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«Planning for Comprehensive Child Eye Health Care in sub-Saharan Africa © Clare Louise Thomas, Image Incubator Summary Report of the Meeting Hosted ...»

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Planning for Comprehensive Child Eye

Health Care in sub-Saharan Africa

© Clare Louise Thomas, Image Incubator

Summary Report of the Meeting Hosted by

ORBIS Europe, Middle East and Africa

4 – 5 May 2011
















3. SUB-REGIONAL PLANS 2011 - 2016









Executive Summary On 4 and 5 May 2011, ORBIS Europe, Middle East and Africa, hosted a conference bringing together international experts in paediatric eye care to discuss priorities for child eye health in sub-Saharan Africa, and to decide the best way to plan, develop and implement services to tackle child eye health in a strategic way. Attending the meeting were 58 delegates from 13 countries in sub-Saharan Africa, as well as a further 11 not-for-profit organisations and five teaching and training institutions.

The Importance of Child Eye Health in sub-Saharan Africa Sub-Saharan Africa has the largest burden of blindness globally with 23 percent of the world’s blind (compared to India with 19 percent and China with 13 percent).

There is a direct link between the incidence of blindness and poverty with 90 percent of the world’s blind living in developing countries. Child eye health programmes have a direct impact on a country’s achievement of the Millennium Development Goals, and in particular Goal 2 Achieve Universal Primary Education, Goal 4: Reduce Child Mortality and Goal 5: Improve maternal health.

Investment in child eye health has a significant return to society, as it is estimated to account for one third of the total cost of blindness and is equivalent to operating on 10 elderly patients with cataract in terms of blind years saved.

There are an estimated 1.4 million blind children worldwide, with many more visually impaired. Sub-Saharan Africa carries the greatest prevalence globally of childhood blindness at 1.24 blind children per 1,000 compared to 0.8 in India and 0.3 in Europe, but 50 percent of childhood blindness is avoidable which makes the region a priority for child eye health care programmes. Early intervention is essential at every level of the health care system, including community, primary, secondary, and tertiary level.

According to WHO recommendations, one paediatric ophthalmic centre is necessary per ten million population. Child eye health programmes in sub-Saharan Africa are scarce, often small scale, do not have a comprehensive approach, and are not part of larger national plans to develop child eye health services. A comprehensive approach and investment in child eye health is required if children are to receive appropriate care and support at the correct time.


1. Child eye health facilities are grossly inadequate throughout sub-Saharan Africa with only 26 centres located in 12 out of 48 countries; facilities are scarcer in French and Portuguese speaking countries.

2. A comprehensive model for child eye care that defines specific roles of health workers and resources through all levels of the health system should be introduced. This model needs to be culturally appropriate, evidence based and nested within well-developed adult eye care services.

3. The majority of child eye care services should be delivered at primary and secondary levels. Competencies at these levels should be clearly defined and linked to the minimum equipment, human resources and other resources needed to make them fully operational. Research at all stages of the process is needed to ensure that the model is evidence-based.

4. One Child Eye Health Tertiary Facility (CEHTF) per ten million population is the WHO’s recommendation. Cross-border arrangements should be established to ensure services are available for children in countries with smaller populations with no access to tertiary level services.

5. There is a shortage of staff at all levels and across all cadres.

6. Training for each level needs to be planned to a minimum standard, which still needs to be established.

7. The “sandwich model1 for paediatric ophthalmology fellowships and other training is recommended wherever possible due to a diversity of constraints during longterm fellowships for scarce and busy ophthalmologists and other cadre forming part of the child eye health team2.

8. Collaboration in fundraising approaches is important whilst respecting the autonomous nature of individual stakeholders and commitment to work together at global, regional, national and local levels towards the provision of child eye health and the attainment of the MDGs linked to it.

Next Steps

1. A declaration based on the conference proceedings will be presented to WHO AFRO to make the case for the urgent need for planning, implementation and resourcing child eye health care in sub-Saharan Africa. This declaration should also be presented to the National Departments of Health in sub-Saharan African countries to inform their planning for child eye health services.

2. Eye care organisations should agree an implementation plan, inclusive of an advocacy plan for cross regional arrangements to resource the draft operational plan developed as a result of this meeting. Planning should take place at subregional level for cross-border arrangements to ensure tertiary level services for children in countries with small populations.

3. A series of sub-regional planning meetings should be held to prepare detailed plans for each region. These activities should take place in a coordinated manner.

4. Consortiums should be established within each sub-region to develop implementation plans detailing resource requirements, to include personnel, training, equipment, consumables etc specific to each sub-region. These plans should also act as discussion documents for governments and the not-for-profit sector to coordinate funding strategies.

5. Clear criteria should be developed and applied to the selection of candidates for paediatric fellowship training to guarantee long-term sustainability and staff retention. This should include a baseline skills assessment of individuals. It should also be used to establish institutional readiness to become a CEHTF.

The sandwich model refers to a training model, typically consisting of two or more training modules of 1 – 6 months, where the fellows develop skills via sequential rotation in training institutions with provision for a practical application in the home institution, in between attending training modules. It also includes on-site visits such as Hospital Based Programmes by experienced practitioners who can provide on-the-job support and skills development that can further strengthen this approach.

