Blindness Prevention Program, Bangladesh
National Eye Care of BD
The Government of Bangladesh has identified blindness as a critical social and health problem and demonstrated its commitment by forming in 1978 a national apex body the Bangladesh National Council for the Blind (BNCB) with a mandate to formulate, facilitate and monitor the national plan of action to prevent and control blindness. Besides, the Government of Bangladesh has ratified the Vision 2020 program; and is committed to achieving vision 2020 goals.
Bangladesh was one of the first few countries to have a national program for prevention of blindness. The Directorate of Health Services in collaboration with BNCB developed and launched first National Program for Prevention of Visual Impairment and Blindness in Bangladesh in the year 1980. This program was based on eye camp strategy in order to work within limited resources available during the time. Consequent to the paradigm shift in early 1990s that discouraged eye camps, and launched Vision 2020 in 2000, eye care program strategies in Bangladesh were changed and directed towards sustainable development approaches.
The health status of the people of Bangladesh has been steadily improving as evidenced from various indicators. The Life Expectancy at birth was estimated to be 66.8 years in 2008 (Sample Vital Registration System 2008). The estimated under five mortality rate in 2009 was 52 per 1000 live births (World bank website). The government is a major provider of health care in the country along with NGO and private providers. Health care in government facilities are provided free of cost. The annual health expenditure per capita was US$ 15 as estimated in 2007 (World Bank Website).
The national health policy was officially adopted in 1998 which is now under the process of revision. The national population policy in its draft form has been approved by the cabinet recently. The national drug policy adopted in 1982 is also under the process of revision. The national nutrition plan has been adopted in 1997 and a national nutrition program is under operations. The national maternal health strategy has been adopted in 2001. In context of all these policies and strategies, the health system of the country is currently undergoing a process of reform under a sectoral approach of Health, Nutrition and Population Sector Program (HNPSP) which was preceded by Health and Population Sector Plan (HPSP) which ran from July 1998 to December 2003.
It is in this context BNCB has taken the initiative in response to the decision taken in BNCB full committee meeting chaired by the Health Minister, to review and update the National Eye Care Plan to incorporate in the ongoing Health Care program of the government. Accordingly a National Eye Care Plan Review Sub-Committee of BNCB was formed with selected members. As a methodology, the sub-committee undertook review and research of the existing plan, programs and literature, sought views of stakeholders, and prepared this draft which was widely shared and consulted with cross section of professionals and people including the clients in all the divisions; and finally all the inputs will be synthesized in the national plan through a national level workshop.
The updated National Plan of Action on Eye Care is based on the eye care needs of population. Plan focuses on human resource development, infrastructure and technology, strategies for control of major blinding eye diseases. Advocacy, resource mobilization, community participation; and continuous monitoring of the implementation of the plan through a coordinated mechanism would also be key elements of the national plan.
Strategies of Blindness Prevention Program, Bangladesh
1. Strengthening Advocacy
2. Infrastructure and Technology development
3. Human Resource development
4. Reducing disease burden
5. Improving co ordination and partnership
6. Monitoring and evaluation
Eye Care Scenario in Bangladesh
Magnitude and Prevalence of Blindness
In a developing country like Bangladesh prevalence of blindness puts an additional burden to our socioeconomic conditions. According to The Bangladesh National Blindness and Low Vision Survey 2000, the age standardized blindness prevalence rate is 1.53% and thus, there are approximately 675,000 blind adult (30 and above age group) in the country (586,880 to 784,000)
The same survey revealed that blindness and low vision (LV) were found to be associated with ageing as both degrees of visual impairment were common among elderly persons, in women as compared with men (1.72% v 1.06% blindness prevalence), in illiterate persons, and, in males, among those who were manual workers when compared with non-manual employees. The study also found that bilateral blindness prevalence was highest in Divisions of Barisal (2.28%) and khulna (1.97%), lower in Chittagong (1.43), Sylhet (1.31%) and Rajshahi (1.21%) and lowest in Dhaka division (1.13%).
