Issue 2018

Vision & Development Ophthalmology in Development Cooperation

Human Resources for Eye Health Vision & Development Ophthalmology in Development Cooperation Issue 2018

Human Resources for Eye Health

ARTICLES

Dr. Amir B Kello Human Resources for Eye Health (HReH) in Sub-Saharan (SSA). 4

Ronnie Graham Achievements in Advocacy for HReH in SSA . 6

PRACTICE

Elie Bagbila The Development of HReH in . 8

Dr. Sisay Bekele HReH Development in . 10

Nunes Sampaio Development of HReH in . 12

Wolfgang Gindorfer The NIURE Experience, . 14

Impressum: Editor and publisher: Light for the World International Responsible for content: Rupert Roniger Photos: All photo by Light for the World Graphic design: www.nau-design.at, Barbara Weingartshofer

If you are interested in an earlier issue of VISION & DEVELOPMENT, please e-mail [email protected] Dear Reader,

Globally there were an estimated 253 and established its first national ophthalmol- million visually impaired people in 2015 of ogy training programme in Ouagadougou­ whom 36 million people were blind and 217 (page 8), Uganda that trained OCOs as million people had severe or moderate visual refractionists and also started training of impairment. A further 1.1 billion people had optometrists for the first time in the country near-vision impairment. 89 % of visually and Ethiopia that significantly contributed impaired people live in low and middle- to increasing the number of trained ophthal- income countries; and 55 % of visually mologists and allied ophthalmic personnel in impaired people were women. However, the country through two residency training in Sub-Saharan Africa available human programmes in Jimma and Gondar although resources for eye health are inadequate to only the programme in Jimma is highlighted meet the challenge (page 4). here (page 10). There are many agendas in the eye health With the anticipated increase in the sector in Sub-Saharan Africa, from a specific ­demand for eye health services due to popu- disease focus to technology, evidence and lation growth and ageing, Sub-Saharan Africa financing but one issue around which every- should make the right decisions regarding one can unite is the need to strengthen the its HReH policies to be adopted now in the eye health workforce. Mr. Graham describes context of future anticipated eye care needs the role of strategic advocacy in resolving the of its population and ensure the HReH needs human resources for eye health (HReH) work- are met. force crisis in Sub-Saharan Africa (page 6). Considerable progress has been achieved in the field of HReH development with the support of LIGHT FOR THE WORLD in many countries in Sub Saharan Africa including Mozambique that produced results in training of ophthalmic technicians and ophthalmolo- Dr. Amir Bedri Kello, gists (page 12), Burkina Faso that managed Director Eye Health/NTDs to increase the number of ophthalmologists Light for the World

We thank our partners!

Dr. Silvia Bopp Stiftung 4 VISION & DEVELOPMENT LIGHT FOR THE WORLD

Human Resources for Eye Health (HReH) in Sub-Saharan Africa (SSA)

Dr. Amir Bedri Kello, widely recognised as one of the most fundamental con- Director Eye Health/NTDs, Light for the World straints to achieving progress on health generally and eye health specifically. Due to lack of adequate human resources for eye THE BURDEN OF EYE DISEASES health and poor eye care service delivery systems in According to the recently published data in The Lancet most of the SSA countries, cataract still remains the Global Health by the Vision Loss Expert Group, globally leading cause of blindness in SSA. Cataract is a treatable there were an estimated 253 million visually impaired condition with an intervention that is known to be very ­people in 2015 of whom 36 million people were blind and cost-effective. Moreover, emerging conditions such as 217 million people had severe or moderate visual impair- posterior segment diseases like glaucoma, diabetic retin- ment. A further 1.1 billion people had near-vision impair- opathy and macular degeneration are gaining increased ment. 89 % of visually impaired people live in low and importance as causes of blindness and vision impairment middle-income countries; and 55 % of visually impaired and require sub-specialist level qualifications for their people were women. proper management. In Sub-Saharan Africa (SSA), there were 4.3 million HUMAN RESOURCES FOR HEALTH IN SSA people who were blind and further 17.4 million people who had severe to moderate visual impairment. The prevalence Of the many challenges faced by the health sector in of vision impairment, including blindness and MSVI, was SSA, the human resources for health (HRH) issues are the highest in Western SSA and the lowest in Southern among the major ones. Existing weaknesses in health sys- SSA (Table 1). tems including shortage of skilled health workforce in ma- Although SSA has very high burden of eye diseases, jority of the countries is recognized as a major challenge it has inadequate number of eye care cadres to address to delivery of essential health interventions and progress these challenges. The critical shortage of health workers towards achieving health objectives in SSA. Of the 46 in SSA, including human resources for eye health, is now countries in the Region, 36 have critical shortage of HRH,

TABLE 1: REGIONAL BURDEN OF VISION LOSS IN SUB-SAHARAN AFRICA

Source: Compiled from data presented by the IAPB Vision Atlas

Region Number of Population Prevalence Number Near VI Countries in millions of VI Number Blind Number MSVI in millions

