Can VISION 2020 be implemented in rural ... - Wiley Online Library

Tropical Medicine and International Health

doi:10.1111/j.1365-3156.2008.02140.x

volume 13 no 10 pp 1284–1287 october 2008

Can VISION 2020 be implemented in rural government settings? Findings from two programmes in Tanzania Edson Eliah1, Andrew Shayo2, Charles Gendo3, Paul Courtright1, Manisha Theraney4 and Susan Lewallen1 1 2 3 4

Kilimanjaro Centre for Community Ophthalmology, Good Samaritan Foundation, Moshi, Tanzania Ministry of Health and Social Welfare, Singida Region, Tanzania Ministry of Health and Social Welfare, Mara Region, Tanzania Helen Keller International, Dar-es-Salaam, Tanzania

Summary

objective To generate information on essential components and the cost recovery potential of VISION 2020 programmes in rural Africa. methods We took a structured approach to planning, training, implementation and supervision of programmes in Singida and Mara regions, Tanzania involving both government and non-government partners. Extensive mentoring was provided to monitor activities and costs. results Annual numbers of patients receiving eye care increased sevenfold, cataract surgeries by a factor of 2.6 and spectacles dispensed by a factor of 16. Running costs were shared; the government provided 40–60%, non-government organisations (NGOs) 25–45%, and patient fees 15%. conclusion Comprehensive eye care can be delivered with cooperation among partners. However, continued coordination and cooperation from government and NGOs are critical to reach VISION 2020 goals. keywords VISION 2020, implementation, district planning, Tanzania, cost recovery, sustainability

Introduction VISION 2020: The Right to Sight initiative (Cook & Qureshi 2005) advocates that eye care be organised for districts of 1–2 million people. Many African countries are organised into such administrative districts, sometimes called regions or provinces. Planning eye care services this way is intended to ensure that all populations are served, in contrast to a less organised approach that historically has resulted in services clustered around capitals or desirable places to live. The latter may result in wasted resources, with duplication of services in some areas while others are completely un-served; in the worst cases, eye services work at odds with each other. The VISION 2020 initiative encourages all eye care service providers to work in partnership, planning together to ensure that resources are used to the maximum extent. This idealistic concept does not always work. Government and non-government organisations (NGOs) may not work together, unhealthy competition may exist among service providers, and the need to demonstrate high ‘numbers’ and substantial cost recovery to donors may encourage organisations to concentrate in urban areas. It is cheaper to provide eye services to dense populations and 1284

unit costs fall at high volumes (Thulasiraj & Sivakumar 2001). Furthermore, urban centres often provide people at various income levels, allowing schemes in which the rich subsidise the poor (Shamanna et al. 2001). These key ingredients can help ensure a financially successful programme. However, in much of Africa, the majority of people still live rurally, contending with poor roads and large distances to access eye care. This is the case in Tanzania, where 77% of the population is rural (Government of Tanzania 2002). The Ministry of Health and Social Welfare (MoHSW) has ensured that each of the 27 regions has a Regional Hospital, but not all of these provide eye surgery. Private hospitals (NGO or mission) with eye services also exist in some regions. We have worked with two regions over the past 4 years, applying VISION 2020 principles of planning and partnership to see whether these could result in good quality services for the rural poor and what part of the running costs might be generated from patient fees. These regions are typical of many in rural eastern Africa with estimated monthly household income of US$ 48, only about half of which is in cash (Government of Tanzania 2001). We believe that our findings are applicable in other parts of rural Africa.

