Bridging the gaps
By the year 2020, the international eye care community hopes to have eliminated avoidable blindness as a public health problem. The global partnership, VISION 2020: The Right to Sight, has provided a focus for all concerned (from international policy makers to village level health workers), identified five priority eye conditions, and clarified the key components to achieve this purpose.1, 2 However, as Daniel Etya’ale, co-ordinator for VISION 2020 in Africa points out, there is still a big gap between what needs to be done and what is being done and he estimates that currently hardly 20 per cent of the current needs in Africa are being met. On a more optimistic note, there has been a move towards closer and more functional partnerships between professional groups, governments, NGOs and industry.
What are the gaps?
Experience has taught us that medicines, techniques and skills do not on their own solve the health problems of all: applying relevant solutions is the challenge. There is a gap between what we know and what we need to know (the knowledge gap), between health problems and solutions (the research gap), and between evidence-based solutions and what health workers actually do (the ‘know-do’ gap). Inadequate infrastructure and technology result in service gaps. Human resource gaps need to be filled with trained people working efficiently together. Communication gaps, gender gaps and wealth gaps create a distance between eye care providers and people, the intended beneficiaries. Relevant to all of these gaps is information, depicted in the illustration (Figure 1) as a flow feeding into, and drawing from, each component, provided appropriate ‘bridges’ are built.
This issue of Community Eye Health Journal aims to create ‘gap awareness’ amongst our readers.
Richard Wormald’s article identifies knowledge and research gaps in ophthalmology and suggests ways to bridge them.
In an interview with Allen Foster, Daniel Etay’ale describes his work in bridging the gap between the international VISION 2020 agenda and VISION 2020 action plans in Africa, demonstrating the importance of advocacy and planning.
Hannah Faal’s article approaches the human resource gap in two ways: organising available eye care workers to reach into the district through a system of ‘vertical teams’; and strengthening the performance of a team through recognition of their functional roles (the job they are trained to do) and their team roles (their personal qualities and skills which contribute to the running of the team).
Sally Hartley’s article reminds us that professionals have much to learn from the people they serve, and examines how communication can facilitate this.
Sam Powdrill’s article, the last in our ‘Technology for VISION 2020’ series, is a fitting example of bridging the technology gap with guidance on how to repair surgical instruments, especially when working in remote areas.
How to bridge the health information gap is a hotly debated topic. New communication technologies promise quick and easy information transfer but threaten to widen the gap between the technology haves and have-nots, the so-called ‘digital divide’. We need to find ways to provide information to eye care providers working in diverse circumstances, from resource-poor rural settings, to centres with access to computers and high-speed internet. In her article, Sally Parsley, E-communications Manager at ICEH resources, describes how to use the internet to access free eye health publications and global discussion forums, while at the same time pointing out that we need a combined approach, using print and new technologies, to reach eye care workers around the world.
What can we learn from the broader health field?
There is much to be learnt from experiences in bridging the gap in the broader health field. The knowledge gap is not unique to eye problems. The Global Forum on Health Research suggests a 10/90 gap, whereby less than 10 per cent of research is concerned with the health problems that account for 90 per cent of global disease.3 Where research does create relevant knowledge, the ‘know-do’ gap threatens to prevent its application. The World Report on Knowledge for Better Health, due to be launched at the World Summit on Health Research in November 2004, aims to promote ways to overcome the ‘know-do’ gap.4
Public policy scholars have examined the transfer of policies from international to country level. Ogden, Walt and Lush, for example, suggest that internationally driven policies, while raising the profile of an issue through branding and marketing, such as DOTS (Directly Observed Treatment, Short-course) for Tuberculosis control, may simplify approaches to ‘one-size-fits-all’, and inhibit locally appropriate programmes.3 There is up till now no evidence that this has happened with the VISION 2020 initiative, possibly because the collaborative approach, and the system of VISION 2020 workshops, takes national and district level realities into account so that plans are locally relevant and applicable.
