The eye care model of Nepal has been deemed a success. The Vitamin A supplementation programme and trachoma elimination are successful eye care programmes in the country. However, the number of blind people has almost been the same over the past 30 years. Furthermore, cataracts, uncorrected refractive errors, glaucoma, age-related macular degeneration and diabetic retinopathy have emerged as the most common eye disorders. Women continue to carry two-thirds of blindness, those living beyond district headquarters, marginalised and low-income ones everywhere, and vulnerable population like children have limited access to eye care services.
A year ago, the United Nations General Assembly (UNGA) adopted eye health as an essential part of Sustainable Development Goals (SDGs). The World Health Organisation (WHO), the International Agency for the Prevention of Blindness, United Nations’ Friends of Vision, and Lancet Global Health Commission on Global Eye Health have advocated for eye health to be included in achieving SDG for years. However, the world report on vision by the WHO explicitly describes a shortage of skilled human resources as one of the greatest challenges to increasing the availability of eye care services and reducing the prevalence of vision impairment and blindness.
Shortage of manpower
The same is the scenario in developing countries, including Nepal. There are just about 370 ophthalmologists, 500 optometrists, over 1,000 ophthalmic assistants, 350 formally trained opticians, and 120 ophthalmic nurses registered in their respective councils and societies. These numbers are significant compared to that of those 30 years earlier. However, the existing numbers are not enough to serve the people.
One reason for poor access to eye care services in Nepal is that governmental health facilities provide negligible eye care services, with about 90 per cent of eye health services primarily delivered by eye hospitals run by non-governmental organisations, followed by private health facilities. Though the NGO-run eye hospitals are also conducting community outreach programmes to reach people in rural areas and sub-specialty services, these services are not adequate. Moreover, scarce eye health human resources are also amongst many moving out of Nepal for better opportunities.
Besides, there is an inequality in the distribution of existing human resources for eye health in the country, with almost all serving in bigger cities and towns, and geographically more in the hills and the Terai than in mountainous regions. To aggravate the situation, the eye health awareness among rural people has been less about cataracts, glaucoma, diabetic retinopathy, night blindness, and trachoma than those from semi-urban and urban areas.
If we are to tackle preventable sight loss, meet the objectives of the global initiative of universal eye health coverage, and move ahead to deal with eye health as an essential issue, we need to motivate the existing human resources and have adequate alternate part-time human resources for eye health care. Nepal’s midterm review of vision 2020 called for innovative ways to screen visual impairment to recognise the shortage of eye health workers. The same review also recommended using alternative/complementary resources such as teachers, students, and other health volunteers to screen for visual impairment.
A vision screening test is intended to identify people with undetected vision problems. The main goal is to detect changes in vision, which is an indication of possible ocular health problems. Vision problems can be treated if they are detected early; many causes of vision loss are amenable to treatment, or the proper treatment can decelerate the progression of vision loss. The process of vision screening is simple, and the skill of vision screening can be easily transferred. The trained school nurses, school teachers, and students have showcased that they can effectively screen students and record visual acuity in Oman, Vietnam and Nepal respectively. For the past few years, Nepal has been celebrating Vision Screening March Month with eye health workers deputised for the programme, for which those alternate human resources as mentioned above can play a vital role in reaching a greater population and making it a success.
Although refresher training, periodic supervision, and monitoring are recommended for these alternate human resources for eye care, they are an asset in a low-resource country like Nepal with a shortage of eye health workers. The refractive error is one of the most common causes of visual impairment among children. More than 6,500,000 children go to school (up to grade 10th) in Nepal, and the net enrolment rate is 96 per cent in primary schools. However, there is no system of vision screening at the time of admission to school except for a small minority in a few private schools resulting in the majority of children entering and exiting school without a simple eye screening.
Simple and easily treatable eye conditions like refractive error go undetected, interfering with performance in academia, extra-curricular activities, and social inclusion, and even leading to dropout from schools, which, in the future, reduces employability productivity, and generally impairs quality of life. With the introduction of school nurses in Nepal, together with them, training teachers and students and conducting vision screening along with identification of common childhood ocular conditions can serve nearly one-fifth of the population of Nepal.
Primarily, school screenings are limited inside schools only. Nevertheless, motivated and trained nurses, teachers, and students have reached out to their nearby communities as part of their extra-curricular activities and screened the vision of out-of-school students and other age groups from their nearby communities. The vision screening can detect changes in vision, which is important in identifying those at risk of vision-threatening conditions like cataracts, uncorrected refractive errors, glaucoma, age-related macular degeneration, and diabetic retinopathy. However, screening initiatives are successful only if referred persons seek and obtain the appropriate eye care.
(An M.P.H. from TU, Khatri is the coordinator of Students for Universal Eye Health Coverage Project, USAID-Childhood Blindness Programme at B. P. Eye Foundation. firstname.lastname@example.org)