Cataract was the predominant (79.6%) cause of bilateral blindness. The cataract surgical coverage (CSC) was notably low over the whole of Bangladesh (32.5%), especially in Barisal division. The level of cataract surgical coverage was found significantly lower for women than men, as was the CSC in rural areas when compared with urban settings.
One of the striking findings of the study was the number of uncorrected aphakes, with one quarter of intra-capsular cataract extraction eyes not being corrected with a spectacle lens. The imbalance of distribution of refractive rehabilitation was also evidence by the findings that women, eye camp surgeries, illiterate subjects and rural dwellers were less likely to wear aphakic spectacles. The study emphasized the need for greater quality and quantity of cataract surgery, with strategies targeted at improving operative technique and particularly at ensuring effective post-operative rehabilitation.
The same survey also indicated that the prevalence of Low Vision is 0.56% of total population of 30 & above age group. The main causes of low vision, as per above definition, were: retinal diseases (38.4%); corneal diseases (21.5%); glaucoma (15.4%); and optic atrophy (10.8%). Based on the prevalence of 0.56% for low vision, it is estimated that approximately 250,000 adults1 in Bangladesh are in needed of low vision services.
Despite a substantial reduction in the fertility rate in Bangladesh in recent years, overall population growth continues to rise. As such there will be an estimated 175 million people in Bangladesh by the year 2020, with more than half of the population being over the age of 30 years, and one-fifth (34 million) being 50 years of age and older. The survey recommended organizing eye care service delivery in Bangladesh in near future, focusing principally on cataract surgical and refractive error correction services. The recommendation is consistent with the prioritized areas of action for the region as outlined by WHO South East Asia policy document “Vision 2020- The Right to Sight”.
Using the WHO global estimate of Childhood blindness prevalence2 of 0.75/1,000 children, there are about 40,000 blind children in Bangladesh. Childhood cataract is the leading cause of childhood blindness in Bangladesh and over 12,000 children are suffering from unnecessary blindness due to un-operated cataract and in need of surgical care from well-developed eye care facilities. Another 10,000 children3 are blind due to corneal scarring which could have been entirely prevented through effective primary health care and primary eye care services in the community. For every million population in Bangladesh, there would be 300 blind children. About a third of them (100 children) are blind from cataract. The provision of 100 (uniocular surgery) to 200 bilateral cataract surgeries per million populations would be needed to restore vision in these children. Community based preventive measures will be required to prevent 25% of all childhood blindness, which is related to Vitamin A Deficiency disorders, diarrheal diseases, malnutrition and measles. Childhood cataract is a major treatable cause of childhood blindness that can be benefited from future intervention strategies in line with the priorities set by the WHO’s Vision 2020.
Refractive errors in children aged 5 to 15 years are an important public health problem. Myopia and hypermetropia are the leading causes of refractive error in children in this age group-both of which are visually impairing conditions that can be significantly improved through adequate refractive correction. Population based refractive error studies in children have shown that nearly half of the visual impairment associated with correctable refractive errors in this age group is not receiving attention, especially those children living in disadvantaged social and economic conditions. As such refractive errors remain uncorrected and unnecessary visual impairment persists.
In Bangladesh, assuming a prevalence of 4% of children aged 5 to 15 years to have visual acuity of less than 6/18, it is estimated that there are approximately 1.3 million children having visual impairment due to refractive errors3, the large majority of which are amenable to correction.
The government is the major provider of the health care in the country along with NGOs and private sector. The per capita annual government expenditure on health and family welfare is less than US$3 (Bangladesh Taka 180, Household Expenditure Survey, 2001). The government health sector has a well-organized service delivery network that is extended down to the village level. The focus of the program in the rural areas is primary health care that included essential health and family planning services but does not include eye care.
According to the National Eye Care capacity Assessment conducted by National Institute of Ophthalmology (NIO), ORBIS International and Sight Savers International in 2003, the country presently has about 141 hospitals providing eye care services that include service provision or deemed to have potentials in terms of strategic location and infrastructure for developing eye care services. Of the total hospitals, 71 hospitals representing 50% are from the government, 56 representing 40% from the NGOs and 14 from the private sector representing 10%. The mentioned hospitals include 20 medical colleges, 65 government district hospitals, 53 NGO secondary eye hospitals and 8 private (for profit) hospitals/clinics and 5 tertiary hospitals. Two of the tertiary hospitals belong to the government and the remaining 3 are in NGO sector, Of the medical colleges, 14 are in the government and 6 in the private sector.
