Eye Talk: Dr GVS Murthy on Pediatric Eye Care

There has been a sea change in the status of pediatric eye care in India over the past three decades. We can use the health system building blocks to illustrate this further.

a. Health Service Delivery

From a few centerrs of excellence providing pediatric eye care services, programs like the Orbis Pediatric Ophthalmology Learning and Training Centerrs transformed the situation in India.

The National Program for Control of Blindness and Visual Impairment set out a goal of establishing at least 50 specialized centers for pediatric eye care in the country during the 10th five-year plan. So, the intention was to establish at least one specialized pediatric eye care unit per 20 million population. This was much lower than the World Health Organization norm of one specialty Center for 10 million population. Today the country has over 100 pediatric eye care facilities both in Tier 1 and Tier 2 cities. This is a great achievement. Many of these hospitals are in the NGO sector and the unfinished agenda in that sense would be strengthening the government sector efforts for more pediatric eye care units.

b. Health Workforce

There were no fellowships in Pediatric Ophthalmology in the 1990s when Sankara Nethralaya, and LV Prasad Eye Institute first started fellowships and training programs for ophthalmologists. This evolved into a pediatric ophthalmology team training program which was a game changer as it led to the realization that pediatric eye care needed a team approach. Today, nearly 50 hospitals in the NGO and government sector offer these training programs. When the first situational analysis was undertaken in 2003, the number of trained or oriented pediatric ophthalmologists was limited but now the numbers have increased significantly. There is an increasing interest to be trained in pediatric ophthalmology now.

c. Medical Products and Technologies

Affordable technology has increased the diagnostic acumen of pediatric eye care teams. Locally manufactured equipment like the Neocam have reduced costs and made services more accessible. The quality of care has improved dramatically and visual outcomes are far better than before. Similar is the case with childhood refraction and low vision assessment. Assistive devices have become more affordable and are of a better quality.

d. Health Information

During the situational analysis in 2003 we found skills and infrastructure gaps for delivering quality pediatric eye care. This helped in identifying which hospitals had the potential to be scaled up and what skills needed to be imparted. Monitoring and reporting templates were devised for assessment of services. School screening programs also benefitted due to improved reporting frameworks.

Changing trends have been seen in pediatric eye disease. Today, Retinopathy of Prematurity (RoP) is an important cause of childhood vision loss which was not the case 20 years ago. There is increased case load for pediatric cataract, low vision, squint and refractive errors today. Corneal causes of childhood vision impairment have reduced significantly while there is an increase in congenital and genetic causes including retinopathies. Reporting formats and evidence generation in eye institutes have provided excellent leads on trends. Also there have been a number of studies conducted in schools for the blind which have provided rich data on causes of childhood blindness.

e. Financing

Pediatric surgeries were a costly and cumbersome affair with the long term follow up that is required. The needs to subsidize costs was realized early on and organizations like Orbis have made services more affordable by providing a cushion for children from families in need. The Government of India has also made provisions in the Health Insurance schemes to facilitate services. Some State Governments also cover the costs of pediatric procedures. One example is the Chinnari Chupa (Young Child’s Vision) in Telangana which is an initiative to provide social security to needy families.

f. Leadership & Governance

The efforts of International NGOs, IAPB, WHO have helped in creating a pool of young leaders in many countries to advocate for the needs of the child. These young leaders have been excellent ambassadors and have become regional role models for pediatric eye care. The National Program for Control of Blindness and Visual Impairment has taken up the challenge and provided opportunities for skill building and infrastructure development.

The needs of the child who is visually impaired or blind are very important which is why the WHO and IAPB had prioritized Childhood Blindness as one of the key areas for concerted action as part of the Vision2020: The Right to Sight efforts. We all know that with improvements in immunization coverage and survival, visually impaired children will live into adulthood in most countries. Therefore, if not addressed during childhood, they will have to live as blind or visually impaired persons for 50-60 years of their future life. Can you imagine that for yourself?

We also know that the visual stimulus is critical for child development and children deprived of the same will lose the learning opportunity that would have existed otherwise. Nearly 50% of childhood blindness is preventable or imminently treatable. Developing skills and infrastructure is, therefore, critical in making a huge difference to children’s lives. The impact is not only on the child but also on the entire family as the child can be mainstreamed and does not need an attendant perennially. This improves productivity of all members of the family and the child can be afforded an opportunity to optimize their vision.