The approach of reaching right into the community through a link of health workers has been successfully demonstrated in other health areas. One illustrative success story comes from the Gadchiroli district in India where SEARCH (Society for Education, Action, and Research in Community Health) trains village level workers to apply a package of low-cost low-technology interventions for the care of mothers and newborn babies. Research into the effectiveness of this approach showed an almost 50 per cent reduction in neonatal mortality among isolated, rural villagers.6
Participatory approaches which involve stakeholders in all stages of service development build bridges between professionals and people. Successful projects have documented their experiences, providing useful models for eye care providers.
What have we learnt about bridging the information gap? A recent article in The Lancet claims that “there is little if any evidence that the majority of health professionals, especially those working in primary health care, are any better informed than they were ten years ago”7 and suggests that the 10/90 research gap mentioned earlier,3 may well be a 1/99 gap when it comes to health information. The authors draw out crucial lessons from the past. They suggest that ‘pull’ is better than ‘push’ and that producers of information should find out what people want, rather than ‘pushing’ information out to them. Those producing eye health information from an international base face the challenge of finding out what eye health workers in specific locations need to know, the communication medium that best suits them, and to what extent materials can be developed or adapted locally.
We have also learnt that the participation of end-users helps information transfer. At the high-tech end of the spectrum this might involve enhancing the flow of information within and between countries (such as HIF-Net at WHO8 ) or, as a low-tech activity, involving users in the production of educational materials (such as The Healthy Eyes Activity Book9 ).
We have seen the success of ‘Entertainment-Education’ in applying mass entertainment and popular culture to health promotion. Its usefulness to eye health has been demonstrated in trachoma control programmes in Ghana, Tanzania, Ethiopia, Nepal and Niger where National Trachoma Control Programmes combined the talents of the BBC World Service Trust and local health communicators and artists in an International Trachoma Initiative (ITI) funded strategy which combines radio, community media such as dramas, video and print materials.10
A common theme in this issue is that VISION 2020 has provided the impetus for a ‘paradigm shift’ or a change in the way of thinking about providing eye care services: thinking about population care rather than individual patient care; acting as a team rather than a skilled individual; recognising the importance of local knowledge; adopting an evidence-based approach to practising eye care; and communicating information in multiple ways for different audiences. It is timely for the eye health community not only to be mindful of the gaps to achieving the aims of VISION 2020, but also to cross the divide between disciplines, and learn from the rich body of experience acquired in ‘bridging the gap’ in other areas of human endeavour.
1 Thylefors B. A global initiative for the elimination of avoidable blindness. Community Eye Health Journal Vol.11 . Issue 25 1998.
2 VISION 2020: The Right to Sight www.V2020.org (accessed 26 August 2004).
3 Global Forum on Health Research. 10/90 report on health research 2003-2004. www.globalforumhealth.org/pages/index.asp (assessed 26 August 2004).
4 WHO. World report on knowledge for better health. Geneva: World Health Organization, 2004. Available from: www.who.int/rpc/meetings/en/WR2004AnnotatedOutline.pdf (assessed 26 August 2004).
5 Ogen J, Walt G, Lush L. The politics of ‘branding’ in policy transfer: the case of DOTS for tuberculosis control. Soc Sci Med. 2003 Jul;57(1):179-188).
6 Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999;354:955-1961).
7 Godlee F, Pakenham-Walsh N, Ncayiyanana D, Cohen , Packer A. Can we achieve health information for all by 2015? The Lancet Published on-line July 9, 2004 image.thelancet.com/extras/04art6112web.pdf (accessed 26 August 2004).
8 HIF-Net at WHO inasp.info/health/hif-net (accessed 26 August 2004).
9 Francis V and Wiafe B. The healthy eyes activity book. London: International Centre for Eye Health; 1996.
10 Frost Yocum, L. BBC World Trust – Reaching audiences and preventing trachoma in five countries. In: Faal H, Gilbert C and Pararajasegaram R, editors. Proceedings of the 7th General Assembly of the International Agency for the Prevention of Blindness; 2004 Sept 20 – 24; Dubai. In press 2004.