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Advocacy to improve the delivery of eye care

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					                                                       seRVICe DeLIVeRY




                                                       Advocacy to improve the delivery
                                                       of eye care
                                   RD Thulasiraj                                                                              services. In this case, a key group of policy
                                   Executive Director, LAICO, Aravind Eye Care System; President, VISION 2020:                makers to target could be those in
                                   The Right to Sight: India, Lions Aravind Institute of Community Ophthalmology,             education and industry (or labour), as they
                                   Aravind Eye Care System, Annanagar, Madurai 625 020, Tamil Nadu, India.
                                                                                                                              are in a position to improve access to
                                                                                                                              refractive error eye care for these two
                          Advocacy has a role to play in any eye care        that the design of an intervention or
                                                                                                                              population groups. For example, they can
                          initiative. It can help individuals or organisa-   programme should offer benefits to all – it
                                                                                                                              encourage eye examinations of students by
                          tions to obtain more resources, and it can         should be a ‘win-win’ solution. Those who
                                                                                                                              instituting school screening programmes;
                          support programme implementation and               are advocating for better delivery of eye
                                                                                                                              they can also encourage eye examinations
                          service delivery. This article focuses on using    health services (whether they are eye
                                                                                                                              among the workforce by providing financial
                          advocacy as a tool for improving the delivery      health providers, hospital managers, or
                                                                                                                              incentives to companies who screen their
                          of eye care services – both in terms of            VISION 2020 national coordinators) should
                                                                                                                              employees for refractive error.
                          reaching more people, and in terms of              therefore clearly communicate these
                                                                                                                                  Advocacy messages targeting policy
                          improving the quality of services available        benefits – supported by the relevant
                                                                                                                              makers should focus on the positive impact
                          for specific eye conditions.                       evidence – to the groups that are the targets
                                                                                                                              that initiatives will have, which in turn will
                              When planning an advocacy strategy             for their advocacy.
                                                                                                                              reflect well on policy makers themselves. In
                          aimed at improving eye care delivery, it is
                                                                                                                              the case of refractive error services,
                          important to identify those groups who are         Target groups for advocacy                       advocacy can focus on the positive impact
                          in a position to make a difference. These are      The following groups are key targets for         these services will have on education (better
                          the targets for advocacy – the people at           advocacy:                                        attendance and better academic results)
                          whom you need to direct your efforts. They
                                                                                                                              and on the increased productivity that will
                          can make important decisions that directly         Policy makers (government)
                          affect service delivery or simply influence        Policy makers at all levels of government        result in the workforce.
                          others in a way that will improve the              should be targeted by those advocating for
                          situation.                                         better eye care delivery. Policy makers are in   Community leaders
                              If these key target groups can see the         a position to create and implement regula-       These individuals, who can be elected
                          benefits of what is being advocated, it will       tions. They can also offer incentives and        community leaders, local industrialists,
                          be easier to both get their support and            monitor compliance.                              village elders, or heads of local voluntary
                          ensure that this support is sustained. For            Let us take the example of refractive         organisations such as Lions and Rotary,
                          example, education officials would like a          error. Amongst the section of the population     have direct contact with the community and
                          reduction in school drop-outs; diabetolo-          undergoing formal education or already in        can exercise significant influence on them.
                          gists would like better compliance to              employment, one of the major eye care            The support of these individuals has a
                          follow-up, and so on. Hence, it is important       interventions required is refractive error       significant impact on general eye care,

                            Exhibits to create awareness
                            about diabetic retinopathy.
                            inDia
Aravind Eye Care System




