The college is taking an active role in implementation of vision-2020 programme. The Vision-2020 steering committee is co-chaired by the president of the college. The College secretary functions as the secretary and the provincial eye surgeons as members.
The development of a national plan for prevention and control of blindness is itself a great achievement since the planning began as far back in 2004. The national steering committee and the college of ophthalmologists in Sri Lanka have taken lot of effort in formulating the national plan with the technical assistance.
The ministry of health has taken necessary steps in the past to develop eye care services in the country and there were a number of non-governmental organizations providing services to poorer sectors of the country who cannot approach major cities. The national eye care plans will help to bring all these efforts under one programme in a most structured manner. Further, in the view of fulfilling the major gaps in service provision, college requests collaboration n all the stake holders together under the coordination of national secretariat of vision-2020, which comes under the ministry of healthcare ant nutrition.
The aims of the college is to collaborate and coordinate better eye care systems at primary, secondary and tertiary levels by implementing vision-2020 national eye care plan with support from the government and non-governmental donor agencies.
There are 37 million people who are blind worldwide, and further 124 million people who have low vision. Around 90% of these people live in the developing countries, where eye health care provision is desperately inadequate. Seventy five percent of blindness in the world is either avoidable or treatable, yet millions of men, women and children all over the worldremain blind. A study conducted in 80’s (P.A. Weerasinghe study) indicated a prevalence of 0.427% of blindness in Sri Lanka1. Hence, an estimated 100,000 persons live with blindness in the country. The actual morbidity figures can be much higher than this.
On the global front an initiative for the elimination of avoidable blindness by the year 2020, as a collaborative effort of WHO and the International Agency for the prevention of Blindness (IAPB), an umbrella organization of a number of International Non Governmental Organizations, was launched in 1999 and endorsed by a number of member governments of WHO. It has been captioned “VISION 2020 - the RIGHT TO SIGHT” and intends to raise awareness, mobilise resources and develop partnerships between various bodies involved in eye care nationally as well as internationally. In this the role of governments, through their ministries of health, is crucial and the development of appropriate and effective national programmes the key element for the success of prevention of blindness activities in eachcountry. In fact, the General Assembly of WHO in its 56th Resolution in 2003 stated that all 192 countries unanimously endorsed and pledged the implementation of VISION 2020 plans to prevent blindness and to promote eye heath in their countries.
A series of planning meetings were held in Sri Lanka after its formal commitment with signature for Vision 2020 during SAARC conference in 2000 hosted by the College of Ophthalmologists of Sri Lanka. The College hosted a planning meeting in 2004 facilitated by key international experts including WHO consultant, etc. Sri Lanka reorganized its national steering committee, and the focal persons for respective eye diseases prepared action plans. A national programme for prevention and control of blindness was prepared in line with following Vision 2020 priorities.
1. Disease control including the magnitude and pattern of blindness and visual impairment in Sri Lanka.
2. Human resource development for comprehensive eye care.
3. Infrastructure/Equipment/Supplies
4. Management Structure and Governance
BACKGROUND INFORMATION
POPULATION
Sri Lanka has a population of 20 million of whom the majority are Sinhalese (74%). Other ethnic groups are made up of Sri Lankan Tamils (12.6%), Indian Tamils (5.5%), Moors, Malays, Burghers (of Portuguese & Dutch descent) and others (7.9%). Although Sri Lanka is a multi- religious country, Buddhists constitute the majority with 69.3%. Other religious groups are Hindus 15.5%, Muslims 7.6% and Christians 7.5%. Sri Lanka's literacy rate of 88.6% is one of the highest in Asia.
ADMINISTRATION
The Democratic Socialist Republic of Sri Lanka is a free, independent and sovereign nation. A system of administration through provincial councils was introduced in 1988. Legislative power is exercised by Parliament, elected by universal franchise on a proportional representation basis. Executive power of the people, including defence, is exercised by the President, who is also elected by the people.
The distribution of the population is as follows:
Population per Province
Province Population in '000
(2004 Census)
1 Western 5,526
2 Central 2,506
3 Southern 2,346
4 Northern 1,122
5 Eastern 1,540
6 North-Western 2,214
7 North-Central 1,145
8 Uva 1,223
9 Sabaragamuwa 1,840
HEALTH CARE SERVICE
Health care infrastructure, manpower and coverage
Sri Lanka is divided into nine Provinces 25 Districts and 305 Divisional Secretary areas. The Provincial Administration is vested in the Provincial Councils, consisting of elected representatives of the people, headed by a Governor who is nominated by the Central Government. In the Health sector, the Provincial Director is the Chief Administrative Officer in each Province. He has immediate support of the Deputy Provincial Directors in each District. Little over half of the population is concentrated in the Western, Central and Southern provinces. These three provinces together make 23.2 per cent of the total land area of the country during 1999; Sri Lanka had approximately 304 persons per square kilometre.