Western SSA 19 391 5.58 % 1,891,551 7,854,587 41.2

Central SSA 6 114 4.58 % 309,618 2,046,239 11.6

Eastern SSA 15 376 4.57 % 1,660,526 6,227,415 36.0

Southern SSA 6 78 3.33 % 419,063 1,231,151 12.3

Total 46 959 4,280,758 17,359,392 101.1 HUMAN RESOURCES FOR EYE HEALTH 5

TABLE 2: DISTRIBUTION OF EYE HEALTH WORKERS IN SUB-SAHARAN AFRICA

Ophthalmic Ophthalmologist Optometrist nurses & AOP

Minimum required 4 10 10 per million population

Actual number Total per million population Population

Anglophone 2.4 12.7 7.1 574 million

Francophone 2.1 0.5 4.6 281 million

Lusophone 0.9 1.1 3.8 53 million

Total for Sub-Saharan Africa 2,038 7,529 5,561 908 million

8 with only about 0.8 physicians, nurses and midwives per ­reducing vision loss by 25 % by the year 2019. As the 1000 population while the minimum acceptable density VISION 2020 initiative and the GAP both indicate, the threshold is 2.3 per 1000 population. required HReH need to be available, appropriately skilled, The following factors have been identified by WHO/ supported, and productive. HReH should not be seen as a AFRO as the main reasons for the shortage of health stand-alone entity that needs to be addressed separately workforce in SSA that constitutes a key impediment to but as being part of the six health systems building blocks meeting the needs for health care delivery: migration of that are interdependent. Eye care service provision is not qualified health workers, inadequate remuneration and only linked to availability of HReH but also equipment incentives, maldistribution of the available health workers, and supplies, financing, information flow, and governance underinvestment in the training of sufficient number of at the implementation level. Weaknesses in one of the health workers, inadequate capacity of HRH departments ­sectors impacts the others. to carry out the main HRH functions, and low or inade- IAPB Africa has identified HReH as the major factor quate implementation of most of the existing HRH plans. for ensuring eye care services in SSA and has formulated The situation of HReH in SSA is no exception in this regard. its HReH Strategic Plan 2014 – 2023. SSA countries are investing increasingly in the training of ophthalmologists, MAJOR CHALLENGES IN HREH optometrists and AOP. Considerable progress has been made after the The shortage of trained eye doctors has forced some launching of the WHO global initiative in 1999 to eliminate SSA countries to revert to what is called task shifting to avoidable blindness by the year 2020: VISION 2020 – The address the eye care services need of their population Right to Sight. Human resources development was one of including provision of cataract surgery by non-physician the three pillars of the VISION 2020 – The Right to Sight cataract surgeons who were expected to be placed in rural initiative. However, most of the countries in the SSA still do areas with no ophthalmologists. Although task shifting has not meet the recommendation for the minimum number of been successfully implemented in some countries of the eye care cadres that was set by the WHO. SSA, where they could guarantee an ongoing supportive The shortage in HReH is particularly pronounced in supervision and oversight by the respective ministries of Francophone and Lusophone countries of SSA. The chal- health, in most cases this cadre is plagued with low pro- lenge is not only due to the inadequate number of HReH ductivity due to lack of the necessary support. but also issues of maldistribution with the majority of eye Task shifting should not be seen as the solution for care workers residing in the capital cities or few other big every problem in HReH and it cannot be an answer for the cities leaving most of the population that lives in rural emerging eye conditions that are mainly diseases of the Africa with no or little eye care services if at all. posterior segment. These diseases require well trained and qualified ophthalmologists preferably at sub-specialty­ WHAT IS BEING DONE ­level. HReH policies adopted now in SSA regarding More recently, WHO has developed Universal Eye specific cadres should be viewed in the context of future Health—the Global Action Plan (GAP) with the goal of anticipated eye care needs of the region. 6 VISION & DEVELOPMENT LIGHT FOR THE WORLD

Achievements in Advocacy for HReH in SSA

Ronnie Graham, Independent Consultant, Lower Largo, Scotland.

1. THE CRISIS IN THE EYE HEALTH WORKFORCE IN SSA w what you There are many agendas in the eye Kno t to change health sector in Sub Saharan Africa, wan from a specific disease focus to tech- in fl Id nology, evidence and financing but u e e n n t one issue around which everyone can c if in y s unite is the need to strengthen the s g b

e s e r t s r eye health workforce. g t a o & t r e The population of Africa will dou- r p g o

t n y ble by 2050 and many new challeng- i o n

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SSA is failing to meet even the mini- e mum requirements for its eye health workforce, far less the expectations of comprehensive eye Health. e In response to this growing crisis, s n i a I ev l IAPB Africa developed a regional m D p pl on ac em ti advocacy plan to support its new Hu- tio ent ac n man Resources for Eye Health Strat- plan egy, A Vision for Africa: 2014-2023, providing direction for all subsequent advocacy activities by IAPB Africa.

