the present backlog could be removed in two years, theoretically speaking, in Bangladesh. This means that the available ophthalmologists in Bangladesh will have to conduct 100 cataract surgeries per month per head, which is an easily doable proposition, although at present out of 900 ophthalmologists in the country only 30% to 40% conduct cataract or micro-surgery at a rate of only 4 to 5 per week. The cause of underperformance is due to work environment, lack of monitoring, incentives and governance. The NEC, INGOs and NGOs have to work more collaboratively to remove the backlog and set examples through effective leadership and management. Supply of necessary equipment and other paraphernalia to these ophthalmologists along with orientation, training and incentives will have to be the supply side priorities, while other measures will be required as shown above to address the demand side issues. Coordination of the partners will also be an onerous job of LD, NEC to spread the resources and services from all the partners equitably throughout the country.

The following tool (table) may be used to update the stated services and coverage provided by the public-private and NGO sectors for a better coordination of services by location, to avoid duplication or absence of services in a given location as well as sharing resources among all the development partners, private and public sector in eye care efficiently.

Coverage of districts by service type and service providers (Template): District Services* (add Refractive Cataract Glaucoma Diabetic Oculoplasty Low row) error retinopathy vision

* The cells are for mentioning the abbreviated names of the partners if these are giving the mentioned services

REFERENCES

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