The district of Colombo has the highest density of 3,305 persons per square kilometre. The districts of Mannar, Vavuniya, Mullaitivu and Moneragala those are remote from the major urban centres have a density less than 100 persons per square kilometre. As at December 2003 there are 520 hospitals and 387 central dispensaries. Total bed strength is 61521. There were 112 private sector hospitals
Ministries responsible for rehabilitation and education
The Ministry of Social Services and Social Welfare is responsible for children and elderly persons with disabilities including blindness and severe visual impairment. The Ministry is working for the protection of the rights of the persons with disabilities including accessibility and rehabilitation services. With regard to education, it is the Ministry of Education (MOE) that is accountable for any curriculum for the children, including those with special needs such as visually impaired or hearing impaired children. A dedicated Director for Special Education is working for the promotion of inclusive education and non formal education. Additionally, the organizations for
Blind and for the deaf is involved in lobbying, advocacy and mercy-work for persons with related impairments, however the coverage is far from adequate.
CURRENT EYE CARE SERVICES AND STRUCTURE
Current magnitude of blindness, low vision and disease control
A National Plan for the Prevention of Blindness was drawn up for the period 1994-1999. Since then much has been achieved in terms of expansion of eye care services, with an increase in the quantity and quality of output. As cataract blindness is increasingly being controlled, other blinding eye diseases (such as glaucoma, diabetic retinopathy, blindness in children) are assuming greater importance. As the population of Sri Lanka is also ageing, diseases such as cataract and glaucoma are likely to increase. Diabetes is also becoming more common, and an increase in visual impairment and blindness from diabetic retinopathy is anticipated. A population based study is required to estimate the prevalence and magnitude of blindness at present. A study is being conducted in the Central Province of which the
Statistical analysis and the final results will be available in the near future.
The priority blinding diseases for control in Sri Lanka are:
1. Cataract
2. Blindness in children
3. Glaucoma
4. Diabetic retinopathy
5. Refractive errors &Low vision
Age is a well-known (and unpreventable) risk for cataract formation. In developing countries, cataracts occur early in life and are more prevalent. Poor nutrition, infectious diseases and their sequel, and exposure to ultraviolet radiation are all possible explanations. The prevalence of cataract among elderly in developing nations is almost 50 percent. By the year 2025, it is estimated that 40 million people in the world will be blind from cataract. Blindness due to cataract is correctable through a simple surgery. In Sri Lanka the government is the main provider of health care. Cataract surgery is a highly cost effective intervention: generally sight is restored after a relatively low-cost operation. In addition to the restoration of sight,
There is an enhancement of the quality of life.
The Cataract Surgical Rates (CSR), defined as the number of cataract surgeries done per million populations per year, has significantly increased over the last decade in Sri Lanka.
However, when compared with the prevalence of cataract blindness, it is obvious that the majority of patients are still without the appropriate service. In addition, while the CSR is reported to be quite high in some places, many districts have poor or lack of necessary infrastructure and equipments to meet the threshold level.
The global prevalence of childhood blindness is thought to be around 0.07%, or approximately one tenth of the prevalence of blindness in adults (Rahi et al. Measuring the burden of childhood blindness. Br J Ophthalmol. 1999 Apr: 83(4): 387-8) In low income countries with high under five mortality rates, the prevalence may be as high as 1.5 per 1000 children, while in high- income countries with low under-5 mortality rates, the prevalence is around 0.3 per 1000 children. Using this correlation to estimate the prevalence of blindness in children, the number of blind children in the world is approximately 1.4 million.
Eye diseases in children cannot be viewed as a mere extension of adult eye conditions. Given the special features of the eye in childhood, treatment of the visually threatened eye requires specialized training and skills, as well as a child-friendly attitude in the professionals dealing with children. It has been proposed to establish four Paediatrics Ophthalmic Units in teaching hospitals.