2. WHAT IS Advocacy appears regularly on inevitable challengers, opponents STRATEGIC ADVOCACY many list of priority activities to be and critics. It is therefore essential What exactly is advocacy and how undertaken in eye health but in most that all stakeholders unite behind can we all engage in the process? cases, little is actually done to take the same issue and speak with one Advocacy involves a change in both the agenda forward, despite the fact loud voice. policy and practice, but effective that we have abundant ammunition at Strategic advocacy can be under- advocacy always requires a change in our disposal such as ­evidence-based taken at a number of different levels, practice. arguments of the total burden of or domains. Regional advocacy It is about change. eye disease (1 in 4) and the potential involves working with WHO-Afro and It is systematic. return on investment (1 to 4). the African Platform for HRH: Sub-re- It takes time. Advocacy plans must be feasible, gional advocacy involves working It is ‘low cost’, but is not ‘no cost’. affordable, realistic and be present- with the sub-Regional Health Author- Finally, it is always contested! ed professionally—and ready for the ities and professional bodies. HUMAN RESOURCES FOR EYE HEALTH 7

3. HOW ADVOCACY CAN National advocacy, as promoted successful and towards the end HELP US RESOLVE THE by IAPB over the last few years, fo- of June 2017 IAPB was advised WORKFORCE CRISIS cuses on assembling all key stake- that “The Department of Health holders in the country—including Integration, of all aspects of the has revised the national HRH plan the HRH Directorate, the National Global Action Plan, is central to which addresses HReH significantly. Eye Care Coordinator, professional improving eye health in Africa. This The Ministry is finalizing its 5-year bodies, training institutions, civil so- includes integrated workforce plan- ­national eye care strategic plan which ciety and the international eye health ning. There are 2 clear steps in the also incorporates the issue of HReH agencies, because, ultimately and process (1) Using strategic advocacy abundantly”. The new National HRH despite any number of international to achieve integrated workforce Plan was attached. resolutions and declarations, change planning and (2) Using the same Having successfully integrated happens at the national level. advocacy tools to increase govern­ the planning of the current eye IAPB Africa initially focused ment funding for the eye health health workforce (ophthalmologists, on 5 countries, Senegal, Ghana, workforce (training, deployment and optometrists, cataract surgeons and ­Cameroon, and Mozambique, retention). In practice, some coun- ophthalmic nurses) into the new adding 6 more in 2015—Mali, Burkina tries followed the advocacy planning national HRH plan, much still remains Faso, Malawi, Zambia, and process rigorously whilst others to be done. Uganda and 3 more in 2016— have been able to take short cuts to The HReH advocacy group can Ethiopia and Benin, reflecting the achieve the same objective, making be further strengthened with the full regional and linguistic diversity of use of the WHO WISN workforce participation of all stakeholders in the continent. planning tool to reinforce the IAPB eye health: More detailed planning of The IAPB strategy had the initial planning process. the eye health workforce needs to be goal of integrating HReH into the undertaken to ensure a workforce ‘fit 4. CASE STUDY: ETHIOPIA national HRH plan, with the ultimate for purpose’ and, perhaps above all, objective of increased budget alloca- A small delegation from Ethiopia the advocacy group must continue tion to support the expansion of the participated in the IAPB advocacy to push for increased government eye heath workforce. capacity building workshop in Togo support for the eye health workforce Such an achievement would mark in January 2017. At that time, Ethiopia as part and parcel of the global, a major paradigm shift whereby­ had just developed a new national movement to resolve the health ­Ministries of Health assumed a eye care plan and a new national workforce crisis. ­greater responsibility for their eye HRH plan. However, the 2 plans were 5. CONCLUSIONS health workforce. This basic propo­ not linked: The first being a vertical sition is outlined below. disease control plan and the second Strategic advocacy, if done well, a cross cutting approach to health can produce impressive results. It is 1. Governments have not historically system strengthening. On their return an approach and a set of skills which prioritised eye health home, the team moved quickly and all eye health agencies can adopt if 2. But they invest heavily in the at the end of February, the Techni- we are to break the cycle of mobi- health workforce (33 % of health cal Advisor for Eye Health shared a lising ever increasing resources to budgets) progress report noting that: support isolated eye health projects 3. This is an opportunity to integrate “After the meeting, I communi- in an increasing number of countries. the eye health into workforce cated with persons in HRD. They Donor supported projects are a planning have developed a HRH plan and useful and important addition to 4. While the ‘fiscal space’ for health even though it is already endorsed national eye health programmes varies enormously from country to they have promised to include HReH but without national ownership country, health budgets are gener- into the existing HRH document. To and investment we will continue ally increasing, according to WHO. progress our advocacy on the above to struggle with the ‘development and other important issues, we have dilemma’ whereby increased donor Since then, Ethiopia, Zambia, to develop a steering committee support simply relieves government Malawi, Mozambique, Kenya, South from our NCPB and human resource of its responsibilities for the health of Africa and Cameroon have succeeded directorate.” its people and distorts their efforts to in integrating eye health workforce This approach to bringing about strengthen health systems and there- planning into national RH plans. change at the national level proved by achieve universal health coverage. 8 VISION & DEVELOPMENT LIGHT FOR THE WORLD

