Management Challenges in
Primary & Secondary
Eye Care in India
Prof. R.S. Goyal
Institute of Health Management Research, Jaipur
Eye care scenario in India
Prevalence of blindness in India is relatively
large (0.7%) as compared to world as a whole
(0.57% ).
Country has 15 – 18.6 million people with blindness
accounting for one fourth of the world’s blind population.
 India has highest burden of blindness in the
world.
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Regional Burden of Blindness
(RBB)
Region
Established Market Economies
% of global
population
(A)
15.1
% of global
blindness
burden (B)
6.3
RBB (B/A)
0.41
Former Socialist Economies of
Europe
India
6.6
2.9
0.44
16.1
23.5
1.46
China
21.4
17.6
0.82
Other Asia and Islands
13.0
15.3
1.18
Sub-Saharan Africa
9.7
18.8
1.93
Latin America and the Caribbean
8.4
6.1
0.72
Middle-Eastern Crescent
9.6
9.5
0.99
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Recent trends indicates that prevalence of
blindness due to infectious diseases is
decreasing, but age-related impairment is
growing.
Around 82 % blind people are above 50 years of
age.
Visual impairment is relatively higher among
women ( in all ages) than males.
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Cataract has been recognized as the major cause
of blindness in the country.
Around 3.8 million people become blind due to cataract
every year. It is also the leading cause of blindness, globally.
Under the current demographic scenario (rapid
aging of population), it is feared that prevalence
of visual impairment in India will further
increase in coming years.
There are also regional imbalances in prevalence
of blindness across states in India.
Status of prevalence of blindness
in states of India
Category
Prevalence (%)
States & regions of the
country
Low Prevalence
<1
Punjab, Himachal Pradesh,
Delhi, West Bengal, & N.E.
States
Moderate
Prevalence
1 to 1.49
Gujarat, Haryana, Kerala,
Bihar, Karnataka, Andhra
Pradesh and Assam
High Prevalence
1.5 to 1.99
Maharashtra, Orissa, Tamil
Nadu & Uttar Pradesh
Very High Prevalence
2 and above
Madhya Pradesh, Rajasthan
and Jammu & Kashmir
Current status of eye care in
India
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The National Program of Control of
Blindness ( NPCB) was launched in the year
1976 as a 100 percent centrally sponsored
program.
The objectives of NPCB include;
To provide high quality of Eye Care
 To expand coverage of eye care services
 To reduce backlog of blindness
 To develop institutional capacity for eye care services.
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The program also extended assistance to voluntary
organizations for cataract operations and eye banking.
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The NPCB sought to bring down prevalence of
blindness in the country to 0.3 % by 2010 by
promoting ;
1. Cataract Operations
2. School Eye Screening ( Preventive measures &
Screening Program)
3. Eye bank
4. Strengthening of Infrastructure
5. Operationalization of Tele-Ophthalmic Vision
Centers
6. Capacity Building
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A global initiative Vision 2020: The right t
o sight”
by WHO
& IAPB to eliminate avoidable
blindness by the year 2020, was launched in India
in 1999.
 Its strategy focused on;
disease prevention and control, training of personnel,
strengthening of the existing eye care infrastructure, use of
appropriate and affordable technology and, mobilisation of
resources.
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Goals and strategy of NPCB and Vision 2020
complemented each other in India.
A host of international NGOs are contributing to
Eye Care in India. These include;
Sight
Savers
International,
ChristoffelBlindenmission (CBM), ORBIS International,
Operation
Eyesight
Universal,
Rotary
International, International Eye Foundation, Lions
Clubs International Foundation, Help Age India,
Seva Foundation and many others.
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L.V. Prasad Eye Institute, Hyderabad
Sankara Nethralaya, Chennai
Arvind Eye Care System
All India ophthalmological Society
Eye Bank Association of India
Venu Eye Institute and Charitable Society
are some of the leading national NGOs providing
primary and secondary eye care in India.
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NPCB supported a large increase in the
infrastructure for eye care in the countryRegional Institute of Ophthalmology, Eye
Banks , Mobile Units, up gradation of
PHCs, construction of Eye Wards and
dedicated Eye OTs etc.
The NPCB has also established 590
District Blindness Control Societies (DBCS) to
strengthen the eye care delivery at the district
level.
NPCB gave particular emphasis on
promoting cataract surgeries in the
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Yet, voluntary and private sectors are
shouldering the major burden of corrective eye
surgeries (65%) in the country.
About 11,000 ophthalmologists and an equal
number of trained and recognized mild level
personnel (MLP) are currently available in the
country against the desired ratio of at least 4‐5
MLP for each ophthalmologist.
Nearly half of the ophthalmologists in the
country are surgically inactive.
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The ophthalmologist to population ratio in
urban India is 1:25,000 but in rural India it is
about 1:250,000.
