The eye health programme in Dera Ghazi Khan district, Pakistan
In planning for eye care services in Pakistan in 1997, the following factors were taken into account:
- Blindness prevalence rate of around 2%
- More than 70% of the communities live in the rural districts while almost the same proportion of ophthalmic services are based in urban areas
- Presence of a reasonable public health care delivery infrastructure in Pakistan
- Potential in district eye units but significant gaps in equipment, physical space, appropriate clinical skills and management systems
- The need for cost-effective and sustainable ways to reach the remotest communities. Strengthening cataract services was prioritised as a first step to addressing the problem.
All ophthalmologists from the public sector district hospital were trained in extra capsular cataract extraction and intraocular lens (ECCE+IOL) implantation and provided with operating microscopes and instruments. It soon became apparent that, for real impact, a more comprehensive approach was required. A comprehensive district eye care programme was designed in partnership with the government in 2001. Twenty-two districts were chosen for the delivery of the programme, 19 districts have so far been included.
Planning for the comprehensive district eye care programme
In October 2002, a team of staff from the Punjab Comprehensive Eye Care Cell and FHF representatives conducted a needs assessment visit to a programme district, Dera Ghazi Khan. This densely populated and remote district of Punjab is about ten hours drive from the city of Lahore. Occupying an area of 11,294 square kilometres, the district’s population of over two million are largely poor and have a traditional tribal culture. While huge resourcing gaps were identified, there was a valuable asset – a capable and motivated ophthalmologist, Dr. Javed Iqbal; finding the right people to drive the programme locally is a critical ingredient for a successful district programme.
The upgrade was formally inaugurated on 3 March 2003 by the provincial Health Minister. The widely attended function was part of Eye Week, which comprised a range of promotional, treatment and prevention activities. Looking back on progress so far, there have been many positive outcomes, including:
- Local partners enabled so that they address their own eye care problems
- Quality eye care more accessible and affordable
- An effective partnership with the public sector
- Sustainability of the programme facilitated by building on existing health structures
- District eye care programme success has positive implications for other health specialties.
Having created the capacity to provide quality health services, it hasn’t always been easy to raise the awareness, confidence and demand for those services. Like many programmes, the Pakistan-Australia District Eye Care Project is a work in progress. Table 1 illustrates the before and after profile of Dera Ghazi Khan district.
Table 1: A pre and post upgrade comparison of the eye unit in Dera Ghazi Khan district
|Out Patients Department||One room with insufficient equipment||Three well-equipped rooms|
|One shared OT with one microscope and some surgical instruments||A well spaced and well-equipped dedicated OT|
|Ophthalmologist||One ophthalmologist, never exposed to refresher training after his basic training||One ophthalmologist with on-going continuing medical education exposed to microsurgical training (two weeks), clinical refresher (two weeks) and management, communication and ‘Training of Trainers’ course (two weeks), one international conference|
|Mid-level workers||Two general cadre paramedics
shared with Ear Nose and Throat dept.
|One paramedic trained for one year as an ophthalmic technician and two general cadre workers|
|No eye care training for any primary health worker||All medical officers, paramedics and 30% of district lady health workers trained in minor eye problems, diagnosis, management and referral|
|Clinical results||Pre-programme||First year post-upgrade|
|OPD patient number||22,954||32,360 (41% increase)|
|Cataract operations||983||1,657 (69% increase)|
|Ratio of IOL and
|IOL: 507 (52%)
Non-IOL: 476 (48%)
|IOL: 1,116 (67%)
Non-IOL: 541 (33%)