But a child will not come forward and tell adults about her/his eye problem. Notably, children cannot tell if they have a problem to begin with. Thus, early recognition is key. Awareness levels are low when it comes to parents in rural setups. Even when the eye condition is identified by parents, they do not feel the need to prioritize intervention misconstruing that the child I stoo young for surgery. That aside, the question remains, while quality eye care is available, is it accessible to all? Do the parents need a helping hand to understand and prioritize their children’s eye problem? When we come across the above factors, the connecting piece is using our collective resources to help them help their children receive timely quality eye care and treatment.

It is the government, NGOs, social sector, private sectors, eye health service delivery agents who have an important role to play to make this happen. To that end, partnerships and collaborations are key to delivering quality eye care to the children of India.

The Government is a key player in delivering health care including pediatric eye care to populations. International and National NGOs help in germinating an idea and piloting a thought to see whether it is operationally feasible and has the potential for being scaled up. The government has the authority and responsibility to sustain the process. The Government can also help in coordinating the efforts so that different NGOs can be brought on to the same platform so that the span of coverage of services could be increased. This is the essence of Universal Health Coverage and Universal Eye Health. Partnerships are a value-addition and increase the sum of the whole.

Stakeholder consultation and brainstorming to identify the causes and potential ways to address the problems is important. This should, then, be followed up with regular interactions and monitoring of the progress in the implementation.

There have been many stories of successful partnerships that I have been part of. I remember when the World Bank supported cataract blindness project was initiated, we made a lot of efforts to build partnerships with shared responsibilities and accountabilities. NPCB set up a National Monitoring Committee under the Chairmanship of Late Dr G.Venkatswamy to guide the project implementation. This was an example of shared goals which are critical to make a partnership work successfully. The lead for making it work came from the Government and the NGO sector was very happy to work closely with the Government. Trainees from the Government were nominated to NGO institutions in equal numbers like the Government institutions. This is an example of positive partnerships. The World Bank Project was a game changer in Indian eye care. It led to improved quality and successful models of high volume cataract surgery. This would not have been possible if the Government had behaved like a ‘benefactor’ rather than an equal stakeholder.

In fact, the eye care sector is very resilient due to the strong linkages between the government and the formal NGO sector. That is why it has the potential to bounce back from the COVID days very quickly. Most of the eye hospitals in the NGO sector started their emergency clinical services by May 2020 and elective surgeries by September 2020.

Initially, the patient flow was very low but by November 2020, most eye hospitals reported that they were functioning at 75-80% of the load at the corresponding time period in the past couple of years. This is a very positive development.

There will be new challenges that need to be addressed. Ensuring adequate spaced seating in the clinics and regular sanitization of the waiting and examination areas are critical. Counselling and health education will take on a different meaning. Patients and their escorts will need to be repeatedly cajoled to use masks and maintain a healthy distance in the waiting rooms and when they enter the consultation spaces. In the counselling sessions, patients would also like to discuss their apprehensions on COVID-19 and time should be earmarked for the same.

The number of consultations will need to be staggered so that all infection prevention protocols can be adhered to. Restricting entry of too many attendants should also be enforced. Infection prevention protocols need to be strictly followed in patient examination areas and both the equipment and the consultation rooms will need to be sanitized at specified intervals.

The health provider and patient communication will also be different. Many hospitals may start using wireless mikes and speakers to communicate with patients from a ‘safe’ distance. This will be a challenge for the elderly patients who may also be hearing impaired.

There may also be a mix of approaches – Community-based or vision-center based initial examination, screening and follow up may become more acceptable and affordable, both to the health system and the patient.

All these are doable and should be implemented at the earliest. There will be initial hesitancy both from the health system and the patients initially but everybody will get used to the new way of life. In the early 1990s the discussion used to revolve around use of Intra ocular lenses and patient concurrence for the same. But from a low 2-3% IOL implantation rate we quickly reached universal IOL implantation!

Many innovations/procedures that result in improved quality even if it is marginally more expensive has a high likelihood of acceptance.

We have to all remember that we have committed ourselves to achieving the Sustainable Development Goals through the practice of Universal Health Care. Therefore ensuring an increase in the breadth of eye care services provided and the depth of population covered with accessible and affordable services to prevent financial catastrophic expense for eye care is critical.

We could look at the strategies for the future in two ways:

• Comprehensive Health Care services
• Inclusive Eye Care services

Operationalizing Universal Eye Health at an increased pace than ever before is the need of the hour. Quality, empathy and financial protection should be our Mantra for the future. COVID-19 is one pandemic but it is not a ONE-OFF health emergency. There will be more in the future for which we have to be prepared. We should not compromise the gains of the past three decades. We can do that by need-based evolution in the way we deliver services.