Yet a rapid assessment in 14 districts in the
country has pegged the coverage of eye care
services at around 70%.
Also, IOL implantation rates gone up to 90% (
of all surgeries) in 2006‐07.
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The number of cataract surgeries performed has
grown to 5 million in a year. A rapid assessment
(2001-2) of the coverage of surgical interventions
for cataract blind shows 70% reach.
There are also evidence of improving visual
outcomes as assessed by the rapid assessment
surveys among cataract operated.
Issues in childhood blindness..
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Specific infrastructure for detection and
management of childhood blindness is not
available at most primary and secondary health
care facilities in the country.
Human Resources particularly the trained
personnel are inadequate at the PHC/CHC
level.
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At the tertiary level, very few centers (both Govt.
and NGO) are equipped to manage childhood
blindness.
Because of inadequate trained ophthalmic
human resources, many conditions like ocular
injuries are treated by non‐ophthalmologists like
general surgeons or physicians in most places.
Posterior segment care is grossly inadequate.
Only 150 ophthalmologists (including govt. and
private sector) are trained to deal with posterior
segment disorders.
From a Socio‐economic Perspective..
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There is a bias in the reach of cataract services.
The urban, literate population is getting a better
coverage.
Lack of escort/care providers, fatalistic attitude
and fear in spite of increased commonness of
services, and long waiting in decision making to
undergo surgery in the average Indian household
are also important barriers.
The Gender Issues..
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Several studies have shown that the female carry
a 40% higher burden of cataract than the male.
However, women access/use of cataract
corrective services is either less or at the best
equal to men.
To achieve equity in the backlog, there is a need
to ensure that 60% of all cataract surgeries are
performed on women.
Challenges in Blindness Control
in India
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A strategic approach to program
management is missing
Isolated efforts by the private, voluntary
and public sectors
Poor balancing between the quantity and
quality of care
Deficiencies in the cycle of care
In appropriate utilization of existing
facilities
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Lack of trained human resources and their
unequal distribution in rural and urban
areas
Large gap in ophthalmic training &
education
Socio‐cultural, logistic and financial issues
Lack of general seriousness towards the
eye care
Low level of awareness for eye
care in the community
Strategic Management Process
for Eye Care interventions
22
Priority areas for Strategic
Management of Eye Care
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Comprehensive BCC / IEC strategy for eye care
Capacity building of existing human resources
Increase uptake in eye care training institutions
through expanding infrastructure for addressing
HR shortage
Formulate efficient PPP model using SWOT
analysis of Government and Private sector
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Develop quality norms for primary and
secondary eye care and procedures ensuring
adherence for quality control
Efficient MIS to be developed for quality
implementation and monitoring of eye care
interventions
Evaluate the interventions based upon baseline
and goals envisaged
Suggested areas for efficient
management of NPCB
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Proper completion of Surgical Records for
cataract surgery and other services needs to be
maintained with complete, correct and reliable
information;
Standard referral cards from primary to
secondary/tertiary level of care;
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Development of Management Information
Systems at various levels so as to plan, monitor
and evaluate the programme in an efficient
manner;
Network of Sentinel Surveillance Units to be
established to study profile of beneficiaries and
outcome of interventions;
Independent evaluation on various programme
activities and outcomes with standard protocols
comparable with other nations.
PEC through PHC
1. Better nutrition-Prevents vitamin A deficiency
2. Safe drinking water and sanitation programmesContribute to trachoma control
3.Quality maternal and child health care-Reduce
retinopathy of prematurity
4. Health education-Prevention of eye trauma
Effective management of eye care
programs in outreach
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Strong leaders who build vision, commitment,
positive attitudes, and a sense of mission
Increasing the uptake for eye care services
through outreach and demand
Generation activities, health education, and
social/service marketing
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Quality and size of human and other
infrastructure resources
Quality and number of instruments, equipment
and supplies
Systems and procedures that optimizes the
utilization of all of the above resources
Efforts required for preventive
Eye Care
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Increased availability and affordability of eye
care services;
Increased commitment to prevention from
national program leaders, medical professionals
and private and corporate partners;
Creation of awareness for increased use of eye
health care services;
Implementation of effective eye care strategies
to eliminate infectious causes of vision loss.
Recommendations
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Collaborative approach is required from
Government and private sector to achieve the
NPCB and Vision 2020 goals
Government may focus on increasing outreach
services and providing primary eye care services
at PHCs while Private sector may focus on
quality secondary eye care
Efficient PPP models may be developed after
mapping of present facilities and need
assessment
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Strengthening of preventive eye care through
school screenings, awareness and community
participation
Minimum quality norms should be laid down for
government and private eye care facilities
Capacity building of medical & paramedical staff
for primary eye care