There are about 700 ophthalmologists and about 618 Mid Level Eye Care Personnel in the country 70% of the all eye surgeries in Bangladesh4 are cataract surgeries. The productivity of ophthalmologists is affected by the limited availability of ophthalmic nurses and paramedics. There are only about 2,822 hospital beds available for eye patients in the entire country. Facilities at all levels have inadequate ophthalmic equipment and supplies, and often, the existing equipment is non-operational due to inadequate maintenance procedures and/or lack of trained people who can repair ophthalmic equipment.
Eye care services are virtually non-existing at rural community level. Eye care is provided mostly in secondary level hospitals located in the district towns. However, the eye department of the district (government) general hospitals, in most cases, is not equipped with essential diagnostic and microsurgical equipment and adequate human resources, Recently, government has provided equipment for all district hospitals that include one set of slit lamp microscope, one set of ophthalmic operating microscope, one set of direct ophthalmoscope with spare bulb and 2 sets of instruments for cataract surgery. The government has also arranged for availability of either one senior or junior consultant (eye) for 65 district hospitals. Separate OT arrangement for eye surgeries also been made in these hospitals. So it is expected that all district hospitals from now onwards will be able to provide eye care services.50 upazila hospitals have junior consultant post District hospitals act as secondary referral centre and linked with upazila and below through existing PHC structures. To promote access to primary health care including eye health for the poor government has established community clinics :1 for 6000 population at the village level. Five thousand (5000) primary health care workers have been trained on primary eye care. MSR support provided to District hospitals having cataract surgical teams. Vouchering scheme for IOL (Cash support to poor patients) surgery in District of Manikganj introduced & sustained. Development, Sharing & introduction of monthly & annual reporting format for strengthening of MIS eye health. Cataract Surgical Rate (CSR) increased from 957 (2005) to 1146 in 2009 (population 140 million).
There are a few NGO eye hospitals and private for-profit eye clinics in some old / large district towns but they do not provide sub-specialty care. There are tertiary level government & NGO facilities only in Dhaka & Chittagong which provides sub specialty eye care. The NGO facilities charge a modest or subsidized fee for services. Thus their fee structures and charity motives allow some poor patients in seeking NGO services. Majority population con not afford to pay for private services. District level services include refraction, cataract surgery, treatment of corneal ulcer, treatment of ocular injury and medical treatment of glaucoma. A large number of ophthalmologists are working in the larger tertiary level government & NGO facilities and a few NGO facilities in Dhaka & Chittagong. Services in tertiary facilities include all the district level services and surgical treatment of glaucoma and YAG laser treatment.
There are 4 eye hospitals in the country where a full-fledged pediatric ophthalmic unit has been established. Two eye hospitals have established corneal sub-specialty unit; and only two eye banks are functioning in limited scale. Six vitreo retinal units exist in the country. The development of sub speciality in eye care is gradually picking up which need to be augmented both in Government and Non-Government sector.
Program for the Control of Blindness
In Bangladesh, considerable steps have been taken in the last planning period to develop and promote Vision 2020 at the national level. Vision 2020 was officially launched in Bangladesh in 2000 Many of the activities of Vision 2020 have been included within the National Health, Nutrition and Population Sector Program (HNPSP), Planned for July 2003 – June 2006; such as comprehensive district level eye care program run by some NGOs.
Vision 2020 disease priorities in Bangladesh :
There are many blinding conditions in the country. However, four key blinding diseases have been identified as priorities cataract, childhood blindness, refractive errors and low vision. The other blinding diseases include: corneal diseases, glaucoma, ocular trauma and diabetic retinopathy.
