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«PROJECT REPORT Candidate Number: 491130 MSc: Community Eye Health Title: Assessment of Vision Centre as a primary eye care delivery model, using the ...»

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Candidate Number: 491130

MSc: Community Eye Health

Title: Assessment of Vision Centre as a primary eye care delivery

model, using the health systems approach- A case study

Supervisor: Dr Gudlavalleti V. S. Murthy

Word Count: 9977

Project Length: Standard

Submitted in part fulfilment of the requirements for the degree of MSc in

Community Eye Health

For Academic Year 2009-2010






Study Rationale:



Ocular Morbidity – Changing perceptions


Primary Eye Care:


VCs- the concept:


Health systems:





Study Location


Site selection


Study Design


Time frame of the study


Selection of respondents:


Data collection:


Data Analysis:


Ethical Considerations:





6.1.1. Vision & Policy

6.1.2. Strategic planning:

6.1.3. Operational planning:



6.2.1. Recruitment criteria

6.2.2. Training

6.2.3. Incentives & Motivation



6.3.1. Source of funds

6.3.2. Cost Consciousness



6.4.1. Data collection:

6.4.2. Review and analysis:

6.4.3. Technology for information management:



6.5.1. Service components

6.5.2. Coverage

6.5.3. Community engagement & collaboration

6.5.4. Integration with health system



6.6.1. Accessibility

6.6.2. Availability & Continuity of care:

6.6.3. Health seeking behavior

6.6.4. Patient satisfaction



6.7.1. Access for disadvantaged groups

6.7.2. Affordability:



6.8.1. Cost recovery & Sustainability:





–  –  –


Figure I: The LVPEI model for eye care service delivery Figure 2: Essential Functions of VC.

Figure 3: WHO Health System framework Figure 4: Framework for health systems performance measures.

Figure 5. Geographic distribution of SCEH eye care units in North India Figure 6: Framework of concepts, themes and sub-themes developed for analysis Figure 7: Level of overall patient satisfaction at the two VCs.



BP Blood Pressure BS Blood Sugar CBR Community Based Rehabilitation CEC Community Eye Care CEO Chief Executive Officer CHC Community Health Centre DPO District Program Officer ENT Ear, Nose and Throat HQ Headquarters HR Human Resource IAPB International Agency for Prevention of Blindness INR Indian National Rupees IT Information Technology Km Kilometre LSHTM London School of Hygiene and Tropical Medicine LVPEI LV Prasad Eye Institute MIS Management Information System MSGD Mata Shree Gomti Devi Trust, Rajgarh NGO Non Governmental Organization NPCB National Program for Control of Blindness OOP out of pocket OPD Out Patient Department PEC Primary Eye Care PHC Primary Health Centre SCEH Dr. Shroff's Charity Eye Hospital SES Socio-economic status VC Vision Centre VT Vision Technician WHO World Health Organization

–  –  –


My deepest gratitude is due to the following:

My institution, Dr Shroff’s Charity Eye Hospital, India, especially Mr. Arun K. Arora (CEO) for supporting my efforts in up taking this prestigious course.

The governing bodies of British Council for the Prevention of Blindness (Boulter Fellowship) and Commonwealth Scholarship Commission for finding me worthy of receiving their financial grant.

Dr Gudlavalleti V. S. Murthy, my supervisor, teacher and mentor who patiently guided me through all the stages of the course. His stimulating suggestions and encouraging approach have enabled this work to reach its culmination.

Dr. Daksha Patel, course director LSHTM, for her valuable guidance & constant support throughout the course.

The ICEH family especially, Karl Blanchet & Elizabeth Mercer for their kind help.

Dr. B. R. Shamanna who has been instrumental in initiating me into Community Eye Health. He has been a guiding light all through.

The entire staff of Community Eye Care Department of SCEH for rendering their whole-hearted support and cooperation during the entire project, especially, Shantanu Das Gupta (Head Marketing and Outreach), Anurag Mishra (senior coordinator), Vinod (Project Coordinator) and their field teams.

The management and staff at Indian Institute of Public Health (IIPH, Hyderabad) for supporting me and allowing me to use their skills and services during the analysis, especially Dr. Neena John and Nand Kishore for their valuable advice and positive criticism.

Angela Mcallister and Farah Naaz Khan, visiting volunteers from Combat Blindness Foundation (CBF, Madison) and University of Alabama (UAB, USA) respectively for their active contributions during different phases of the field work.

My family who has made me what I am. Had it not been for them, this arduous journey would have seemed insurmountable.

Finally, all the study participants without whom this study would have not been possible.

–  –  –

ABSTRACT Introduction: The VC has been well accepted as a practical model for delivering barrier free primary eye care to remote underserved communities by utilizing community resources. The nature and extent to which health services are delivered and the pattern of their uptake in the target groups is greatly dependant on the various health system components that serve as building blocks for creating the required foundation.

Purpose: The purpose of the present study was to assess the performance of two VCs delivering PEC to the rural communities in North India and identify the enabling and constraining factors with respect to the health systems framework.

Methodology: A descriptive case study methodology was used, wherein each VC was considered as a “case unit”. Detailed information was collected about all aspects of its performance, from multiple sources using different tools (interviews, document review & direct observation).