The Development of HReH in Burkina Faso

Elie Bagbila, Country Representative, Light for the World—Burkina Faso

In Burkina Faso, as in many countries in Sub-Saharan Africa, the 2010, respectively only one can- health workforce gap is the main challenge for the development of didate was recruited. The lack of enthusiasm for ophthalmology was comprehensive eye health services. Light for the World, in col- striking: “Ophthalmology does not laboration with its partners, including the Austrian Development put food on the table”. In addition, Agency and L’Occitane Foundation, has made human resources in the lack of coordination between the National Eye Health Programme and eye health its focus in Burkina Faso for more than a decade. the Human Resource Department led to not respect the placement of 1. THE HIBERNATION PERIOD Rehabilitation programmes, using the ophthalmologists in priority regions OF EYE HEALTH PROFES- workforce of neighbouring countries. as stipulated in the contract. SIONALS (1980 – 2005) Light for the World strengthened 2. THE AWAKENING: In the 1980s and 1990s, the fight its advocacy at all levels, including FIRST STEPS FOR against blindness in Burkina Faso reinforcing relations with the Oph- HUMAN RESOURCES IN focused mainly on onchocerciasis thalmological Society of Burkina Faso EYE HEALTH (2005-2015) and the mass distribution of drugs. (SBO) and raising awareness of the The number of ophthalmologists The 2006 census on HReH showed Human Resource Department of the remained almost the same for a long that Burkina Faso had 25 ophthal- Ministry of Health. The results were time, with around 20 ophthalmolo- mologists and 130 ophthalmic nurses. encouraging. In total, between 2009 gists all concentrated in the major Only 4 of the 13 regions had oph- and 2018, Light for the World trained urban centres. Gradually, in the years thalmologists and more than half 9 ophthalmologists for Burkina Faso, 1990 to 2005, awareness increased of the health districts at the time and all of them, with one exception, about the need to strengthen human had no coverage in eye care what- are placed outside of Ouagadougou. resources for eye health (HReH). soever. 68 % of ophthalmic nurses Additional 2 ophthalmologists will Slowly we witnessed the arrival of a worked in Ouagadougou and Bobo graduate in 2018 and should also be new generation of ophthalmologists Dioulasso. After having started its placed in priority regions. after a lethargy in the recruitment activities in Burkina Faso in 2004, In parallel, Light for the World in- and training of specialists by the Light for the World opened a Country tensified its advocacy in 2008-2009 Ministry of Health. The training of Office in 2009, and immediately for the recognition of eye health as a cataract surgeons was used as a pal- began its ophthalmology scholarship health priority. The second national liative solution to compensate for the programme with IOTA in Bamako, strategic plan for eye health 2009 – lengthy duration of the ophthalmol- Mali. The approach was simple: The 2013 dedicated a whole chapter to ogy training that took place outside Ministry of Health took responsi­ human resource development. At the country. At the time, Burkina Faso bility for the recruitment, scholarship regional levels, Light for the World had 28 cataract surgeons. The first ­administration, inclusion on govern- supported the inauguration and national eye health plan 2003 – 2007 ment payroll and placement of the development of the Ophthalmolog- experienced major challenges in newly trained eye doctors. ical Centre of Zorgho in 2004 and implementation. At the community The programme did face some projects to increase and improve the level, eye health services were mainly challenges at first. Out of the 5 service provision in collaboration with organised by Community-Based scholarships available in 2009 and public hospitals in Nouna, Koudou- HUMAN RESOURCES FOR EYE HEALTH 9

health training modules for teach- ers, primary and community health workers were started.