Cataract remains the major cause of avoidable blindness in Bangladesh. The national prevalence survey reveals that there are 4,200 cataract cases per million population and an incidence rate of 840 per million, Current CSR in Bangladesh is considerably below the required level to even manage the incidence. Good quality cataract surgery is essential, not only in terms of benefits to the individual patient, but to increase the uptake of cataract surgery. The cataract surgical rate should be increased to at least 1,500/million population to deal with annual incidence only.
There are 550.000 cataract blind in Bangladesh which can easily be treated with available technology. Implantation of Intra Ocular Lens (IOL) is the best procedure for restoration of sight of a cataract blind person. This requires substantial increase in the CSR to 1500-2000 from existing rate of 957 in next few years. For elimination of cataract backlog a CSR of between 2000 – 2500 is required where as in order to bring cataract blindness under control a CSR between 2500-3000 would be necessary.
Despite the increased cataract surgical intervention the following issues remain:
I. The proportion of IOL surgery is only around 59% across the country. Dhaka and Rajshahi divisions accounted for the major (65%) contribution, while Barisal has the least (less than 1%) followed by Khulna (6.6%).
II. The quality of cataract surgery has to be measured by long-term post-operative visual acuity, which requires significant improvement with regard to the use of technology. Some of this would be addressed by switching over to the IOL surgery there by reducing the need for refractive correction. There is also a need for follow-up for reducing post-operative complications and measuring outcome of the surgery to monitor quality of restored sight. For this standard protocol for service delivery and monitoring quality needs to be developed and agreed by the ophthalmic profession and eye care providers for putting this in to practice. There are several dimensions to these issues:
a) Geographic Coverage: This has very wide variation within the country between various divisions. There is almost 3-fold difference with Sylhet performing over 1,300 surgeries per million populations while the rate in Barisal is slightly higher than 500.
b) Socio-economic: There is a bias for the urban, since, eye care infrastructure is mostly urban based, hence literate and financially affluent population are getting a better coverage of cataract services than the others.
c) Gender Issues: The female and male population ratio is almost 50:50 and it is estimated that the prevalence of cataract amongst both the groups is same. Different service delivery studies conforms that the majority of the female population due to various socio-economic factors do not equally receive the services. Hence, emphasis should be given to the female population to reduce the gaps.
Refractive error and low vision
Refractive errors and low vision, in the past, have not been recognized as significant causes of blindness. The national prevalence survey reveals that the number of refractive errors cases in Bangladesh is 27,250 adults and 9,925 children per million of population. It means there are estimated 3.3 million adult refractive error cases with<6/12 VA and 1.3 Million children refractive error cases with <6/18 VA. In addition there are 1,950 adults and estimated 120 children, per million of population, that would be expected to benefit from low vision service.
In addition, the total number of population at the age of 40 needs refractive error correction for near works. Refractive error & low vision should be given utmost importance especially for children because delayed intervention can lead them to blindness.
However, some of the challenges to address this issue include the lack of adequately trained
human resources, availability of glasses and provision of accessible and affordable services. In specific terms, training of Medical Officers of Upazila level in basic ophthalmology especially in refraction, introduction of optometry course in the country, training opportunity for the opticians, and providing incentive to the private sector so that glasses can be made available and accessible at affordable price especially in rural areas need to be organized.
People with permanent low vision who are not treatable with conventional refraction services are referred as low vision patients. Low vision remains a major challenge with even ophthalmic personnel having a low awareness of this condition. The centres that provide low vision services in the country are only few. The capacity to provide service is far less than the potential need. There is a need to create capacity in terms of trained human resource, establish a reliable and affordable supply chain for low vision devices and have a mechanism in place, which can actively identify those who can benefit from low vision services.
Childhood blindness is relatively complex and demanding area of work. Though the overall numbers of blind children are low compared to adults, in terms of blindness years, it is second only to cataract. Over the past few years quite a lot of effort has gone into enhancing
under standing of this key disease area.
The Childhood Blindness Study in Bangladesh revealed that 31% of the blindness was due to problem with the lens (cataract), and 27% of the blindness was due to problems in the cornea (Vitamin a deficiency). Including glaucoma (4%) and aphakia (5%), 67% of the childhood blindness is thus avoidable (preventable or treatable). The study also found that 90% of the childhood blindness was developed within first 5 years of life. The study indicated that an estimated 40,000 children are blind in Bangladesh.
