Haiti NECP 2008-2012

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					NATIONAL VISION 2020 PLAN
 FOR THE PREVENTION OF
   BLINDNESS IN HAITI
        2008-2012

         DRAFT




                            1
1. INTRODUCTION

Haiti is one of the central Caribbean countries, sharing the island of Hispaniola with the
Dominican Republic. Haiti has a territory of 27 250 km². It is a very mountainous
country with difficult access, where communications are highly complicated: less than
1500 km of roads are paved, and 54% of the territory is arid mountains. Means of
communication are inadequate, not functional or non-existent.

People and population 2006:
Total Population: 8.600.000 inhabitants, 40% live in rural areas.
Illiteracy rate is estimated in 65; over 70% of the population lives below the extreme
poverty line and 70% of the economically active population is unemployed.

Administrative structure
Districts                     Capital                        Population
Artibonite                    Gonaives                                         1 013 779
Centre                        Hinche                                             500 000
Grande-Anse                   Jeremie                                            641 399
Nord                          Cap-Haitien                                        800 000
Nord-Est                      Fort Liberte                                       250 000
Nord-Ouest                    Port-de-Paix                                       420 971
Ouest                         Port-au-Prince                                   2 494 862
Sud                           Cayes                                              653 398
Sud-Est                       Jacmel                                             457 013




                                                                                        2
Age structure:

Haiti Demographic profile 2005-2010
                 Indicator               2005            2010
Population (thousands)                          9 296        10 060
Percentage aged 0-4 (%)                          13.3           12.6
Percentage aged 5-14 (%)                         24.6           23.4
Percentage aged 50 or over (%)                   11.7           12.4
Population density (per sq. km)                  335            363


Latin America and the Caribbean Demographic profile 2005-2010

                 Indicator               2005
Population (thousands)                       557 979
Percentage aged 0-4 (%)                          10.1
Percentage aged 5-14 (%)                         19.8
Percentage aged 50 or over (%)                   16.9
Population density (per sq. km)                    27




Health Conditions in Haiti
The country faces problems of organization, infrastructure, resources and a shortage of
human resources to cover the whole national territory. There is partial primary health
care coverage by health agents. There is also partial Vitamin A distribution coverage for
school children. The percentage of population with medical insurance is under 5%.The
health system in Haiti is made up of the public sector, the private non for profit (non
governmental and religious organizations) and the private for profit sector.

Health Training
1 Public School of medicine
2 Private schools of medicine
4 Public Schools of nursing

2. BLINDNESS
Blindness Worldwide

     WHO estimates the worldwide number of persons who are blind to be 38 million
and the number of persons with low vision is 110 million. Two thirds of these visually
impaired cases might have been cured or prevented through increased awareness, or
with relatively simple treatments and surgical interventions. Most persons with a
visual handicap are found in developing countries, this is mainly due to the lack of
access to adequate services. Within the region, the main causes of blindness are cataract,
trachoma, onchocerciasis, xerophthalmia, glaucoma, diabetic retinopathy and
traumatism.

Blindness and low vision are a public health problem throughout the world, and support
and rehabilitation are a burden to the economic conditions of families and eventually to
the national economy. This is why WHO, together with worldwide known NGOs, has
launched the VISION 2020 worldwide program.


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This program, that brings together governments, WHO, international and local NGOs,
as well as associations of professionals in eye care, aims to determine worldwide lines
of action that, recognizing regional and local specific issues, will reach a greater number
of people more rapidly



Blindness in the Caribbean:

The Barbados Eye Studies demonstrated the following causes of incident blindness:
Cataract: 52%
Cataract and Open Angle Glaucoma: 9%
Open Angle Glaucoma alone: 10%
Diabetic retinopathy: 10%
Others: 19%

Vision 2020 was officially launched in Trinidad-Tobago in April 2000. The four
priorities in the initiative defined for the region are:
          Cataract, primary cause of worldwide blindness
          Glaucoma, most common in black population
          Diabetic retinopathy
          Child blindness and major refraction problems

Blindness in Haiti:
There are no statistics available for Haiti. Comparing Haiti with those countries with the
same population and similar conditions, it can be estimated that:

   1. 1% of the population, approximately 80.000 individuals, are estimated to be
      blind, where :
                  i. 50 to 60 % is due to cataract (50.000 cataract blind )
                 ii. 20 to 25% is due to glaucoma
                iii. 5% Diabetic retinopathy
   2. 4% of blind individuals are children.
   3. 7% of children in school have unattended refraction problems

The figures shown at the diabetes D day in Latin America, lead to believe that diabetic
retinopathy is not as common in Haiti as it is in the rest of Latin America.

It is estimated that 50% of the blind individuals in the Caribbean are in Haiti.



