Developing and expanding an eye health workforce in Pakistan by dfsiopmhy6

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									                            Developing and expanding an
                            eye health workforce in Pakistan
                            Niaz Ullah Khan, Country Director: Pakistan
                            Munazza Gillani, Programme Manager: Pakistan
Jamshyd Masud/Sightsavers




                            Fatima, a Lady Health Worker, testing the visual acuity of a family during her routine visit to slums in
                            Gadap Town, Karachi



                            Abstract:                                                   and prevention of eye disease. This strategy
                                                                                        has been implemented with full ownership
                            Availability of trained human resources                     and stewardship by the public sector and has
                            (HR) is vital for the effective functioning of              been a successful recipe for scaling up both
                            any health system. The National Eye Health                  the training and deployment of eye health
                            Programme (NEHP) in Pakistan has placed                     professionals within existing health services.
                            special emphasis on the institutionalisation
                            of human resource development (HRD) to
                            enhance coverage and access. This includes
                            the establishment of training institutes in
                                                                                        Background:
                            both the public and non-government sectors;                 Pakistan is a diverse country with a population
                            training of ophthalmologists in community                   of 165 million people divided into five
                            eye health; specialised training programmes                 provinces with two federally administered
                            for allied vision sciences professionals such               zones. The first population based national
                            as optometrists and ophthalmic technicians;                 blindness survey, conducted in 1987-
                            and revitalising the eye health component of                1988, showed a prevalence of 1.78%. The
                            primary health care through the training of                 second population based national blindness
                            Lady Health Workers in eye health promotion                 survey, conducted in 2003-2004, revealed

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a prevalence of 0.9%. This demonstrated a          programme trains ophthalmologists in the
significant halving of the blind population over   areas of public eye health and management,
a period of 15 years. Presently, it is estimated   with a specific focus on community health,
that there are about 1.5 million people with       advocacy and outreach activities. The first
blindness and nearly four million people who       batch of community ophthalmologists played
are visually impaired in the country.              a significant role in laying the foundation
The first five years of the NEHP (1994-1998)       on which a national eye health programme
focused on understanding the need for HRD,         could be developed. This took the form of
the institutional structures, and on developing    comprehensive eye care (CEC) cells in the
linkages within and across the region with         four provinces and these cells served as
the assistance of international partners. A        the planning and coordination units for the
pilot phase to train different cadres of eye       devolving national programme, and provided a
care teams was run in conjunction with a           leadership role in designing, implementing and
district comprehensive eye care (DCEC)             monitoring the district CEC programmes and
strategy that invested in strengthening eye        HRD training programmes in their respective
health infrastructure and HR capacity for          provinces. The College of Ophthalmology and
eye health at the district level. The second       Allied Vision Sciences (COAVS) plans to start a
NEHP (1999–2003) used the learning and             Masters in Community Eye Health from 2010.
experience from the first plan to enhance and
scale up institutional development for training
in all the provinces in the country and this       Developing mid level eye care
was linked with a parallel scaling up of DCEC      professionals/personnel:
programmes in the country. As part of the
third NEHP (2005-2010), subspecialty training      The situation analysis supported by WHO
has now been added to the range of training        in 1980 revealed a lack of trained human
programmes to address specialty needs now          resources, specifically those providing
arising from improved detection and referral of    support to the ophthalmologists working at
complicated eye conditions.                        the tertiary and secondary levels. As a result,
                                                   there were low outputs and limited outreach
                                                   services for the communities. The national
Programme initiatives and                          committee approved a training programme
                                                   for eye health professionals, initially training
outcomes:                                          ophthalmic technicians for a duration of one
Since the 1990s the national committee             year. This was started in 1993-1994 at PICO in
for prevention and control of blindness has        Peshawar with the support of Sightsavers. In
sensitised and lobbied key policy and decision     the second national eye care plan, and based
makers to institutionalise HRD programmes          on deliberations and feedback from partners,
in Pakistan. This included situation analysis      human resource planning was redefined and
and human resource planning in the                 organised with a career path requiring a three
provinces, together with development of a          year course for the students. The process
CEC strategy. Initially, the committee agreed      progressed and was implemented in phases,
with three critical human resources needs i.e.     with establishment of institutes for training in
development of community ophthalmology;            each province in Pakistan.
development of other eye care personnel            The Pakistan Center for Vision Sciences
like optometrists and ophthalmic technicians,      (PCVS) was established within PICO Peshawar
and revitalising the eye health component of       which served as the progenitor for other
primary health care.                               provincial institutes. A new precedence of
                                                   public-private partnership (PPP) was set in
                                                   Punjab through upgrading of the Punjab
Developing community                               CEC Cell, firstly to a new Punjab Institute of
ophthalmology:                                     Preventive Ophthalmology (PIPO) and then
                                                   to a College of Ophthalmology and Allied
With the support of international                  Vision Sciences (COAVS). All construction
partners Pakistan Institute of Community           and establishment costs were provided by
Ophthalmology (PICO), Peshawar, initiated          the provincial government, and other capital
a one year masters degree programme                costs for infrastructure, equipment and training
in community ophthalmology in 1998.The             were provided by Sightsavers, Fred Hollows


                                                                                           Page 17
Foundation and WHO.                                                      and also a reduction in simple eye infections
In Sindh province, a new vision sciences centre                          that could be easily treated at the primary
was set up at Civil Hospital in Karachi through                          level but were unnecessarily increasing the
a PPP with Sightsavers. As a result of intense                           outpatient load at the district hospitals.
advocacy efforts and using the precedence                                In 2008, a national initiative to train 20,000
of demonstration models in the other three                               LHWs was initiated as a part of existing health
provinces, the government of Balochistan                                 structures and now the government of Pakistan
province established a training programme                                is funding the training of 50,000 LHWs in eye
for ophthalmic technicians at their multi-                               health as part of primary health care.
purpose training centre in Quetta through
PPP with Sightsavers. A leading national
non-government organisation, Al-Ibrahim Eye                              Going to scale
Hospital in Karachi, known as Isra School of
Optometry and supported by Sightsavers, also                             According to Pakistan’s national eye health
offers a four year course in line with approved                          plan, the country needs 215 community
national guidelines.                                                     ophthalmologists, 2,650 optometrists/
                                                                         graduates in vision sciences and 3400
The various institutes thus developed in the                             ophthalmic technicians/nurses. In addition,
country were used to raise the profile of eye                            80,000 PHC workers deployed at the
health and blindness and, through sustainable                            community level need orientation in eye health.
production of an eye health workforce, increase
the coverage of eye health services, strengthen                          Sightsavers facilitated the establishment of
the human resources for eye health as part of                            four training institutes at the provincial levels
health systems strengthening, and provide the                            and one in the NGO sector to meet the human
rationale for creation of posts and deployment                           resource needs for the national eye health
of trained staff within the public sector.                               programme. These institutes are producing an
                                                                         average of 10 community ophthalmologists,
                                                                         100 OTs and 80 optometrists/vision
Strengthening the primary                                                graduates each year. So far, 86 community
                                                                         ophthalmologists, 47 optometrists, 10
health workforce                                                         orthoptists and 440 OTs have been trained
The government of Pakistan launched a                                    in Pakistan. In the national eye health
National Programme for Family Planning                                   programme 2005-2010, the provinces provided
and Primary Health Care in 1993-94. The                                  concurrence and commitment for creating the
programme focuses on deployment of Lady                                  posts needed for the programme. In Punjab,
Health Workers (LHWs) at the community level                             all positions have been approved and created,
for health promotion and disease prevention.                             and the graduates are being placed against
A LHW is responsible for a population of about                           those positions. In Sindh and North West
1,000 people or 125-150 households, and visits                           Frontier, advocacy efforts are underway with
each household at least once a month. She is                             relevant government authorities to create new
considered as the first line health workforce.                           posts for eye health professionals.
The national eye health committee lobbied                                                      Salma, a Lady Health Worker,
for strengthening the eye health component                                                     with a patient
of primary health care. This advocacy was
supported by research at the community
level, which identified that at least 30% of the
community suffered from non- vision impairing
eye conditions, such as conjunctivitis, allergies
etc . The mean frequency of eye complaints
was 55 cases per month for 1,000 people.
Based on this evidence, eye health
training of LHWs was piloted initially
at the community level around a basic
                                             Jamshyd Masud/Sightsavers




health unit, then at sub-district level and
subsequently at district level. All results
clearly demonstrated an increase in
uptake of eye care services for surgery
at the district level, especially for women,