The national workshop on childhood blindness in 2003 recommended that planning for the control of blindness in children should be based on catchment population of 10 million, rather than 1 million used for planning control of blindness in adults. A total of 16 pediatric ophthalmology centers need to be established by 2010 out of existing 4. Teams of pediatric ophthalmology need to be developed at different levels with different skills mix. There are needs for countinuing Vitamin A supplementation and its augmentation with pregnant and lactating mothers and in pockets of under performance. Inclusive education of children who are blind or visually impaired needs to be expanded. Most importantly, primary eye care needs to be incorporated in the primary health care system and the identified barriers in availing services need to be removed.
Corneal Disease & Ocular Trauma:
The main area of concern is corneal infections arising out of trauma or other infectious reasons, The issues relate to ensuring that the patient engages in right health behaviour when in need, as well as, to ensure that the providers have skills for making the right diagnosis and the required infrastructure to aid diagnosis and treatment. A lot of the corneal injures happen in the rural areas during peak harvesting seasons i,e; trauma by paddy grains and leaves. Often such injuries are minor when they happen and there is a tendency to ignore it or resort to local harmful practices that invariably lead to the formation of untreatable corneal ulcers. Other important causes of corneal injuries are road traffic accident, social and political violence, industrial hazards, etc. Most of the eye care institutions/facilities are not equipped with appropriate diagnostic and surgical equipment and basic laboratory facilities to identify the organism that causes the corneal infections. Thus there is a need to work both at the community level for prevention of eye injuries and ulcer and at the institutional level for developing skilled manpower and appropriate equipment facilities.
For more advanced cases of corneal infections which have lead to corneal opacity, the only intervention often require is corneal transplantation. Although, there is no specific information on how many corneal patients require corneal transplantation in the country, however, it is evident from hospital based statistics that a huge number of corneal opacity cases require cornea transplantation. The current number of cornea collection in the country is very minimum compared to the need and not more than 200 corneas per year2. It would be an important step to establish a base line data both in terms of current backlog as well as the new cases that would require corneal transplant. Thus, there is a strong need of establishment of modern eye banking programs in the country.
Nutritional and infective causes of corneal blindness may be reduced through strengthening vitamin A supplementation. Integration of the primary eye care into the primary health care may control the problem of corneal blindness especially in children to a very major extent.
Glaucoma affects a significant number of people and is one of the leading causes for permanent blindness. According to the Bangladesh National Blindness and Low Vision Survey 1.2% of all adult blindness is due to glaucoma. In general, more people are affected by glaucoma than the number of actual glaucoma blind.
In a population based epidemiological survey on glaucoma among Bangladeshi adults 3, it was found that 2.8% of the population aged 35 years and above were suffering from open angle glaucoma and another 11.2% were glaucoma suspect. Thus, in Bangladesh there are about one million people having open angle glaucoma.
Management of glaucoma is different than any other eye conditions in terms of complex nature of diagnosis and follow up for long period. Currently, only few eye centres have the appropriate technology and trained human resources to diagnose and treat glaucoma patients. One of the immediate steps that can be taken is to ensure that all the eye care providers are encouraged to have in place a process to examine all the patients who come into the system either in the hospital or in out reach programs for glaucoma screening and initiate necessary treatment or referral. This can help prepare community to become more aware of the disease and the treatment options.
Strategies to improve diagnostic skills through instrumentation and training, opportunistic screening and improvements in surgical skills and research in newer and safer medications can help address the issue of glaucoma.
This is an emerging problem and is likely to get compounded by changing life styles and ageing of the population. The prevalence of diabetic retinopathy among the diabetic patient is 27%. If the condition is diagnosed and treatment initiated early; it can prevent blindness. Available technology with laser treatment can easily help preventing this blinding disease.
The current capacity in the country to diagnose and treat diabetic retinopathy is very limited to few centres only to deal with this huge burden. Therefore, there is a strong need to enhance and develop the capacity for early detection and treatment of diabetic retinopathy.
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