Primary Eye Care in rural areas – Challenges and Opportunities

Dr Srinivas Marmamula, Associate Director, Public Health Research and Training, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye care, LVPEI speaks on the importance of routine eye screening to achieve the goal of universal eye health in any region

Background

Vision impairment is a public health concern that affects over 10 per cent of the general population. Over half of those aged 40 years and older have difficulty seeing things at a close distance, for example, reading a newspaper. Fortunately, a large percentage of the population with vision impairment can be addressed with simple intervention such as spectacles for refractive error or a cost-effective surgery for cataract. Detection of vision impairment due to cataract and correction of refractive errors fall under the domain of primary eye care. Primary eye care can be community-based or centre-based.

Challenges

Apart from adequate infrastructure, well-trained human resources in adequate numbers with equitable geographical distribution are prerequisites to providing high-quality primary eye care. However, these prerequisites are rarely met, and this poses a challenge for primary eye care, especially in rural and far-flung areas. Unfortunately, these are the places where the need for primary eye care is high. Geographical distance and issues related to accessibility, lack of integration and linkage between various levels of care are the other challenges that need to be addressed to improve the reach of primary eye care.

In the government sector, primary eye care is in the domain of primary health centres. However, often eye health does not figure in as a major vertical in these centres. There is a shortage of ophthalmic personnel at the primary level. Also, a system of continuing professional development programmes for these ophthalmic personnel is not a very established phenomenon barring isolated professional development programmes, mostly in non-government sector. Lack of standard equipment for basic eye examination in primary health centres is another challenge that needs to be addressed to overcome the public health challenge of vision loss in the community.

Universal eye health is a framework that is currently being talked about to ensure all people have access to promotive, preventive, curative and rehabilitative care without resulting in financial hardship when paying for these services.

Solution

A major public health innovation that LVPEI has brought about in eye care service delivery
is an integrated multi-tier LVPEI Eye Health Pyramid. At the community level are the vision guardians and field assistants who educate people about eye health and perform basic vision screening, and they also monitor those who have been through surgery or require follow-up care. The next level is the vision centre, where a trained vision technician offers refraction services, prescribes and dispenses spectacles, screens for common eye condition symptoms and refers them to the secondary centre. Each such vision centre uses tablet based electronic medical record system with real time integration with the network and caters to the eye care needs of 50,000 population linked to a secondary centre. LVPEI’s primary eye care model is a classic example of an integrated model to address the challenges of primary eye care.

For community based primary eye care, we developed a quick and simple test protocol, basic eye screening test that can be used as a tool for eye screening by grass-root level health workers in the community. This protocol should be included in the training curriculum of the grass-root level health personnel such as ASHA and other allied workers. Routine eye screening should become a mandatory function of the primary health workers if we are to achieve the goal of universal eye health in any region.

Technology has profoundly impacted all the domains in the last 2-3 decades and changed our lives. Healthcare is no exception to the changes. The challenges in providing quality primary eye care can be addressed using technology. At LVPEI, with the evolution of technology and changing eye care scenario, we felt the need to expand the scope of services by leveraging technology. This led to the evolution of ‘technology-enabled vision centres’ or ‘futuristic vision centre’ models. A model that extends the scope of teleophthalmology in existing vision centres and intended to target the ocular morbidity and detect chronic eye conditions that are currently beyond the realm of primary eye care. Those who need higher levels of care can be provided with service in these vision centres avoiding needless travel and associated expenditure. The impact in terms of ‘cost-savings’ would be substantial. This futuristic model, all set to go live in September, is envisaged to bring about a paradigm shift in the way the eye care is delivered at the primary level traversing the barriers to primary eye care.