4. TAKING FLIGHT: ­PERSPECTIVES THAT GIVE HOPE (2018 – 2022)

Admittedly, there are still major challenges in terms of human re- sources in eye health in Burkina Faso. For example, the country still has no sub-specialist ophthalmologists in the areas that have become increas- ingly important, including glaucoma, diabetic retinopathy, paediatric oph- thalmology, and so on. Optometrists and assistant optometrists, awaiting gou and Ouahigouya. A strategy to tical skills of students. The lack of recognition by the Ministry of Health, strengthen the knowledge of com- enthusiasm of young doctors was no are only three! That said, we estimate munity, primary health workers and longer a problem: Indeed, the first that by 2022 there will be at least traditional healers about eye health batch of ophthalmology residents 55 ophthalmologists, and that each began in 2013. counted 6 doctors, and currently the health region will have at least one 4 ongoing batches of the DESOPH ophthalmologist, a big step forward 3. THE BOOST: include a total of 20 doctors. for the country. IMPROVED QUANTITY At national level, in collaboration In November 2017, Light for the AND DISTRIBUTION with the International Agency for World and the Ministry of Health (2015 TO THE PRESENT DAY) the Prevention of Blindness (IAPB) organised a workshop for the devel- In 2016, Burkina Faso had 33 oph- in 2015, Light for the World advocat- opment of HReH, bringing together thalmologists in 7 out of 13 regions. ed for the integration of HReH into a wide variety of relevant stakehold- Despite this success, the pace of human resources for health plan- ers (different departments of the training ophthalmologists was still ning. A special emphasis was placed Ministry, professional bodies, train- not sufficient to meet the enor- on optometrists, a cadre that is still ing institutions, NGOs and donors). mous and growing need for HReH. not recognized by the public service. This workshop, that has resulted Scholarships outside the country are A major victory so far has been the in a National Human Resources for expensive and young doctors found inclusion of optometrists into the Eye Health Development Plan, has the conditions of recruitment unfa- revision of health cadres awaiting marked a new page in the history of vourable. In this perspective, Light approval by the Council of Ministers. this sector in Burkina Faso. The plan for the World supported the initia- Most importantly, as ophthal- provides a clear vision for all con- tive of the Ministries of Health and mologists became more available cerned about the need and priorities, Higher Education and SBO to devel- in the regions, eye health services not only with ophthalmologists in op a Diploma of Advanced Studies could be strengthened for the rural mind, but looking at the entire eye in Ophthalmology (called DESOPH) populations. The ophthalmologists care team, including optometrists, at the University of Ouagadougou. In trained and placed in regions were ophthalmic nurses, primary and com- 2014, Light for the World supported provided with equipment to practice munity health workers. an exchange visit to IOTA for repre- what they learnt. To support the This new chapter for eye health sentatives of the DESOPH teaching operationalisation of the national will see the arrival of sub-specialists team. The DESOPH opened its doors eye health plan 2016-2020, a first and optometrists in Burkina Faso, the to the first students in 2015. In 2016 regional eye health plan was devel- qualitative development of training and 2017, Light for the World sup- oped in the Centre Ouest in 2016, centres for all eye health cadres, and ported DESOPH to acquire didactic followed by the Boucle du Mouhoun the integration of eye health into the materials and teaching equipment, (in collaboration with cbm) in 2017. training of primary and community with a strong emphasis on prac- Initiatives to develop national eye health workers. 10 VISION & DEVELOPMENT LIGHT FOR THE WORLD

HReH Development in Ethiopia The Case of Jimma University Department of Ophthalmology (JUDO)

Dr. Sisay Bekele, Head Department of Ophthalmology, JUDO

Adequately trained eye care workers are one of the core compo- nents in the prevention, treatment and rehabilitation of avoidable blindness. Human resource development was one of the three pillars for the achievement of “VISION 2020: The Right to Sight” that was launched in 1999.

Although, Ethiopia launched gic plan for eye care. The NGOs also tion to the training activities, the VISION 2020 initiative in September advocated for the need to expand department has been delivering a 2002 and human resources devel- training centres for ophthalmologists comprehensive eye care service at opment was one the areas included and started supporting university base hospital and in the satellite eye in the subsequent national strategic hospitals to open residency training outreach centres in the southwest- plans for eye care, implementation programmes outside of the capital ern part of Ethiopia. Ophthalmology was a huge challenge. Training of eye city. residency programme is the main care workers was limited to very few Light for the World is among training programme run by JUDO. centres and until 2006 only Addis the NGOs in the country who have This programme has faced several Ababa University was running the played a huge role in supporting the ups and downs to reach at current training of ophthalmologists at Mene- expansion of the training of mid-lev- stage. Light for the World has been lik II Hospital. As a result, there were el eye care workers and residency instrumental to solve the challeng- disproportionately small number of programme for ophthalmology. es together with JUDO and for the ophthalmologists in the country and With the establishment of a resi- sustainability of the programme by only few hospitals in the country had dency training programme in Jimma giving direct and indirect support trained ophthalmologist in place to town, Jimma University Department for the training programme. Through give comprehensive eye care service. Ophthalmology (JUDO) became the the support of Light for the World, To make the matter worse, the few first residency training programme JUDO became a well-equipped cen- available ophthalmologists were outside of the capital, Addis Ababa. tre to run the residency program for concentrated Addis Ababa and other Moreover, the construction of a new training of ophthalmologists. So far, main cities of the country, making tertiary eye care unit with differ- it has graduated 8 ophthalmologists equitable access to eye care service ent facilities has played a pivotal and there are currently 13 residents impossible. To tackle the challenge, to enable the department to carry in training. NGOs working on eye health in the out multifaceted tertiary eye care The post-basic BSc program in country supported the training of dif- service, ophthalmic training and cataract surgery that was started ferent eye care cadres including that research undertakings. in 2006 graduated a total of 24 of ophthalmologists and mid-level Since 2006, JUDO has been cataract surgeons over a period of eye care workers to address the running postgraduate programme in 6 years. The support of light for the priorities set in the national strate- Ophthalmology Specialty. In addi- world was tremendous during this HUMAN RESOURCES FOR EYE HEALTH 11