3. SITUATION OF EYE HEALTH AND EYE CARE
SERVICES
National Organization

In 1998, a national commission for the prevention of blindness was created by the
ministry of public health following a workshop organized with the assistance of the Pan


                                                                                         4
American Health Organization –World Health Organization (PAHO-WHO) and the
participation of CBM, CCB-SSI & other organizations involved in the prevention and
control of visual impairment and blindness in Haiti.

The main objectives of this commission were:
1. 1. Strengthen the existing cataract services (including the renovation of buildings,
equipment) at:
      1.1. Port Au Prince, University Hospital.
      1.2. Opti - Prevention and other Eye Care Providers in Port Au Prince.
      1.3 Baptist Church Hospital in Cap Haitian
      1.4 General Hospital in Cap Haitian
      1.5.Brenda Strafford Foundation in Cayes.
      1.6 La Providence Hospital – Gonaieves, Artibonite;

2. Training doctors in Ophthalmology

3. Training Intermediate Level Personnel (nurses specialized in ophthalmology or the
training of Ophthalmic Technicians)

4. Integration of Primary Eye Care into the Primary Health Care System (Training of
community health agents in primary eye care).

These objectives received technical and financial assistance from CBM, the Lions Club
International Foundation, Sightsavers International and the Caribbean Council for the
Blind.
During the past years emphasis was given to:
    1. Rehabilitate the ophthalmology department of Haiti’s state university hospital.
    2. Training Ophthalmologists with an emphasis on cataract surgery.
    3. Establishment of an Eye Department at the La Providence Hospital, Gonaieves;
    4. Provission of equipment & supplies to Eye Department in the Justinian hospital
        – Cap Hatian;
    5. Provision of materials & financial support to develop cataract services for the
        poor at Opti Prevension

In July 18, 2000, with the signed global declaration of support to the Vision 2020: Right
to Sight initiative, the public health ministry committed to work actively in the fight
against avoidable blindness on a national level and has recognized the necessity to
involve the public and private sectors in this endeavor.

The Ministry of Health - MSPP is the largest employer with 12 ophthalmologists in its
payroll (25% of the ophthalmologists in the country)


4. PLAN OF ACTION 2008 -2012
Aim: To eliminate the preventable causes that lead to blindness in Haiti.

The approach to implementing the established activity areas of VISION 2020 are:

      disease control;


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      human resource development (HRD); and
      infrastructure and technologies.


DISEASE CONTROL

Table Criteria for identification of target Diseases in the Caribbean (year 2002)
Disease          Importance      Effectiveness of Priority
                                 intervention       Ranking
Cataract         +++++           ++++               1
Glaucoma         +++++           +                  5
Diabetic R       +++             ++                 3
Refractive       ++              +++++              2
Childhood B ++                   ++                 4



CATARACT

Situation Cataract
In Haiti, cataract accounts for 50%- 60% of cases of blindness. Current estimates show
that there is a backlog of approximately 50.000 blinding cataract cases with an annual
incidence of 10.000. The number of cataract surgeries performed has increased from
300 in 1995 to 3500 in 2005. This number only represents a portion of the annual
incidence therefore contributing to the backlog.

In order to really tackle the problem of blindness and severe visual impairment due to
cataract the requirement need to is to make at least 2000 cataract operations per million
populations per year.

Barriers to improving eye care services in Haiti
The percentage of the population with access to eye care services is very small (aprox.
30%).
General Barriers to Eye Care include:
   1. A high rate of illiteracy in Haiti
   2. A national health coverage that does not reach the entire population
   3. Socio-cultural limitations
   4. Inefficient distribution of human resources – lack of HR, medicines, etc. in rural
       areas
   5. Very limited transportation network
   6. Insufficient structures (buildings and equipment)
   7. Cost of services inaccessible to the majority (per capita income at US$200)
   8. Political instability and insecurity
   9. Poor statistics in eye care services except for Brenda Strafford Foundation.

Services & Patients Barriers to Cataract Surgery
   1. Services not available in some departments (Districts)
   2. Lack of opportunities for ophthalmologists to operate, no places for
       ophthalmologists to operate
   3. Long waiting lists


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   4. No enough surgeons
   5. Lack of operating room
   6. Lack of operating equipment
   7. Lack of allied health personnel
   8. Low demand by patients.
   9. Lack of awareness and knowledge of patients of eye diseases and the services
   10. Cannot afford operation. A cataract surgery cost 40 USD for the patient at the
       public services, there is no consensus if this is affordable for the majority of the
       population.

   11. Poor quality of surgeries. Patients prefer going to Cubans to get their free
       service.


During the planning workshop specific cataract surgery barriers were identified
for the following institutions:

HUEH University Hospital
   1. Low demand by patients
   2. Poor customer service
   3. Not enough surgeons
HCH – Hop. De la Communauté Haitienne
   1. Patients cannot afford operation
   2. Lack of allied health personnel
   3. Low demand by patients
ICC
   1. Lack of operating room
   2. Poor customer service
   3. Not enough surgeons
Brenda Strafford Foundation
   1. Waiting lists
   2. Not enough surgeons
   3. Cannot afford operation
Hopital Justinien
   1. Not enough surgeons
   2. Lack of allied health personnel
   3. Previous lack of operating room
   4. Previous lack of operating equipment
   5. Not enough surgeons
   6. Lack of allied health personnel
   7. Lack of adequate supplies
   8. Absence of regular electricity supply;


   Aim: Elimination of cataract blindness

   National targets of cataract operations per year.
      Year                  2005              2012                       2020
      CSR                   440 x million       900 x million            2000 x million
      Number of             3.500             7.200 *                    16.000*


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      operations
**The numbers shall be adjusted to the population in the years 2012 and 2020

Objectives:
   Improve cataract surgical rate (CSR) by district.

   Targets of cataract operations by Department
                                            Cat Op needs       Cat Op needs
Department Capital             Population   Year 2012*         Year 2020*
                                            900x million pop   2000 x million pop
Artibonite   Gonaive            1013779                  912               2028
Centre       Hinche               500000                 450               1000
Grand-Anse Jeremie                641399                 577               1283
Nord         Cap Haiten           800000                 720               1600
Nord-Est     Fort Liberte         250000                 225                500
Nord-Oest    Port-de-Paix         420971                 379                842
Quest        Port-au-Prince     2494862                 2245               4990
Sud          Cayes                653398                 588               1307
Sud-Est      Jacmel               457013                 411                914
Total                           7231422                 6508                14463
*The numbers shall be adjusted to the population in the years 2012 and 2020

    Improve visual outcome
    Services accessible to most people in Haiti
    Services affordable for all people

Strategies:

Availability & Access
    Develop district specific cataract service targets (cataract surgical rates)
    Strengthen 5 or 6 Referral centres distributed throughout the country.
    Training of national ophthalmologists. Expansion of the residency program by
       the MoH should be encouraged
    Improve the training and use of ophthalmic assistants.
    Private ophthalmologists actively involved in outreach programmes
    Identify places where private ophthalmologists can provide services to low
       income patients
    Reinforce existing institutions and negotiate with them to prvide a social service
       for private ophthalmologists willing to operate.
    Provide transportation to patients to the high volume surgical services.

Affordability:
    Define costs of CS in each of the centres.
    Promote cataract surgical services at a cost which all patients can afford.
    Provide subsidised service for poor patients. Establish a resource mobilization
       program in Haiti targeting local people willing to support part of the services.
       There are no organizations currently subsidizing CS, local business enterprises
       could be approached for this purpose, as well as some other entities.
    Make bulk purchase of consumables and low cost good quality supplies.


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      Maximum utilization of consumables.
      Equip a surgical centre where private ophthalmologists can donate their time
       providing service to poor patients.
      Utilize cross-subsidies (This strategy could be established in Justinien because it
       is possible that patients are charged different fee depending on their ability to
       pay).
      Create incentives to increase demand from patients (e.g. charges half of the price
       (or free) for 2nd eye or when patient brings 1-2 more people for CS).
      High volume of CS will reduce costs

Quality
    Centers supported by NGOs shall establish a quality control department to
       improve surgical outcomes and create more confidence of population to
       ophthalmologists.
    Promote high quality surgery which gives good visual outcomes.
    Intraocular lenses should be used in all patients unless contraindicated.
    Ensure good selection of patients for CS
    Monitoring of surgical outcome by cataract surgeons. CS for self and service
       evaluation (available in internet at http://www.iceh.org.uk/eresources/mcso.html

    Establish quality WHO standards:
     1. % of IOL per eye (ideal 90%)
     2. % of persons below 20/200 (less than 10% best corrected)
     3. % of complications (less 10% included 5% vitreus)
    Make a qualitative study among patients to identify perceptions of local services
     vs. Cuban or other international services.

Services Utilization meaning people looking for services = demand.
    Create demand for service by overcoming barriers to the uptake of services,
       through a variety of community interactions. The major barriers to uptake of
       cataract services are:
           - accessibility not easy
           - lack of awareness and knowledge of patients of eye diseases and the
               services
           - poor quality of service
           - high cost of treatment

      Implement educational programs to patients about cataract and other eye
       diseases.
      Establish a link with the primary eye care system. “Health Agents” and
       community-based rehabilitation workers to identify people with cataract, to
       provide follow-up and rehabilitation for patients after cataract operation and to
       create awareness at community level. Targeted communities should be those
       located around the selected centres.
      In places where services are available, mass media (radio- TV) can be utilized to
       educate patients and increase demand.