ª 2008 Blackwell Publishing Ltd



E. Eliah et al. Vision 2020 in Tanzania

Methods The steps to providing ‘district-based’ eye care comprise planning, training, implementation, and assessment of results. In May 2004, key people from Singida (pop. 1.2 million) and Mara (pop. 1.4 million) regions met for 4 days of planning. These were Regional and District MoHSW planning and medical officers and decision makers for NGOs in the regions. The National MoHSW sent a representative. Although such groups of 20–25 are too large for detailed decision making, these were people who needed to be informed and persuaded to implement eye care programmes in their regions. The groups would shrink to a nucleus of decision makers more directly involved with eye care later. Planning was practical, with brief didactic sessions, followed by group discussions of available resources and brainstorming on how to use these. Groups planned with a simple format based on: (1) setting diseasecontrol targets, (2) determining activities needed to achieve the targets and (3) allocating the responsibility for each activity to an individual, along with a deadline. The plans were documented on word processors as they developed. Participants used local statistics (or estimates) to determine the numbers of people in their catchment areas requiring services for various problems (e.g., cataract and presbyopia). They identified all available resources, government and non-government, and agreed on strategies to use these to provide services. Maps were used to make rational decisions about placement of services based on population centres and geographic considerations. After 4 days, the basic strategy of a programme detailing specific activities to be done, by whom and by when had been created. A small planning team refined each plan after completion of the workshop. The cost of the large workshop, which covered planning for three regions, was about US$ 9000. Both regions chose to use their government regional hospital as a base of operations, from which outreach services are conducted to fixed sites every 3–6 months. Outreach services are comprehensive and comprise anterior and posterior segment examination, medical treatment, minor surgical procedures (including trichiasis surgery), refractions and spectacle dispensing, advice and counselling. Patients needing surgery that cataract surgeons can provide are transported back to the hospital. Paediatric cataracts and more complicated cases must be referred to higher-level hospitals. Examinations are free at outreach, but an inclusive fee of US$ 14 is charged for cataract surgery. Singida already had a cataract surgeon but Mara did not. Spectacles are sold at US$ 4 (plastic frames) and US$ 6 (wire frames). Eye drops are sold at cost, which ranges from US$ 0.50–1.00.

ª 2008 Blackwell Publishing Ltd

The critical members of the eye care team included a surgeon, a manager, nurses ⁄ assistants, a counsellor and a refractionist. The first two need to be specifically trained for their tasks; the latter positions also require training but may be filled by different cadres including ophthalmic assistants, nurses or optometrists. The two regions had different training needs to round out their teams. Full-time managers were hired in both regions and trained to keep accounts, organise reliable supplies for the surgeon, schedule and run outreach visits, and to prepare regular financial and patient-service reports. Indicators chosen to monitor the programmes included the number of patients examined, cataracts operated, the cataract surgical rate, number of spectacles sold and the source of funds needed to run the programmes. From the beginning, it was recognised that government resources were not sufficient to run the programmes. Helen Keller International and ORBIS International agreed to support Singida and Mara regions, respectively, through training, implementation and the first 3 years. Results Data available from the regions prior to start of the programmes were collected irregularly. In Singida, most cataract surgeries were done at the hospital although there were occasional free eye camps organised by service clubs. In Mara, there was no fixed surgical service and all surgeries were done by visiting surgeons. Some surgeries were free of charge while others were not. In both regions some equipment was needed; the approximate cost of the equipment for Singida was $ 7000 and for Mara (which included a vehicle) it was approximately $ 35 000. Training costs for the regional teams are difficult to calculate because the training programmes are heavily subsidised and fees do not reflect the true costs. All training was done in Tanzania. In Mara, an existing ophthalmic medical officer was upgraded in a 1-year course to a cataract surgeon; in both programmes, managers, ophthalmic nurses, counsellors and optometrists received 1–3week task-oriented training at the Kilimanjaro Centre for Community Ophthalmology. After training and equipping, the Singida and Mara programmes were implemented in early 2005 and 2006, respectively. Running costs, including all salaries, outreach expenses (largely fuel and allowances), office expenses, drugs, consumables and spectacles were reviewed monthly using a standardised spreadsheet. Donated items were valued at their purchase price. Depreciation on equipment was not included although vehicle maintenance was. The running expenses, source 1285



E. Eliah et al. Vision 2020 in Tanzania

Table 1 Running costs for providing comprehensive eye care services in two regions of Tanzania

Patients examined

Cataracts operated (CSR )

Numbers of spectacles sold

Total average monthly running expenses (US$)

Singida

2002: 3424

2002: 237 (216)

2002: