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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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