Indicators:


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    1. National and district/sub national cataract surgical rates (i.e. number of cataract
       operations per million population per year) (CSR in year 2005 was 440), CSR
       900 x million per year in 2012, CSR 2000 x million per year in 2020.
    2. Proportion of cataract surgery that is with IOLs (IOL Implantation Rate)
    3. Ophthalmologists productivity measured by institution (number of CS done per
       ophthalmologist per year)
    4. Proportion of patients reaching the recommended level of visual acuity 60 days
       after cataract surgery.
    5. Average cost per cataract surgery per centre per year.
    6. Information/communication program established and running (previous
       qualitative study: message, media, etc…)
.

REFRACTIVE ERRORS

Statistical data on refraction errors in Haiti are not available, but it is estimated that 7%
of school-aged children may require refraction correction. There is an active program
for the distribution of recycled eyeglasses in certain eye care centers thanks to technical
and financial assistance from the Lions Club of Bremen in Germany. Haiti does not yet
have an optics laboratory for the making of eyeglasses at low prices, nor are there any
optometry schools or ophthalmologist assistants.


Aim: To reduce visual impairment due to uncorrected refractive errors.

Objectives
1. To initiate a program to detect and treat significant refractive errors in school children
11 to 15 years of age.
2. To provide low cost good quality affordable spectacles.

Strategies:
1. Assess the screening program taking place at the Justinien Hospital in Cap Haitien
   and to adjust it to the Caribbean Vision 2020 standards for refractive errors
   correction in school children.
2. Develop a model RE screening program for school children in Haiti.
3. Promote pilot programs in other areas of the country.
4. Ensure access to an affordable optical service (spectacles laboratory).

Indicators:
 Establishment of a screening model for school children and finalisation of pilot
   programs in Haiti.
 A low priced glass manufacturing laboratory is active by the end of the period.



LOW VISION, EDUCATION and REHABILITATION

Aim: To initiate low vision care and strength rehabilitation and education in Haiti.



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Objectives
 To establish low vision services in Haiti.
 To strengthen the Education and Rehabilitation services for the blind

Strategies
 Identify 3 national providers of low vision services (north, PAP, south).
 Give a short training course to the focal professionals that will provide itinerant
   services.
 Provide focal institution and professionals with basic equipment and LV aids.
 Promote the utilization of LV services by ophthalmologists through a referral
   system
 Improve services in the Artibonite department.
 Strengthen the link between LV services and community based rehabilitation (CBR)
   services.
 Provide awareness training to CBR workers on LV.

Indicators
        Establishment of basic LV services by the end of the period.


CHILDHOOD BLINDNESS

Situation

Estimates for Childhood blindness in Haiti

At the global level for a very poor socioeconomic level the prevalence of childhood
blindness is of 1.5/ 1,000 and the major causes are corneal scarring due to vitamin A
deficiency, measles, ophthalmia neonatorum, use of harmful traditional eye remedies
and cataract.
The statistics on blindness in children in Haiti are practically non existent. Based on
data gathered during school visits, the most frequent causes of blindness in children are
refraction errors, corneal opacities linked to vitamin A deficiency, congenital cataracts
and trauma.
Vitamin A deficiency is still a major public health problem in Haiti. In a study done in
1975 by Alfred Sommer, xerophtalmia was identified as the principal cause of blindness
in the Haitian child. In 1992, during the embargo (1991 – 1994) the interruption of
vaccination and of the distribution of vitamin A capsules caused a reemergence in the
number of pockets of xerophtalmia. Although vitamin A is available nationally, it has
not been effectively distributed to the entire population (only 44%) and the diet is not
sufficient to provide the required amounts. Therefore, multiple cases of vitamin A
deficiency have been reported.
According to the available statistics from the HUEH, the cases of congenital cataracts
account for 5% of all cases of cataracts diagnosed at the HUEH ophthalmology service.
However, care for congenital cataract is very limited because of the following reasons:
    1. Inadequate technical expertise
    2. Absence of qualified personnel
    3. Anesthesia equipment unavailable (general anesthesia)


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Aim: To reduce avoidable causes of blindness in children

Objectives:
1. Elimination of corneal scarring caused by:
            vitamin A deficiency
            measles
            Ophthalmia neonatorum
2. Eliminate new cases of congenital rubella syndrome.
3. To develop therapeutic and surgical services to treat children with:
            cataract
            glaucoma

Strategies:
1, Document xerophthalmia cases found.
2. Find the origin of patients with xerophthalmia.
3. National Society of ophthalmology present a report to the MoH on previous points
1&2)
4. Encourage primary health care, including specific preventive measures at the primary
level, for example:
           (a) Prevention of neonatal conjunctivitis
                        a.    Apply the PAHO protocol.
           (b) measles immunization, to prevent corneal scarring
           (c) vitamin A supplementation, nutrition education, food supplementation and
               fortification of commonly consumed foods with vitamin A, to control
               vitamin A deficiency
           (d) Rubella immunization of school girls aged 12-13 years if congenital
               rubella is an important cause of mortality or morbidity in children.

