Increasing the use of cataract services: using an existing eye care structure in Nigeria
Community-directed treatment with ivermectin (CDTI) is the main strategy of the African Programme for Onchocerciasis Control (APOC). It has enabled the programme to reach remote and underserved communities where onchocerciasis is endemic. With CDTI, the community is involved in key decisions about how the drug is distributed and selects the distributor. In this way, a relationship of trust is established between provider and beneficiary. This provides an entry point for expanding activities dedicated to the prevention of blindness.
Christian Blind Mission International (CBMI) began working with the government of Nigeria in 1995 on their onchocerciasis programme. In 2003, this collaboration was broadened to address the prevention of blindness. The structure provided a way to reach the people living far from eye care facilities (in many states, these facilities exist only in the urban centres). In addition to strengthening the eye care services, efforts were made to create awareness and a demand for cataract services amongst rural dwellers. The programme described in this article aims to organise outreach programmes in northern Nigeria and falls within the authority of the Ministries of Health of the states of Kano, Jigawa, Yobe, Taraba, and the Federal capital territory, Abuja.
Outreach centres and services provided
In each state, at least one outreach activity is held every year. Each state chooses a suitable site to reach as many people as possible.
In 2004, a total of 632 eyes with blinding cataract were operated; this figure increased to 768 in 2005. In 2006, between January and July, 1,920 eyes with blinding cataract have been operated. In all these cases, an IOL was inserted.
During these outreach camps, trained ophthalmic nurses also attended to trachoma trichiasis patients. This supplements the regular eyelid surgery camps organised by the states. More than 500 eyelids with trachoma trichiasis were operated in 2005.
All the patients operated during outreach activities are reviewed at the site of the outreach. They are asked to return to the clinic one week after discharge, and again after six weeks. If there is any problem, they are asked to return immediately. Similarly, if the patients run out of medicines, they are advised to go to the clinic and not to wait for the appointed date. In certain cases, the ophthalmic nurse travels with the patient from his or her area to ensure proper follow-up.
Using the river blindness control structure to create demand for cataract surgery
The CDTI structure is used for the distribution of ivermectin (Mectizan®) drugs to all community members in the endemic areas. Since the distributors are volunteers selected by the communities, and reside within the communities we found that, with additional training, they could take on additional responsibilities. They attended a two-day primary eye care training programme, including one day of field practice, on how to recognise and refer preventable or curable eye diseases prevalent in the communities.
This category of workers has been helpful in identifying cataract patients and referring them for surgery during the outreach programmes. They undertake the following activities:
- creating awareness about cataract blindness among the rural dwellers, using local languages
- identifying the cataract blind persons during annual house-to-house distribution of the drug
- informing the local government co-ordinator of the blindness prevention programme about the number of cataract blind persons identified in each village
- educating the clients about modern treatments, which yield better results, and discouraging them from accessing the traditional couching technique for cataract, which is widely used and dangerous
- informing the clients of the costs of the operation; this is usually shared between the patient, the local government area (LGA), the state government, and CBMI, so that the individual is expected to pay only what he or she can afford
- breaking down barriers to the uptake of such services; this is achieved by reassurance, by escorting patients to the venue of the surgery, and by ensuring that all is accomplished properly. In this way, results will speak for themselves, persuading even the pessimists in those communities
- reminding the clients to go back for periodic review (post-operative care).
Roles of partners in the outreach programmes
The Ministry of Health organises the outreach programme. Its role is also to:
- create awareness by linking up with the LGAs and communities
- screen all cataract blind patients to identify those to be operated
- provide the facility and power source for use during activities
- provide hospitality for the team
- participate in operating (where they have an ophthalmologist)
- determine the outreach centres
- ensure LGA and community involvement
- plan annually for regular and consistent visits to outreach centres.
LGAs are directly responsible to the people in the communities. Their role is to:
- provide the necessary publicity
- provide mats and money for food during the eye camps; this applies to those instances when the LGA has directly sponsored camps to be organised in its domain
- participate in all activities before and during the outreach.
The community members with eye problems:
- use their own resources to reach the site of the outreach
- provide for their own subsistence over the number of days they will spend at the surgical camp site.
The host community:
- mobilises volunteers for crowd control and to assist in carrying patients to and from the theatre.
Influential individuals and groups contribute to the success of the camp by:
- organising some of these programmes
- directly sponsoring patients
- allowing their houses to be used by the entire team.
The international organisation, CBMI, provides the surgery team, usually from CBMI-assisted eye projects, to perform the operations during the outreach programme. The team works to ensure the following:
- advocacy and dissemination of information before the arrival of the team
- patient satisfaction with the services provided
- maximum output during outreaches
- minimum waiting period for the patients
- judicial use of time and facilities
- effective use of the personnel
- availability of equipment and consumables
- affordability of services so that no willing client is denied the services.
Cost-sharing and sustainability
Patients are expected to pay some amount for the cataract services that they will receive, which will depend on the cost-sharing formula chosen for a particular outreach. In determining the cost that patients are to pay, consideration is given to the very poor, poor, and rich patients. In most cases, the majority of beneficiaries are poor. This makes it very difficult to establish a dividing line to categorise or segment the payment. Subsidy is provided across the board to enable patients to take up the services. In a few instances, full sponsorship helps very poor patients to benefit from the operation free of charge.
Outcomes and lessons learnt from outreach activities
We have noticed some positive developments arising from outreach activities. For example, states are identifying personnel to be trained as ophthalmologists, so as to fill this gap in human resources. In several states, individuals and organisations have sponsored cataract surgery camps for the benefit of community members: in 2005, more than 500 cataract blind patients were beneficiaries under such gestures.
The main challenges we have faced are:
- poor mobilisation in areas non endemic for onchocerciasis, leading to poor utilisation by patients
- lack of steady supply of electricity
- inadequate logistic arrangements
- free eye camps threatening the sustainability of permanent eye hospital services.
How have we coped with these challenges? Firstly, an advance team from the VISION 2020 Support Programme arrives at the camp venue to ensure that adequate mobilisation and effective arrangements are made before the arrival of the surgery team. Secondly, plans are underway to procure a stand-by portable generator to complement the ones provided by the states during eye camps.
This case study demonstrates how eye care services have been extended by using the entry point of an existing prevention of blindness infrastructure. This was facilitated by a productive relationship between the state government health authorities and an international organisation.