Prevalence of Diabetes was 14.2% in Males and 13.5% in females. Prevalence of hypertension
Diabetes and obesity: baseline findings of a population based survey in four provinces in Sri Lanka. K. Wijewardena, MR Mohideea, S. Mendis, DS Fernando, T Kulatilaka, D, Weerasinghe, P. Uluwitta. CMJ Vol. 50 no 2, June 2005, pg. 62-69
4.8% of all blind people is due to Diabetic Retinopathy. DR Develops in all with type I and 77% of whom survives more than 20 type II (Prevention of Blindness from Diabetes Mellitus. Report of WHO consultations, Geneva, Switzerland, 9-11 Nov 2005).
Glaucoma is an eye disease causing gradual peripheral vision degradation. An estimated population of 120,000 persons consider to be suffering from Glaucoma in the country. There is need of developing standardized protocol for glaucoma screening and management in addition to provision of necessary equipments at secondary and tertiary hospitals.
While refractive error has been recognised as a major cause for blindness and low vision, there is need of strengthening the existing screening systems and follow up processes in case of low vision clients through primary health care workers. At present, there are three low vision clinics in the country namely Colombo, Galle and Kandy. However these low vision clinics need strengthening and linkages with secondary eye units.
Human resources
According to the available data there are 61 ophthalmologists and 112 ophthalmic technologists serving in state and private sector in the country. However it is still needs a cadre of additional 60 ophthalmologists and 150 ophthalmic technologists to meet the needs of Vision 2020.
Projected Cadre for Eye Surgeons
1. Base Hospital Type (A) - 20
2. District General Hospital - 36
3. Provincial General Hospitals - 10
4. Teaching Hospitals - 10
5. Eye Hospital - 07
6. Sub Specialities - 06
7. Lady Ridgeway Hospital - 01
8. Sirimavo Bandaranayake Children’s Hospital- 01
Infrastructure, equipment and pharmaceuticals
Vision 2020 programme focuses on the upgrading of 04 tertiary care units (in teaching hospitals), 05 other tertiary care units, 18secondary care units and establishment of 08 new secondary care units. Further, the new equipments required for these upgraded eye units are also attached. As supply of IOL is an important issue the strengthening and streamlining of the existing system at the MoH in procuring and supplying of IOLs to the state health care institute may be considered for the better implementation of the V 2020 programme. Similar procedure may be adopted for manufacturing commonly used eye medications.
Patients attending Secondary Care Units through referrals are expected to increase from 20% up to 50%;
MAJOR CONSTRAINTS FOR PREVENTION AND CONTROL OF BLINDESS
1. Unequal distribution of human resources, infrastructure, equipment and therefore respective service delivery
2. Lack of proper information system
3. Lack of monitoring and evaluation
4. Lack of preschool screening for the early detection of eye disease and inadequate school screening
5. Inadequate supply of spectacles for children
6. Insufficient supply of low-vision devices
7. Lack of collaboration between the Ministries and the NGOs and other organizations involved in eye care
8. Lack of knowledge and awareness about services in the communities.
9. Inadequate financial resources available for eye care services
RATIONALE FOR THE NATIONAL PROGRAMME FOR
PREVENTION AND CONTROL OF BLINDNESS IN SRI LANKA
The Government of Sri Lanka signed Vision 2020 declaration in 2000 during SAARC ophthalmic conference hosted by the College of Ophthalmologists. A national committee was constituted to develop a national plan for key priority diseases causing blindness in the country.
This plan is expected to contribute to the following: Assess the present situation, and review of structures on prevention and control of blindness in Sri Lanka within the government health system and non-governmental sector; Ensure equitable distribution of comprehensive eye care services in the country; Explore ways and means of mobilising resources; and Determine methods for monitoring and evaluation of VISION 2020 related activities.
Both the situation analysis as well as future planning was discussed with various stakeholders in a series of meeting about the areas of “Disease Control”, “Human Resources and Management”, and “Infrastructure” issues.
OBJECTIVES OF THIS PLAN
OVERALL AIM
Reduce avoidable blindness in Sri Lanka through the development of a sustainable and equitable national programme for prevention and control of blindness as a part of national health system
SPECIFIC OBJECTIVES
Disease Control
1. To reduce the prevalence and incidence of cataract blindness by 70%
2. To improve the quality of cataract surgical outcome in all ophthalmic units and more than 80% of cases to have visual acuity of 6/12 or more.