2. Develop secondary and tertiary level, to provide specialist training and services for
   the diagnosis and management of surgically remediable visual loss in children with
   emphasis in cataract.
         (a) Select cases to be operated (total cataract, nistagmus)
         (b) To provide the optical correction (IOLs or lenses)
         (c) Genetic counselling to the parents
         (d) Education to the parents: need to evaluate postoperated cases.

Indicators:
 Vitamin A deficiency control programmes or eliminated vitamin A deficiency.
 Presence of a paediatric ophthalmology service


TRACHOMA

Situation:
There are reports of trichiasis due of trachoma in Haiti. Some studies were reported in
the 70s. Recently pockets of trachoma in certain areas of the country have been
reported, e.g. in Grizongade (12 out of 75 blind patients) and in Fort Liberte (an 8 year
old girl), in the Northern department



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Aim:
Elimination of blindness due to trachoma by the year 2020.

Objectives:
1. Perform a proper assessment of the trachoma epidemiological situation.
2. Apply the WHO recommended SAFE strategy for positive pockets

Strategies:
   1. Review the epidemiological situation (literature + possible field visit).
   2. Encourage the eye doctors in Haiti to identify possible cases of trachoma.

Indicators:
 Epidemilogic assessment done.
 SAFE strategy introduce where appropriate


DIABETIC RETINOPATHY:

Situation:
    1. There is no good data on this disease but according to the observations of the
       ophthalmologists the prevalence of diabetic retinopathy is very low in the
       country.
    2. Haiti has a well organized Diabetics Association.
    3. There are 2 lasers to treat DR, 1 in Les Cayes at BS and 1 in private practice in
       PaP.

Aim
To reduce the prevalence of blindness from diabetic retinopathy

Objective

1. Reduce the eye disease complications from diabetes.
2. Delivery of eye care for patients with diabetes.

Strategies:
   1. Ensure that Diabetic retinopathy is adequately dealt with in the existing curricula
       for ophthalmologist.
   2. Train other specialized doctors (endocrinologists, etc…) who see diabetic
       patients in order for them to detect and make referrals to the ophthalmologist.
   3. Identify opportunities for adding basic screening methods for Diabetic
       Retinopathy while performing eye examination for other eye conditions, such as
       those before and after cataract surgery.
   4. Assess the need (# of cases per year)for a laser center in a public hospital

Target 2012
   - To establish 2 centers that can treat retina equipped with lasers and trained
      personnel (North and PauP)




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GLAUCOMA

Situation
The Barbados Eye Studies found that about 7% of the Afro Caribbean population over
40-84 years has glaucoma. No national statistics are available.
Ophthalmologists prefer not to carry out glaucoma surgeries because the perception of
patients of such surgery is not good – when outcomes do not meet patient expectations
it can damage the reputation of the surgeon.
The HSO has been undertaking public awareness raising through media and advocating
with the MoH to include glaucoma as a public health issue.

Aim
To reduce avoidable blindness from glaucoma

Limitations
 Feasibility of the known screening methods to date is low.
 Eye care services for patients with glaucoma are not sufficiently available.

Strategies

The major areas of activities are as follows:

   Ensure that glaucoma is adequately dealt with in the existing curricula for eye care
    personnel.
   Train local surgeons in glaucoma surgery.
   Identify opportunities for adding basic screening methods for glaucoma in patients
    over 35 years while performing eye examination for other eye conditions, such as
    those before and after cataract surgery.
   Wherever possible, ensure that at least the basic equipment and medication are
    available in the services.
   Community education in regard to risk factors, people with risk factors (over 40
    years, family history) should look for en eye exam (optic disc assessment plus IOP).
   Utilise low cost Timolol for those in need of treatment.

Targets 2012
   - To have 3 trained surgeons in Glaucoma.
   - Increase the number of glaucoma surgeries per year.
   - Include glaucoma information for the population in the primary health system.
   - Provide low cost Timolol for all patients in need.



HUMAN RESOURCE DEVELOPMENT (HRD)

The Ministry of Health stated during the 2007 Community Eye Health Course that
training of professionals is crucial in Haiti.



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Situation
Ophthalmologists
There are 49 ophthalmologists in Haiti with 80 % of them based in Port-au-Prince and
only 30 practicing surgery. There are regular eye care services in 7 cities: Port-au-
Prince, Cap-Haitian, and Les Cayes, Jacmel, Gonaive, Cange, Petit-Goave.

In some areas, there are regular visits once or twice a week; while in other areas there
are monthly visits and surgeries- Some of the areas are: Hinche , Jeremie, Saint Louis
du Nord .

Ophthalmologists Distribution by Districts and Hospitals - 2006
Insititution                                Department                      No. ophth
HUEH (University Hospital)                  WEST (Port-au-Prince)                 3
Clinique Eye Care/st vincent                WEST (Port-au-Prince)                 3
Hôp. De la Communauté Haïtienne *           WEST (Petion-Ville)                   4
Clin. Notre Dame de Lourdes                 WEST (Delmas)                         1
Hôp. Adventiste Diquini                     WEST ( Carrefour )                    1
ICC ????? No OR                             WEST (Delmas)                         1
Petit-Goave                                 WEST (Petit -Goave)                   2
Hôpital Ste Croix de Léogane (Vis
                                            WEST (Leogane)
Doctors)
Help                                        WEST (tabarre)                        1
Hopital de la Renaissance (cubans)          WEST (PAP)
dispensaire la providence ( NO OR)          WEST (PAP)
Centre Medical Champ de Mars                WEST (PAP)                            2
Lascahobas (Visiting Doctors)               PLATEAU CENTRAL
Cange                                       PLATEAU CENTRAL                       1
                                            CENTRE (Hinche)
Institut Brenda Strafford                   SOUTH (Les Cayes)                     5
Jacmel                                      SOUTH EAST                            1
Jérémie (Project Gebeau)                    GRANDE ANSE (South West)              0
Gonaives (Cubans)                           ARTIBONITE (Central)
Deschapelles (Hospital Albert
                                            ARTIBONITE (Central)                  1
Schweitzer)
Hôpital Justinien                            NORTH (Cap Haïtien)                  1
Mission Baptiste                             NORTH (Cap Haïtien)                  1
Hôpital de Pignon (Visiting Doctors)         NORTH (Cap Haïtien)
                                             NORTH EAST (Fort Liberte)
                                             NORTH QUEST (Port-de-
                                             Paix)
*Not all 49 ophthalmologists are listed in the table


Training: The HUEH has an ophthalmology training program that was strengthened in
1998 with the assistance of NGOs (CBM, LCIF) by integrating a cataract surgery
training tract. Since then, 10 doctors have been trained.


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Number of new ophthalmologists that finished residency program in Haiti by year
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Total
 0    0      2       0      3        3       3       2      2      3       18

The total numbers of new ophthalmologists that remain in practice are: 14
The total number of eye surgeons is14.

The training program receives academic assistance from foreign institutions such as the
American Academy of Ophthalmology, the Pan-American Association of
Ophthalmology, the OPC (France), and others.
Surgical activities have been reduced to cataract operations, surgical treatment of eye
trauma, and minor surgeries (pterigium, chalazion, etc). Care of pathologies of the
posterior segment remains medical.
Orientation of the young ophthalmologists towards community practice remains
difficult especially for trainers because career perspectives are still uncertain. The
limited economic means of the target population and the weak salary offered by the
state explain why young doctors lose interest in community practice.

In the year 2005 with 50 ophthalmologists, Haiti performed 3500 cataract operations -
an average of 70 surgeries per ophthalmologist.

# Cataract Surgeries per Ophthalmologists per year
Institution                      Department                 Cataract # ophthal       Cataract
                                                            surgeries                Surgeries
                                                                                     per ophthal.
                                     WEST (Port-au-
HUEH (University Hospital)                                                   3
                                     Prince)
                                     WEST (Port-au-
Clinique Eye Care/st vincent                                                 4
                                     Prince)
Hôp. De la Communauté
                                     WEST (Petion-Ville)        204          4            51
Haïtienne *
Clin. Notre Dame de Lourdes          WEST (Delmas)               2           1             2
Hôp. Adventiste Diquini              WEST ( Carrefour )
ICC ????? No OR                      WEST (Delmas)              72           1            72
Petit-Goave                          WEST (Petit -Goave)        70           2             0
Hôpital Ste Croix de Léogane (Vis
                                     WEST (Leogane)
Doctors)
Help                                 WEST (tabarre)
Hopital de la Renaissance (cubans)   WEST (PAP)
Dispensaire la providence ( NO
                                     WEST (PAP)
OR)
Centre Medical Champ de Mars         WEST (PAP)                 85           2            42,5
                                     PLATEAU
Lascahobas (Visiting Doctors)                                    49
                                     CENTRAL
                                     PLATEAU
Cange                                                           189          1             0
                                     CENTRAL
                                     CENTRE (Hinche)


                                                                                    16
Institut Brenda Strafford            SOUTH (Les Cayes)         480                   5        96
Jacmel                               SOUTH EAST                                      1         0
                                     GRANDE ANSE
Jérémie (Project Gebeau)                                          36                 0
                                     (South West)
                                     ARTIBONITE
Gonaives (Cubans)
                                     (Central)
Deschapelles (Hospital Albert        ARTIBONITE
                                                               150                   1        150
Schweitzer)                          (Central)
                                     NORTH (Cap
Hôpital Justinien                                                 42                 1        42
                                     Haïtien)
                                     NORTH (Cap
Mission Baptiste                                                  378
                                     Haïtien)
Hôpital de Pignon (Visiting
                                     NORTH (Pignon)               28
Doctors)
                                     NORTH EAST (Fort
                                     Liberte)
                                     NORTH QUEST
 Visiting Doctors                    (Saint Louis)           79

Problems
    Shortages of personnel,
    low productivity,
    Poor distribution of perssonnel
    Non- optimal quality of outcomes.