                          66        Community EyE HEaltH Journal | Vol 20 iSSuE 64 | DECEmBEr 2007
especially on the success of community-            people known to have diabetes, who are             relevant practitioner groups.
oriented activities such as community              otherwise hard to reach (it is not cost-               Successful advocacy can result in the
outreach and screening.                            effective to find people with diabetes             following:
    Advocacy targeting community leaders           through community screening1). They are            •	increased attendance in paediatric eye
needs to focus on the magnitude and                therefore very well placed to identify diabetic      clinics (in the short term)
impact of visual impairment and blindness,         retinopathy (DR), an ocular complication           •	a reduction in avoidable childhood
as well as on causes, treatment options,           associated with diabetes. This condition,            blindness (in the long term).
costs, and benefits. Once these leaders            which eventually leads to blindness, can be
come to understand the problems and the            halted, but not reversed – so early diagnosis      Corneal infections
possible solutions, they can usually be            is essential.                                      Field trials have shown that, for people with
persuaded to support eye care work. It is              Unfortunately, most of these practitioners     corneal infections, the combination of
useful to remember that many people in             are unaware of DR and of its treatment.2           immediate use of antibiotics and referral to
this group may also                                                    Even when they are aware       an eye hospital has dramatically reduced
directly benefit from eye
care services. In addition,
                              ‘Most health                             of it, referral to treatment
                                                                       and follow-up is often far
                                                                                                      progression into ulceration and subsequent
                                                                                                      loss of vision.4,5 The individuals who get
they have a direct interest   professionals who                        from satisfactory. At          corneal abrasions tend to be rural farm
in the community they                                                  present, equipment that
represent, as their           work with people                         can remotely diagnose
                                                                                                      workers who often resort to treatment from
                                                                                                      traditional healers or primary health physi-
position of influence is
due in large part to their    who have diabetes                        DR could be installed in
                                                                       the premises of profes-
                                                                                                      cians. These healers, either by giving the
                                                                                                      wrong treatment or by delaying treatment or
efforts to help the
community.
                              are unaware of                           sionals who see many
                                                                       patients with diabetes.3
                                                                                                      referral, often make the condition worse –
                                                                                                      this can lead to vision loss.
    Following successful      diabetic retinopathy’                        Advocacy to address            Advocacy in this regard should be
advocacy to community                                                  DR should be targeted          targeted at primary care physicians and
leaders, it is likely that                                             directly at practitioners,     traditional healers. It should focus on
they will become proactive in promoting eye        informing them of the important role they          education and on creating awareness about
care and can be counted upon to provide            can play in preventing and treating it.            the causes and progression of corneal
tangible support for setting up outreach           Advocacy can also be targeted at decision          infection, and what interventions are
activities or permanent primary eye care           makers within medical training institutions,       possible at primary level.
facilities. They can also provide support for      to convince them to include the diagnosis              Successful advocacy can therefore
the development of a community-based               and treatment of diabetic retinopathy, as          significantly reduce the incidence of corneal
referral system and can play a significant         well as patient counselling and remote             blindness, especially in the rural farming
role in encouraging community members to           diagnostic techniques, in their curricula.         community.
sign up as potential cornea donors.                Such a curriculum should be adapted for
                                                   the different audiences – physicians, health       Low vision and rehabilitation
health professionals                               workers, pharmacy owners, and laboratory           Although patients who are blind or have
Health professionals are key targets for           technicians/owners.                                low vision often come into contact with eye
advocacy to improve eye care delivery. For             Successful advocacy can result in the          care professionals, they are not always
some eye conditions, community screening           following:                                         referred to rehabilitation or low vision
is not cost-effective; health professionals                                                           services. This needs to change in order for
                                                   •	increased attendance at DR services
can be invaluable allies in finding patients at                                                       these individuals to lead a more normal life
                                                   •	better follow-up and compliance
risk. They can also play a crucial role in early                                                      and become productive members of the
                                                   •	a reduction in the number of patients
detection and referral. This is true not just of                                                      community.
                                                     presenting with late-stage DR.
eye health professionals, but of health                                                                   In this case, advocacy has to be directed
professionals in general. For example,                                                                primarily at ophthalmologists and optome-
                                                   Better eye care for children
midwives or obstetricians, as shown in the                                                            trists, in order to encourage them to refer
                                                   Generally, paediatricians and other maternal
next section, can play a role in identifying                                                          patients to appropriate low vision or
                                                   and child health practitioners are in a very
babies at risk of retinopathy of prematurity.                                                         blindness rehabilitation services.
                                                   good position to identify conditions such
                                                   as squint, congenital cataract, congenital             Successful advocacy can result in
                                                                                                      rehabilitation services that reach more
Better eye care delivery:                          glaucoma, and nystagmus in children.
                                                                                                      people, both those who are blind and those
                                                   Similarly, midwives or obstetricians will
specific eye conditions                            be the first to know that a baby was               who have low vision.
This section examines advocacy to improve          delivered prematurely and grossly under-           references
eye care for specific conditions. It is useful     weight – both leading risk factors for             1 Hoerger TJ, Harris R, Hicks KA, Donahue K, Sorensen
to be aware of the way in which care is            retinopathy of prematurity. With timely               S, Engelgau M. Screening for type 2 diabetes mellitus:
                                                                                                         a cost-effectiveness analysis. Ann Intern Med
usually sought and delivered for each              referral and intervention, many of these              2004;140(9): 689–699.
specific condition, in order to identify key       conditions can be addressed. Support from          2 Perumalsamy N, Ramasamy K, Kaliaperumal K, Sekar
targets for advocacy in each case.                                                                       A, Karthika A, Nirmalan PK. A pilot study on awareness
                                                   these groups of health practitioners is               of diabetic retinopathy among non-medical persons in
                                                   therefore essential to ensure that no child           South India: the challenge for eye care programmes in
Diabetic retinopathy                               becomes needlessly blind.                             the region. Indian J Ophthalmol 2004;52: 247–251.
                                                                                                      3 Perumalsamy N, Sathya S, Prasad NM, Ramasamy K.
Diabetes is often diagnosed by a physician             Here again, advocacy should be targeted           Software for reading and grading diabetic retinopathy:
and care is provided either by them or by          at health practitioners themselves, in                Aravind diabetic retinopathy screening 3.0. Diabetes
specialist diabetologists or endocrinologists.     particular at those who have influence                Care 2007;30: 2302–2306.
                                                                                                      4 Upadhyay M, Karmacharya S, Koirala S, Shah D,
In many developing countries, ongoing              amongst their peers (for example, the heads           Shakya S, Shrestha J et al. The Bhaktapur eye study:
monitoring of diabetes is often done by            of professional bodies) and at those who              ocular trauma and antibiotic prophylaxis for the
workers in independent clinical diagnostic                                                               prevention of corneal ulceration in Nepal. Br J
                                                   have supervisory or management responsi-              Ophthalmol 2001;85(4): 388–392.
laboratories and medications are obtained          bilities. There should also be advocacy for        5 Srinivasan M, Upadhyay MP Priyadarsini B,
                                                                                                                                       ,
directly from pharmacists, based on                the inclusion of these eye conditions (their                                         .
                                                                                                         Mahalakshmi R, Whitcher JP Corneal ulceration in
                                                                                                         Southeast Asia iii: prevention of fungal keratitis at the
previous prescriptions. These groups of            causes, clinical manifestations, and                  village level in south India using topical antibiotics.
practitioners all therefore have access to         management) in the training curricula of all          Br J Ophthalmol 2006;90(12): 1472–1475.


                                                                          Community EyE HEaltH Journal | Vol 20 iSSuE 64 | DECEmBEr 2007                       67

				
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