period. There were a lot of challeng- providing basic books and some giving hands-on training for the es to undertake the training. Among instruments which are important for ophthalmologists at the department. the challenges were shortage of ophthalmic residents. Some of the This was of a paramount importance academic staffs, limited numbers of residents were also sent to in skills transfer. Through this pro- equipment and shortage of consum- to get exposure to state of the art gramme, some of the non-existing ables. Light for the world committed ophthalmic care. This has been subspecialty clinics were established itself to alleviate the challenges. The instrumental to motivate residents and the services that are given provision of incentives for the staff and attract other doctors to join the improved the quality of the training members has partly contributed for profession as one of the main chal- and the eye care service delivery the improvement in the number of lenges for the residency programme for the patients. Every year, some of academic staff needed for the train- was shortage of applicants. Light for the ophthalmologist from JUDO are ings and nearly all the equipment the World had also created a forum sponsored by Light for the World that our department possesses were with the regional health bureaus to to attend national and international donated by Light for the World. create awareness on the demand conferences. This gave the ophthal- Those have significantly changed of ophthalmologists and the need mologists a forum for continued the quality of the training given to to sponsor trainees by the regional professional development and it has the eye health care workers. Light health bureaus for deployment in a direct impact on the quality of the for the world was also the sole sup- their regions. training. porter of the outreach programme Light for the World has been In general, through the support of that our department is still running. working on continuing staff de- Light for the World, Jimma Univer- This program supplemented the velopment at the training centres. sity Department of Ophthalmology training programme by giving more Ophthalmologist were sent to some has contributed towards human exposure for the trainees to develop centres in Europe to get exposure resource development of the coun- their surgical skills as well as their to the modern eye care system and try by producing mid-level eye care knowledge on conducting outreach acquire theoretical knowledge by workers and ophthalmologists. This eye care service as it will be part of observing the Professors. Professors has improved the HReH to popu- their future career. from Medical University of Graz, lation ratio, which is translated to Light for the world has also been Austria and other universities in equity and access to eye care service giving support for the residents by Europe were visiting JUDO and were in the country. 12 VISION & DEVELOPMENT LIGHT FOR THE WORLD

Development of HReH in Mozambique

Nunes Sampaio, ing the prevalence of avoidable visual Health Sciences. This is how the first Senior Programme Officer impairment in the country. Light for mid-level promotional course of oph- for Eye Health, the World’s support was focused on thalmic technicians started in 2011 in Light for the World – Mozambique bridging government efforts at dif- Beira and in 2012 also in Nampula. ferent levels of eye care delivery from The results of the decentralization of the tertiary, secondary, and primary the training of ophthalmic technicians levels. In this period, the shortage are clearly visible today. The number BACKGROUND of HReH has been felt at all levels of ophthalmic technicians increased The development of human as being one of the main barriers to from 19 in 2011 to 214 in 2017. resources for eye health (HReH) is providing quality and comprehensive Today, the Ministry of Health has a one of the main component of the services. To respond to this challenge, programme and a training schedule “VISION 2020: The Right to Sight”, eye health stakeholders supported for ophthalmic technicians, which is a global initiative jointly launched the National Eye Health Programme published in the Ministry of Health’s by the World Health Organization in its effort to define strategic plan to general education programme. After (WHO), and the International Agency address HReH in the country. the initial courses, which were 100 % for Prevention of Blindness (IAPB) in Decentralization and Expansion of funded by Light for the World and 1999. In order to reduce the preva- Training of Ophthalmic Technicians Sightsavers through the European lence of avoidable visual impairment Historically, the training of all Union, the government took over by the year 2020, there was a need health professionals including oph- almost the entire financing. Almost to invest in development of HReH thalmic technicians was conducted all the expenses for the training because clearly there was not enough in Maputo, the capital of the country. courses that are running currently are HReH to achieve the established There was no clear schedule of the assumed by the government. global eye health targets. training, trainings were done in an TRAINING OF LIGHT FOR THE WORLD start- irregular way, without a programme ­OPHTHALMOLOGISTS ed supporting eye health work in and timeline. In 2010, in the context Mozambique through the Ministry of the implementation of a European In 2011, for a population of 23 of Health in 2003. It supported the Union project, Light for the World million living in 11 provinces in the national eye health programme in its and Sightsavers, discussed with the country, there were only 8 national efforts to implement sustainable, af- Ministry of Health to decentralize the ophthalmologists, of whom 6 were fordable & equitable comprehensive training of ophthalmic technicians located in Maputo. Of the remaining eyecare programme aiming at reduc- to Beira and Nampula Institute of ophthalmologists, one was placed in HUMAN RESOURCES FOR EYE HEALTH 13