Ophthalmologists

Objectives
1. Increase number of ophthalmologists – eye surgeons distributed through out the
country.

      Target number of ophthalmologists

       Target                 2006              2012                     2020
       Number                 50                80                       160
       Opth per population    1 x 160.000       1:100.000                1:50.000


      Targets number of ophthalmologist for the year 2012 by Department

           Department             Capital       Population     Opth Need # 2006
                                                                       0,00001
           Artibonite             Gonaive            1013779              10     1
           Centre                 Hinche              500000               5
           Grand-Anse             Jeremie             641399               6     0
           Nord                   Cap Haiten          800000               8     2




                                                                                         17
           Nord-Est               Fort Liberte            250000        3    0
           Nord-Oest              Port-de-Paix            420971        4    0
           Ouest                  Port-au-Prince      2494862          25    18
           Sud                    Cayes                   653398        7    5
           Sud-Est                Jacmel                  457013        5    1
           Total                                      7231422           72

     Strategy
    Strength the national residency program that graduates at least 6 new
      ophthalmologists per year (eye surgeons). There is no consensus on the need to
      bring a full time professor from abroad to organize the residency program. A
      suggestion was made to bring visitors professors in long visits.
    Attract and retain staff through overcoming existing constraints in their work
      place and providing an enabling environment

         Targets for graduates in ophthalmology
          Year         2008 2009 2010 2011 2012
          # graduates 6      6      6     6     6

       Training (residency) programs

       1. The target for 2012 would be to have 3 residency programs:
           - 2 new programs focusing on cataract and glaucoma.
           - Strengthen the existing residency program at the University Hospital
               including new topics (retina, etc…) in the curricula.
       Target: to train 6 residents per year - 2 in each residency program.

       Possible Centres
       North: Hopital Justinien
       South: Institut Brenda Strafford
       West: HUEH

2. Enhance productivity of existing ophthalmologists.
         Target cataract surgeries done per ophthalmologist
         Year                   2005                  2012
         Cat/Surg/ophthal       70                    90

       Strategy
      Overcoming existing constrains in their work
      Utilization of Allied health Personal
      Improve supply of materials for cataract surgery

3. Enhance quality of existing ophthalmologists and of their training facilities.
       Strategy
     Interest to be trained in small incision (bring an expert from abroad. CBM
       commits to this training)
     Training in Surgery and su- specialities
     Implementation of a surgery quality program in all institutions



                                                                                    18
   Indicators
     Number of ophthalmologists / population (disaggregated data)
     Number of new Residency program graduates per year.
     Number of cataract surgeries done per year per ophthalmologists.

4. Training in community ophthalmology

      Objective
      To integrate community ophthalmology in ophthalmic training curricula for all
      eye care providers

      Strategies
              Integrate community ophthalmology concepts, principles and practice in
      an integrated manner in Residency programmes and other eye care provider
      programmes.

      Indicators
      Community Ophthalmology module in the training curricula.


Mid-level ophthalmic personnel (Ophthalmic Assistants)
There is no current official program for the training of assistants in ophthalmology in
Haiti. There is recognition of the need to train agents to screen pathologies in distant
locations, handle first-aid care, give public information on prevention, and assist doctors
in medical consultations and surgeries. Having this training program, ophthalmologists
could devote more time to surgical work.
A few eye clinics in the country still employ assistants who were trained 23 years ago
by the Eye Care program.

Distribution of Allied Health personnel in Haiti
Insititution                                 Department                        Infir Auxil Assis
HUEH (University Hospital)                   WEST (Port-au-Prince)              16      8
Clinique Eye Care/st Vincent                 WEST (Port-au-Prince)                            2
Hôp. De la Communauté Haïtienne *            WEST (Petion-Ville)                        3
Clin. Notre Dame de Lourdes                  WEST (Delmas)                       2
Hôp. Adventiste Diquini                      WEST ( Carrefour )
ICC                                          WEST (Delmas)                       3      2     2
Petit-Goave                                  WEST (Petit -Goave)                 3
Hôpital Ste Croix de Léogane (Vis
                                             WEST (Leogane)
Doctors)
Help                                         WEST (tabarre)
Hopital de la Renaissance (cubans)           WEST (PAP)                          0
dispensaire la providence ( NO OR)           WEST (PAP)
Centre Medical Champ de Mars                 WEST (PAP)                          1      1
Lascahobas (Visiting Doctors)                PLATEAU CENTRAL                                  1
Cange                                        PLATEAU CENTRAL
                                             CENTRE (Hinche)


                                                                                        19
Institut Brenda Strafford                    SOUTH (Les Cayes)                8      30   0
Jacmel                                       SOUTH EAST                                   1
Jérémie (Project Gebeau)                     GRANDE ANSE (South West)         2      0    2
Gonaives (Cubans)                            ARTIBONITE (Central)
Deschapelles (Hospital Albert
                                             ARTIBONITE (Central)             2      2    1
Schweitzer)
Hôpital Justinien                            NORTH (Cap Haïtien)                          10
Mission Baptiste                             NORTH (Cap Haïtien)
Hôpital de Pignon (Visiting Doctors)         NORTH (Cap Haïtien)
                                             NORTH EAST (Fort Liberte)
                                             NORTH QUEST (Port-de-
                                             Paix)

Objective
Re establish an allied health personnel program in ophthalmology.