3. To ensure the coverage of 75% cases of childhood blindness in the country by 2012
4. To establish ROP screening programmes throughout the country in all neonatal/ premature baby units catering for premature babies at risk and treatment centres in selected areas by
2012
5. To examine the eyes of at least 90% of known diabetics attending diabetic clinics in the government sector by 2012.
6. Basic eye examination of all patients over the age of 40 in all ophthalmic units for
Glaucoma
7. To strengthen the school medical inspection (SMI) of children at grade 1, 4 and 7 by 2009 and undertake necessary interventions
8. To increase the coverage of refractive services up to 50% by 2012
9. To increase the coverage of low vision care from 5% to 25% by 2012
10. To support independent living of 10% of the people living with blindness and visual impairment
11. Increase inclusive education for blind and partially sighted children by at least 5% each year.
Human Resources and Management
1. Establishment of V 2020 secretariat
2. Strengthen the mid level eye care personnel training programmes to increase efficiency and effectiveness of eye care services at primary, secondary and tertiary levels
3. Development of relevant sub speciality in ophthalmology
4. Undertaking the ownership of national programme for prevention and control of blindness by the Government
Infrastructure and equipment
1. Strengthen the infrastructure and supply of equipments at the secondary and tertiary level to facilitate the service delivery
2. Develop and establish four resource centres in Colombo, Kandy, Galle and Jaffna in view of supplying the following;
a) Law vision devices
b) Spectacles for children
c) IOLs
d) Commonly used eye medications
(This is to provide 30% of the requirement at the end of the programme.)
Integration of Primary Eye Care into Primary Health Care
Countrywide integration of PEC services into the existing PHC delivery system, will be phased over a period of 5 years. The unit of working in each district will be the MOH area and the following activities will be accomplished in respect of each MOH area in the District.
a) Training of all the Medical Officers manning the PHC institutions in the area
b) Training of all the Assistant Medical Officers
c) Training of all the PHC Workers (PHIs, PHNs & MWs)
d) Delivery of PEC services at all PHC institutions in the MOH area (Peripheral
Unit, Rural Hospital, Central Dispensary)
e) Delivery of PEC services at home/community level by the PHC workers
f) Establishment of proper referral systems at all levels
g) Supply of necessary equipment kits for PHC workers (Annex 2)
h) The integration of PHC level with education and social services and other relevant officials
Role of the College of Ophthalmologist of Sri Lanka in Vision 2020 Action Plan
The college council nominated 5 consultants to coordinate the main areas causing blindness in Sri Lanka.
- Dr. Champa Banagala- Cataract blindness
- Dr. Mangala Gamage- childhood blindness
- Dr. Tissa Senarathne-Diabetic Retinopathy
- Dr. Saman Senanayake- Refractive errors and low vision
- Dr. Muditha Kulathunge- Glaucoma
The following preliminary actions were taken by the college in implementing the programme in February 2008.
Support Vision 2020 Secretariat
- M.O.U signed on 25th Feb 2008 with Sec. of Health, National Focal Point, four INGOs namely Sight savers int, CBM, IRIS organization and ICEE and the College of Ophthalmology to open the Vision 2020 secretariat at the ministry
- Situation analyses of existing conditions of eye units done by the secretariat
- Proposals to develop new units made
The College of Ophthalmologists will join focal point Dr. P.G. Mahipala and the 5 coordinators of the action plan to conduct awareness programmes in all 9 provinces.
Primary eye care programme was initiated in March 2008 in five provinces. Dr (Mrs) Mangala Gamage is coordinating primary eye care programme. All the provincial eye surgeons are involved in training of primary eye care workers.
The sightsavers international from UK is providing the financial and technical support.
Involvement of the college in Upgrading and Establishment of new eye units
-
- College has identified new units to be opened in 2006
- Ministry issued circular no. 02-61/2005/Hospital Re-categorization
- With the available data college council will take a decision on this matter
- Outline of the plan for the particular year will be given in brief by the respective coordinators.
Other main responsibilities of the college of Ophthalmology with regard to vision2020 programme
- Participate in the National steering Committee
- The 2 joint secretaries of the college will function as Secretaries to the National Steering Committee
- Assist in formulation of guidelines/protocols
- Support and conduct training courses for eye care workers
- Coordinate with Board of study in Ophthalmology at PGIM to develop sub-specialties in the field.
- Work with Vision 2020 Secretariat to Monitor and Evaluate progress
- Feed back /Meetings with Colleague regarding developments
- Develop the years Action plan for the following year.
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