Sofala and another one in Nampu- persuade the government to register PARTNERSHIPS IN la. The duration of training of local optometrists as one of the medical HREH DEVELOPMENT ophthalmologists lasted for about 5 professions. Today there are about to 6 years with no clear timeline for 25 optometrists who graduated In order to improve the training taking the final exams. This resulted from University of Lúrio who were quality of trained cadres, several in graduation of one ophthalmologist absorbed into the government health partnerships were established in every 5 to 6 years. system and work in different hospi- the southern and eastern regions It was from this perspective that tals in the country. of Africa, especially with College Light for the World prioritized the of Ophthalmology Eastern Central TRAINING OF EQUIP- training of ophthalmologists abroad, and Southern Africa (COECSA) and MENT MAINTENANCE specifically in the United Republic of Kilimanjaro Center for Community ­TECHNICIANS Tanzania (in Moshi) and the Repub- Ophthalmology (KCCO). Initially lic of Kenya (Nairobi). During the In Mozambique, there is no the team of the National Eye Health last 8 years, 10 scholarships were professional career for maintenance Programme made visits to other awarded to postgraduate students in technicians specifically for oph- countries in the region to interact and ophthalmology. Light for the World thalmology. But it is an important learn about the development pro- also supported practical internships category for smooth functioning of gress in eye health in these countries. in Uganda for 2 residents who were eye health activities by ensuring the In December 2017, at the invitation attending the course at Maputo repair and maintenance of ophthal- of the Mozambique College of Oph- Central Hospital. The number of mic equipment. Therefore, in October thalmology, with the support of Light national ophthalmologists gradually 2017, Light for the World financed a for the World, the COECSA team paid increased, reaching 20 in 2017. Today, training of equipment maintenance a visit to the Ministry of Health, spe- 9 provinces out of the 11 in the coun- technicians in coordination with cifically the institutions linked to the try have national ophthalmologists the Ministry of Health through the Eye Health Programme, to see how as compared to only 3 provinces in Department of Maintenance and ophthalmologists are being trained 2011. Currently, the Ministry of Health, National Eye Health Programme. The in the country including conditions of in coordination with Light for the training was conducted by consult- infrastructure, quality, curriculum and World and COECSA, is focused on im- ants from Aravind Eye Hospitals, the technical capacity of trainers. The proving the quality of training at the India. team left clear recommendations for Maputo Central Hospital. At the same improving the quality of training, as CHALLENGES FOR time, there is a discussion about the well as improving service delivery. HREH IN MOZAMBIQUE expansion of the residency training HREH DEVELOPMENT PLAN programme Beira and Nampula, Despite the different strategies IN MOZAMBIQUE where attachment programme for and efforts being undertaken to ophthalmology residents has already improve quantity and quality of Until 2015, Mozambique did not started. HReH in Mozambique, there are still have a national HReH development many challenges to reach the main plan that guided training and place- TRAINING OF OPTOMETRIST objective of the country to provide ment of eye health personnel. With In 2014, the first optometrists comprehensive eye care services technical and financial support from trained in the country graduated from also in the most remote areas of the Light for the World, the National Eye the University of Lúrio in the Province country. Another challenge is related Health Plan was drawn up in 2014. It of Nampula, with support from Brien to the retention of eye health staff was at this time that the subject of Holden Vision Institute. Because it particularly the retention ophthalmic human resource development was is a new professional category that technicians as this cadre does not widely discussed, where objectives, was not part of the professional have career progression plan. As the targets and indication of new career framework of the Ministry of Health, result of this situation, some ophthal- paths were defined which should it was very difficult for the govern- mic technicians are leaving the eye be part of the programme. It is a ment to take up this professional health sector for other health sectors tremendous success for eye health career. The Mozambique Eye Care where there is opportunity for career that today the HReH development Coalition (MECC), which at the time progression, which makes efforts of plan is part of the Ministry of Health’s was led by Light for the World, took a increasing the number of allied oph- general human resources develop- very important role in advocating to thalmic personnel challenging. ment plan. 14 VISION & DEVELOPMENT LIGHT FOR THE WORLD

The NIURE Experience Development of HReH to Address Uncorrected Refractive Errors in Uganda