        Target OA per population        2012                    2020
        Haiti                           1:200 000               1:100 000
        Number                          40                      80

     Profile of Ophthalmic assistants
   -  OA will be capable of checking vision, measuring IOP, giving basic eye care,
      performing basic refractions, referring patients.
   - Ophthalmic assistants should work under supervision and be examined regularly
      by the ophthalmologists.
   - Ophthalmic assistants would go out to the field and refer patients, and will be
      responsible to train primary eye care staff.
   - The Medical School of the public sector should be informed and involved in this
      training

       Strategies
        Change the mentality that ophthalmologists have about loosing patients while
          having ophthalmic assistants, as this would increase referrals.
        Nurses could be trained as ophthalmic nurses.
        Establish a Center to train OA or Ophthalmic Nurses.
        Mid level personnel should be trained to work in the selected centers
        OA can be trained initially to make simple tasks at the primary level that can
          be upgraded in further trainings up to a refractionist level and to perform
          special tasks at selected centers.

         Targets for graduates in OA or ON
         Number of ophthalmic assistants required depending on the employment
  opportunities.
         Each High Volume Center should aim to have at least 4 technicians per eye
  surgeon.

       Indicator
       Proportion of OA/ON per population.


                                                                                     20
Optometrists & refractionists

Situation
    - There are few optometrists working in Haiti, who were trained abroad.


Strategies
             Develop initially a training of Ophthalmic Assistants.
             Further training may include refraction.
             Revise or develop new standardized curricula, as appropriate.


Opticians

   Situation
   There are three opticians in the country, whose role is eye examination and glasses
   prescription and manufacturing. Only one of them can be consulted for contact
   lenses.
   Objectives
   Train personnel capable of manufacturing glasses (3) by the year 2010


Primary Health Personal

Objectives
1. To train the “Health Agents” in primary eye care mainly in the area of work of the 6
selected hospitals.
2. Training of existing health Personnel (nurses, auxiliaries, midwives, community ?
3. Establish primary eye care training in the 6 selected hospitals.


Eye Clinic Administrators

Objectives:
1. Provide a course on management and administration.



INFRASTRUCTURE

Aim
To provide universal coverage and access to services for the preservation of vision and
restoration of sight.


Objective




                                                                                      21
To develop district-level eye care services, with primary eye care integrated into the
PHC system.

Strategies
   1. Identify poorly served areas and engage with partners to identify resources for
       infrastructure development in those areas ( 5 or 6 Centers would be
       strengthened)
       Selection of Centers
       1.    HUEH
           Port au Prince
       2.    Grace Children Hospital (ICC)
           Port au Prince
       3.    Hospital Justinian (public)
           Cap Haitian North and North-east and North-west
       4.    Brenda Strafford (private)
           Les Cayes, Grande Anse and Nippes
       5.    Other possible centres are Albert Schweitzer (private) Lower Artibonite
             and Central, Hopital de la Communaute Haitienne (semi-private) Petion
             Ville North East Port au Prince and St. Francois de Sales (private w/social
             section) Downtown Port au Prince

CENTRAL ORGANIZATION

- The NCPB to receive official recognition from the government.
- Appoint a national coordinator
- Utilize the office space provided by the MOH


BIBLIOGRAPHY:

   1. United Nations: Population Division: World population Prospects:
      The 2006 Revision Population Database.
   2. Organización Panamericana de la Salud: Situación de Salud en la
      Americas: Indicadores Básicos 2006.
   3. Proposals for the development of a national policy for the prevention
      of Blindness by Dr. Francois Roamin, Dr. Brigittte Hudicourt, Dr.
      Michel A Pean, M Gary Downey. October 2000
   4. National Program for the prevention of Blindness 2005-2010. Dr.
      Ritza Eugene, Dr. Myriam Justafort, Dr. Guerline Roney, Dr. Jean
      Claude Cadet.
   5. Situation of Ophthalmology in Haiti. January 2006. Dr. Alexandra
      Buteau Staco.
   6. Pan American Health Organization: Technology and Health Services
      Delivery: Eye Diseases in People 40-84. The Barbados Eye Studies:
      A summary report. THS/OS/06/8




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