Anaesthetist, nurse, optometrist/refractionist, low vision specialist, orthoptist and a coordinator.

6. The paediatric ophthalmology fellowship curriculum currently being developed at Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) should be used as a standard for other training centres venturing into this area.

7. A comprehensive list of all training opportunities across sub-Saharan Africa for all cadres should be developed and regularly updated.

8. The recommended model for CEHTFs should be shared and readily available to all on CyberSight, the ORBIS telemedicine website, as well as on any other appropriate website.

9. The IAPB Africa office and Regional IAPB representatives should act as a resource to accelerate the development of child eye health services across the regions.

10. Country based data recorded during the course of the conference will be handed over to the IAPB Africa office for IAPB sub-regional co-ordinators to fill information gaps (including a list of all training opportunities across sub-Saharan Africa for all cadres once it has been developed).

1. Introduction On 4 and 5 May 2011, ORBIS Europe, Middle East and Africa, hosted a conference bringing together international experts in paediatric eye care to discuss priorities for child eye health in sub-Saharan Africa, and to decide the best way to plan, develop and implement services to tackle child eye health in a strategic way. Attending the meeting were 58 delegates from 13 countries3 in sub-Saharan Africa, as well as a further 11 not-for-profit organisations4 and five teaching and training institutions5. The meeting also drew delegates from the national and provincial departments of health within South Africa.

Utilising the wealth of experience amongst the participants, the two-day meeting set out to reach consensus on the best models and practices for managing avoidable childhood blindness. The premise for the meeting was that eye care services for children should be located within existing health care systems and nested within mature adult cataract services, national plans and priorities.

The meeting aimed to start the development of a 5-year plan in collaboration with key global and Africa-wide stakeholders to deliver comprehensive eye care services for children based on the strengths and interests of each stakeholder, and to assess how to secure the necessary funding. This included initiatives to train medical staff across the sub-continent, strengthen existing eye care services and establish new services in areas of need. The meeting also made an attempt to identify and map existing child eye care services (comprehensive as well as free standing ophthalmology or community focussed projects), and highlight where new eye care services in sub-Saharan Africa are required.

Recognising at the onset that insufficient data was available to ensure informed planning, the conference programme made provision for inputs and discussion

around a number of themes, including:

• Presentations addressing the global and African context of child eye health.

• Stakeholder presentations mapping their existing support to child eye health projects.

• Approaches to, and models for, comprehensive child eye care, including the training of relevant health care practitioners essential to the child eye care team.

• Country-specific examples of operational child eye health programmes in action and country based situational analyses.

• Options for resourcing child eye health projects.

All presentations made at the conference are available on the following link:

http://telemedicine.orbis.org//bins/content_page.asp?cid=1-12581-12583&pre=view Botswana, DRC, Ethiopia, Ghana, Kenya, Madagascar, Mozambique, Nigeria, South Africa, Sudan, Tanzania, Zambia, Zimbabwe.

The International Agency for the Prevention of Blindness (IAPB), Sightsavers, CBM, Fred Hollows Foundation, Vision Aid Overseas, Operation Eyesight Universal, Initiative Zimbabwe, the Kilimanjaro Centre for Community Ophthalmology (KCCO), the Himalayan Cataract Project, International Centre for Eyecare Education (ICEE) and the Netherlands Leprosy Relief.

Groote Schuur Hospital, the Community Eye Health Institute of the University of Cape Town, the International Centre for Eye Health, the Eye Foundation Hospital Group and the Deseret Community Vision Institute.

This report does not include extensive detail on activities per country, per organisation or stakeholder present at the conference, or the scope of work carried out by particular stakeholders working in the field of child eye health. Readers seeking this are referred to the conference presentations.

2. A situational analysis of child eye care services The commonly accepted benchmark for child eye health has been set by the WHO, which has recommended that, by 2020, one paediatric ophthalmic centre, a Child Eye Health Tertiary Facility (CEHTF) per 10 million people, should be in place. There was general agreement at the conference that such a CEHTF should have, as a


• A fellowship trained paediatric ophthalmologist, which generally refers to an ophthalmologist who has delivered a minimum of 50 supervised paediatric cataract surgeries.

• A child eye health team supporting the ophthalmologist, including a paediatric anaesthetist, a paediatric-oriented optometrist (in countries where this cadre exist), a paediatric nurse trained in paediatric orthoptics, a vision technician and a non-clinical manager/coordinator.

• Capacity to perform surgery for a range of serious paediatric conditions, including paediatric cataract, strabismus and glaucoma.

• Minimum equipment for treatment of complex paediatric eye conditions.

• Theatre space.

• Capacity to manage an effective referral and follow-up service for children, preferably through the services of a dedicated non-clinical manger or coordinator.

Dr Daniel Etya'ale noted that a functional and responsive system, with clear roles assigned to each level, and a good and well-structured referral and counter referral system is needed. This tiered approach could be illustrated as a pyramid with the right person in the right place at the right time6.

6 See Appendix F for a draft of the roles of the different cadre involved in the management of childhood blindness Taking this as a starting point, groups divided into geographical regions within subSaharan Africa to discuss the current situation across their regions.

2.1 Summary comments from group work One CEHTF per 10 million people

Mapped against the WHO recommendation, sub-Saharan Africa is grossly underdeveloped:

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