Results: A favourable set of policies were put in place to assist the establishment and optimum functioning. The management has attempted local NGO partnerships and integration with existing health services as much as possible. The two VC were fairly similar in all aspects except NGO-collaboration and level of training of the service provider. Both the VCs were functional for one year at the time of the study and were providing most of the PEC services. „Acquaintance with service provider‟ and „good feedback‟ about the VC, were the top factors for influencing uptake of services. Of the 3356 patient (7 – 12 patients per day), 1400 (41%) needed refraction and 711 of them (50.8%) purchased spectacles. The overall surgery acceptance rate was 55%, which was significantly higher at the optometrist manned VC. Most of the patients were coming from within 10 km from the VC and were travelling on foot or by public transport. The average out-of-pocket expense (travel cost + service charges) per visit came out to INR 51 (SD 54.11). Most of the patients were very satisfied with the services but suggested improvement points like better amenities (drinking water & seating); better signage and activities to spread awareness of the centre.

Conclusion: Good governance with sound long term planning; appropriately recruited and suitably trained workforce; stable finances; an efficient health information system and proactive community partnerships are vital ingredients for delivering effective, equitable and sustainable primary eye care services through the VC.

–  –  –

„Vision 2020 – The Right to Sight‟ initiative advocates the approach of strengthening PEC to achieve the ultimate goal of providing barrier free access to all levels of eye care for everyone needing it (1). Stakeholders in eye care have undertaken initiatives to develop innovative solutions to achieve this (1-5). Vision centre model is one such innovation that has become very popular with eye NGOs in India. It is a primary care delivery unit,linked to a formal eye hospital, manned by a locally recruited and adequately trained semiprofessional capable of delivering basic eye care at the community level (6) The VCs have also gained government‟s will, who have agreed to provide adequate support in setting up such facilities and infrastructure with required budget allocations (7). Fast paced developments in other sectors such as Information technology have further bee utilised for strengthening the services as well as the reach of eye care delivery through these units.

Study Rationale:1.2.

The functioning of a health system is composed of a variety of related and unrelated components which independently contribute to its overall performance. The service delivery point is only the final step in a cascade of processes and functions that happen backstage creating the required foundation. There is no single tool/methodology that provides a detailed assessment of the impact of each of these building blocks on the overall output.

The Health system framework provides one such platform that can help examine them individually as well as their relationship with each other.

The purpose of the present study is to dissect all the aspects of the performance of a primary eye care unit (Vision centre) and identify its strengths and weaknesses and postulate possible strategies for improving one or more of its functions.

–  –  –

2. REVIEW OF LITERATURE Ocular Morbidity – Changing perceptions 2.1.

Although cataract still remains the major cause of avoidable blindness worldwide, recent years have witnessed changing perceptions towards eye diseases(8). Non blinding conditions such as refractive errors have been recognised as important public health issues (9, 10). The management of these conditions requires provision of health promotion, prevention, early detection & treatment and rehabilitation services to the community. This necessitates adopting a comprehensive approach of providing eye care services – be it the base hospital services or outreach services in the community (11).

Primary health care:2.2.

Primary Health care is the basic level of care over which the rest of the health system is structured. Landmark international declarations like the Alma Ata declaration (1978) and later “Health for all by 2000 AD”, have prompted nations to work towards “provision basic health care services for all sections of the society with a framework of integrated health structure”(12, 13).India was one of the first countries to adopt the concept of PHC into the national health plan and a multiple-tier health system was developed with the primary health centre and community health workers (14).

Primary Eye Care:2.3.

PEC is a frontline activity, providing care and identifying diseases before they become serious medical issues. It is an integral part of comprehensive eye care, targeting not only the prevention of blindness and visual impairment, but also reducing other ocular morbidities (15). It‟s essential components are eye health education, symptom identification, visual acuity measurement, basic eye examination, diagnosis and timely referral for conditions requiring surgical/ specialty care (16). Eye care in India has mostly been a standalone program dominated by the NGO sector (17-19), but recently efforts are being made to create a primary integrated health delivery system under one broad head (7).

–  –  –

Figure 1: The LVPEI model for eye care service delivery (2).

Vision Centre- the concept:


Various population-based surveys indicated that poor access, whether geographic, financial or physical, forms a major barrier to utilization of eye care services (20, 21). To overcome these barriers an innovative infrastructural model was proposed by the LV Prasad Eye Institute (LVPEI) (2).

“A VC is a permanent eye care facility in the community which acts as the first interface of the population with comprehensive eye care services provided by an exclusive skilled eye care worker”(6).

Figure 2: Essential Functions of VC.

–  –  –

Health systems:


WHO defines health systems as “Any organization, process or resource whose primary purpose is provision, preservation or promotion of health” (13). The Health systems framework is composed of the following components, each of which has specific roles in the provision of health care to the community (23).

There has been a growing interest by national health systems and the donor community in strengthening the capacity of health systems to ensure equitable and efficient delivery of health services (24) Figure 3: WHO Health System framework (13) “Service delivery is an immediate output of the various inputs into the health system, such as governance, health workforce, information systems and procurement of supplies and finance” (25).

–  –  –

“Health systems Assessment is an indicator based approach for assessment of health system using data from various sources like stakeholder interviews, document reviews, direct observation, (facility survey and other secondary data) facility reporting systems” (24).

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