NATIONAL INTERVENTION­ Wolfgang Gindorfer, Senior From the outset, the ultimate aim ON UNCORRECTED RE­ ­Consultant URE, Light for the World of NIURE in terms of human resource FRACTIVE ERRORS (NIURE) development has been to introduce The NIURE programme in Ugan- optometrists within the health care da comprises of multiple strategies system. To achieve this, Light for PREVALENCE AND to address URE and School Eye the World and the Brien Holden ­MAGNITUDE OF Health (SHE) on a national level, Vision Institute developed the first ­REFRACTIVE ERRORS with a strong emphasis on human optometry training (4 years Bach- According to recent data pub- resource development to ensure that elor’s degree course) at Makerere lished by the Vision Loss Expert high-quality refraction and provi- University. We provided a state-of- Group in the Lancet, there are an esti- sion of optical services are available the-art optometric teaching lab and mated 253 million people with visual where needed. an integrated academic vision centre impairment globally, of whom 36 In agreement with the Ugandan housed within Makerere to ensure million are blind. Women are dispro- Ministry of Health (MoH) and its the best possible learning conditions portionately affected as they repre- national eye health plan, a sustain- for the students. The first batch of sent 55 % of visually impaired people. able development strategy was 6 students shall graduate in 2018 Nearly 90 % of visually impaired developed with NIURE programme and become the first “home grown” people live in low and middle-income interventions being integrated within Ugandan optometrists. countries. More than 75 % of visual the government health care structure. In parallel, we are presently impairment is avoidable. The NIURE programme has jointly working on formal recognition of the Globally, the major causes of been developed and implemented by optometry profession and to lobby visual impairment are uncorrected Light for the World and Brien Holden for integration within public service. refractive errors (49 %) and cataract Vision Institute under the auspices of This is a crucial step, to integrate op- (26 %). Cataract still represents the the MoH since 2008. tometrists into the eye health team major cause of blindness (35 %), and onto the government payroll. HUMAN RESOURCE followed by uncorrected refractive With the optometry degree in place, ­DEVELOPMENT AND NIURE errors (21 %) and glaucoma (8 %). we have created a critical mass of in- An estimated 19 million children are According to the IAPB Vision Atlas, dividuals who continue to advocate vision impaired, of whom 12 million Uganda presently has 45 ophthalmol- for official recognition, career path, children have a visual impairment due ogists for a population of more than etc. One crucial milestone achieved to refractive error. Around 1.4 million 40 million people. As in most African in 2017 has been receiving govern- have irreversible blindness, requir- countries the majority is primarily ment sponsorship for 10 optometry ing access to vision rehabilitation practising in the capital. Additionally, students ensuring acceptance of services to optimize functioning and about 240 Ophthalmic Clinical Of- the course by the Ugandan gov- reduce disability. ficers (OCOs) are providing primary ernment. This surely will also have Uncorrected refractive errors eye care throughout the country, but some positive influence to get this (URE) can hamper performance at refraction skills are limited to utmost new profession regulated as part of school, reduce employability and basics. When starting to address URE public service in due course. productivity, and generally impair in Uganda, we started by assessing With the vision of optometrists in quality of life. the human resources available in the sufficient number, skills and equi- country and define the gap. table distribution, the estimate was HUMAN RESOURCES FOR EYE HEALTH 15

that at least 10 to 15 years would be required to set up the course and provide a 4-years training till a tangible number of optometrists has entered the labour market. To bridge this gap, from 2008 onwards, NIURE offered a 6-weeks training course in objective and subjective sphero-cylindrical refraction to 74 OCOs primarily based at govern- ment health units across the country. These OCOs were selected by the National Eye Health Coordinator in close collaboration with Regional Ophthalmologists. This programme component has now ended, as we are expecting Ugandan graduates in optometry from this year onwards. In the meantime, Uganda now has a broad base of OCO/Refractionists working throughout the country. As another important programme component was service delivery, NIURE developed a national optical workshop based at Entebbe Gener- al Referral Hospital that produces CONCLUSION AND tailor-made spectacles according optometrists being soon part of the FUTURE VISION to the prescriptions received from eye health providers, we anticipate trained OCOs across the country From the outset, all parties that ophthalmologists will be able to using coded frames. To enable this, found it imperative to directly work focus on intraocular surgeries such initial 6-month training was provided with existing health care staff and as cataract surgery and managing to 3 spectacle technicians of which develop a strategy to sustainably severe eye conditions thus utilis- two have been employed by the integrate refractive services in the ing this very limited, high profile NIURE programme. Ugandan health service provision. professional cadre to its maximum To increase demand and uptake Introducing the new cadre of optom- potential for the benefit of patients of the services for URE, 8 district etry, lobbying for its recognition and in need. programmes were implemented for streamlining within public service as Soon, we hope to see an extend- SEH, local advocacy, and community an intrinsic allied health staff, were ed comprehensive eye care team dialogue. Awareness raising was key components. OCOs employed by to enhance opportunities achieving strengthened through the placement government were trained to bridge universal eye health in Uganda. A of vision corridors at major schools the service-gap through special- slight shift towards training teams in and selected health centres. In this ised refraction training. While it is this regard is desirable where all eye context, another important human envisaged that the trained OCOs health cadres participate for im- resource development component shall continue to provide compre- proved performance, changing the targeted secondary school teach- hensive refraction, the optometrists mind-set from a pure clinical training ers. Indeed, till date exactly 1,000 shall play a leading role in the future towards a wider team approach. teachers in the 8 districts received regarding supportive supervision for A draft position paper on training a 1-day training to identify basic URE, SHE, low vision services and teams has just been developed by eye problems and test the vision of blindness preventive diagnostics as the respective committee of the their pupils, while another 200 are well as referral. International Council of Ophthal- still going to receive training in 2 Through our human resource de- mology awaiting final approval of its districts until the end of 2020. velopment intervention resulting in board. LIGHT FOR THE WORLD

Niederhofstraße 26 CEO: Board of Ambassadors: 1120 , Austria Rupert Roniger Prof. Ronald McCallum AO (Australia) [email protected] Board of Trustees: Dr. Benita Ferrero-Waldner (Austria) www.light-for-the-world.org Dr. Karin Krobath Lord Colin Low (UK) Dr. Martin Filipec Lord Joel Joffe (South Africa/UK) Hanna Jovanovic (Ethiopia) Woldesenbet Brhanemesqel Prince Maximilian von und zu Deborah Oyuu Iyute ­Liechtenstein (Liechtenstein) Ludwig Büll Henry Wanyoike (Kenya) George Briford Martine Vandermeulen Menno van Hulst

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