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For the training of LHWs, Sightsavers                      Evidence building and advocacy are pivotal




                                                       v
shifted its approach towards health systems                to the success of any human resource
strengthening rather than working as a vertical            development strategy. Encouraging research
approach where PHC workers were trained                    for evidence and hypothesis assessment
by ophthalmologists. Using this systems                    provides a foundation for effective lobbying,
strengthening approach, our partners were                  networking and influencing the decision and
able to train 32,000 LHWs in Pakistan. The                 policy makers.
government of Pakistan has scaled this
                                                           There is considerable benefit to be obtained




                                                       v
approach up by providing training to the
                                                           by undertaking human resource planning
remaining 50,000 LHWs across the country.
                                                           for eye health together with the relevant
Through Sightsavers’ advocacy work, the                    planning section in health ministries and
government of Pakistan has recognised the                  departments. This ensures ownership,
HRD programme as a demonstration model                     institutionalisation and subsequent
that can be replicated and gradually scaled                allocation of resources.
up across the country. The government has
                                                           The needs and approaches have to vary




                                                       v
now approved another Masters degree in
                                                           for different tiers and levels of services i.e.
community ophthalmology at COAVS and
                                                           ophthalmic technicians at the community
a graduation course in Vision Sciences in
                                                           level, optometrists at secondary and tertiary
key medical teaching institutes in Pakistan
                                                           levels. These evolve over the period with
from 2009. In addition to this, in three
                                                           experience and learning, and every country
provinces; Punjab, Sindh and Balochistan,
                                                           should decide based on local practices and
the government has taken over all necessary
                                                           international learning.
operational expenditure, whilst Sightsavers
has been providing necessary support in the                It is quite challenging to advocate for
                                                       v




faculty development and standardisation of                 a wholesale package from an eye care
the courses.                                               context only. A strategy that demonstrates
                                                           how human resource planning for eye
                                                           health is interlinked with the wider health
Key learning                                               development agenda, and how there is
                                                           inter-dependence between different sectors
    Mapping out of the key stakeholders                    and fields, will enable us to bring about a
v




    involved at different levels and tiers is              step by step change in health care delivery.
    pivotal to identify strategic entry points
                                                           Partnership development that places the
                                                       v




    and collaboration with other programmes.
                                                           onus of ownership and stewardship in
    This makes the process cost effective
                                                           public institutes and provides necessary
    and beneficial with a win-win situation for
                                                           investment for pilot initiatives is the key
    everyone.
                                                           to develop demonstration approaches
    Making VISION 2020 a reality at the country            and undertake sustained and consistent
v




    and regional level is impossible without an            advocacy for scaling up human resource
    appropriate human resource development                 development and deployment.
    strategy at different levels and tiers.
    Provision of equipment and infrastructure
    is likely to be less useful without availability   Resources and further reading
    and functionality of human resources.
                                                       Gilbert, C.E et al on behalf of the Pakistan National Eye
    Learning from the processes and initiatives
v




                                                       Survey Study Group, (2008), Poverty and blindness in
    is critical for efficient change management        Pakistan: results from the Pakistan national blindness
    and creativity for sustainable development.        and visual impairment survey. British Medical Journal, vol
    Initially, the programme focused on                336 No. 7634:29-32
    ophthalmologists training the LHWs in              Hussain,A; Awan,H; Khan,M.D.; Prevalence of non-vision-
    eye health. However, from programme                impairing conditions in a village in Chakwal district,
    evaluations, we learnt that integration of         Punjab, Pakistan’ Ophthalmic Epidemiology; Volume 11,
    eye health into primary health care and the        Number 5, December 2004 , pp. 413-426(14)
    national health management information             Khan AA. Charting new frontiers of hope in Pakistan.
    system is not possible without the active          Community Eye Health J 2007;20(64): 65.
    involvement of and shifting the ownerships
                                                       Khan N, Khan AA and Awan HR, Women health workers:
    to the national programme for primary
                                                       improving eye care in Pakistan Community Eye Health J
    health care.                                       2009;22(70): 26


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