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VOL. 17, NO. 3, 2004
Original Articles Human resources and infrastructure for eye care in India: Current status G. V. S. MURTHY, SANJEEV K. GUPTA, DAMODAR BACHANI, H. K. TEWARI, NEENA JOHN
ABSTRACT Background. An ophthalmic workforce and infrastructure planningsurveywasundertakentoprovideavalidevidencebase forhumanresourceandinfrastructurerequirementsforelimination of avoidable blindness. This is the first time that such an extensive survey has been done in India. Methods.Pre-testedquestionnaireswereadministeredtoall district-levelblindnessofficialsandophthalmologytraininginstitutions during April 2002–March 2003. Supplementary data sourceswereusedwherevernecessary.Dataanalysiswasdonein Stata 8.0. Projections of the existing ophthalmologists and dedicated eye beds were made for the entire country using the mean, median and range for each individual state. Results. The response rate was 89.3%. More than half the eye care facilities were located in the private sector. Sixty-nine per cent of the ophthalmologists were employed in the private and non-governmental sectors; 71.5% of all dedicated eye beds were managed by these two sectors. Five states (Maharashtra, Uttar Pradesh, Karnataka, Andhra Pradesh and Tamil Nadu) had half the practising ophthalmologists in India. There was a wide disparity in access to ophthalmologists and dedicated eye beds across the country. Using the median to obtain medium projections,itisestimatedthatthereare9478practisingophthalmologists and 59 828 dedicated eye beds in India. Conclusions.India will be able to meet the requirements for trained ophthalmologists and dedicated eye beds to achieve the goals of Vision 2020. Some states will need special attention. Insteadofanacross-the-boardincreaseinophthalmologistsand eye beds, regions which are deficient will need to be prioritized andconcertedactioninitiatedtoachieveanequitabledistribution of the available resources. Natl Med J India 2004;17:128–34 INTRODUCTION A number of population-based surveys over the past decade have Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India G. V. S. MURTHY, SANJEEV K. GUPTA Community Ophthalmology H. K. TEWARI, NEENA JOHN Directorate General Health Services, Ministry of Health and Family Welfare, Government of India, Nirman Bhavan, New Delhi 110011, India DAMODAR BACHANI Ophthalmology Section Correspondence to G. V. S. MURTHY;
[email protected] © The National Medical Journal of India 2004
shown that the prevalence of blindness and visual impairment is a major problem in India.1–4 Cataract, corneal opacities, glaucoma and posterior segment conditions are responsible for a major proportion of the blindness.1–4 These causes of blindness can only be redressed by skilled ophthalmologists in a hospital setting and cannot be managed by other eye care professionals solely in the community. An evidence base is needed to better understand trends in human resources for health.5 Unfortunately, no regular mechanism exists in India for the collection of data on human resource trends in the provision of eye care services.6 We carried out an ophthalmic workforce and infrastructure planning survey for the first time in India to assess the current situation and provide information for future human resource planning for eye care. The results of the survey will be utilized to identify gaps and strengthen facilities to achieve the goals of the Vision 2020 global initiative. Vision 2020: The Right to Sight is a global initiative launched by the World Health Organization in partnership with international non-governmental organizations (NGOs) and national governments to attain the goal of elimination of avoidable blindness by 2020.7 The three essential elements of the global initiative include identification of strategies/targets for disease control, evaluation of human resource needs and their development, and assessing the infrastructure/technology needs and their development. Cataract, refractive errors, low vision, trachoma, vitamin A deficiency-related blindness, onchocerciasis and childhood blindness are the major thrust areas for Vision 2020.7 The National Programme for Control of Blindness in India was launched in 1976 as a completely Central Government-sponsored scheme. The programme has adapted to the needs of the country over the past 3 decades and is now geared towards meeting the goals of Vision 2020. Human resource and infrastructure needs have been identified for India by adopting the recommendations of the global taskforce for the implementation of Vision 2020.8 METHODS This study was conducted in collaboration with the Ophthalmology Cell, Ministry of Health and Family Welfare, Government of India from April 2002 to March 2003. A specially designed, semi-open ended questionnaire was pretested in 10 districts and mailed to all the districts in the country. The questionnaire had 3 sections: A. Identification data: District, address, contact details, etc.; B. Eye care infrastructure in the district: Number of eye care facilities, ophthalmologists and eye beds in all health facilities
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in the district, separately for the government and private sectors and NGOs; C. Details of ophthalmologists: Names and qualifications of all ophthalmologists in the district, separately for the government and private sectors and NGOs. The questionnaires were sent to the District Collectors of all 591 districts in India through the National Informatics Network and were also posted to all the State Blindness Control Officers. Follow up mechanisms were instituted 12 weeks after mailing the questionnaires and at least 3 reminders were sent to the district programme managers and state programme officers over a 6-month period. National-level blindness control programme managers personally visited states from where the response was poor. Questionnaires relating to training infrastructure and eye care facilities were sent to medical colleges and institutions accredited by the National Board of Examinations for the Diplomate National Board (DNB) in Ophthalmology. The questionnaires for the medical colleges and DNB training institutions included the following additional information. 1. Type of institution (government/private/NGO/university/ others) 2. Duration, annual intake, year of inception and recognition status for the different courses offered (MB,BS, MD, MS, DOMS, DO, DNB, PMOA, others) 3. Detailed information including qualifications of faculty 4. Availability of library, internet, wet laboratory, low vision services, journal subscription 5. Clinical and surgical load over 3 years 6. Status of diagnostic and other equipment 7. Research projects undertaken and publications from the institution in the past three years. In addition to the above-mentioned primary data collection methods, supplementary data sources were also utilized when districts defaulted in responding. These included: 1. Directory of private eye hospitals in metropolitan cities of India (including access to raw data) published by the National Programme for Control of Blindness; 2. Computerized Management Information System (CMIS) database on district-level information on eye care facilities: Maintained by the National Programme for Control of Blindness; 3. Directory of Members of the All India Ophthalmological Society (including state chapters): Published by the All India Ophthalmological Society and state chapters; 4. Websites of leading eye care institutions. Data were entered in a specially designed database in MS Access. All data were imported into Stata 8.0 for data cleaning and analysis. Estimation of the number of ophthalmologists and eye beds To estimate the number of ophthalmologists and eye beds in the country, some assumptions were made. First, the median and mean number of ophthalmologists and eye beds were calculated for each state based on the number of districts that responded. The range (minimum and maximum reported from a district in each state) of ophthalmologists and eye beds reported from the responding districts was also calculated. Based on these values, a medium, low and high projection were estimated for each state. Assuming that the median number of ophthalmologists and eye beds from the responding districts were generalizable to the populations in the non-responding districts in a state, the median value was extrapolated to all the non-responding districts. The
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estimated numbers for the non-responding districts (based on the median for the whole state) were summated with the actual numbers obtained from the responding districts to arrive at the medium projection for the entire state. Similarly, the lower end of the range (district with the least number of ophthalmologists/ beds) was used to estimate the low projection, by assuming that populations residing in all the non-responding districts had at least the minimum eye care services (i.e. lower end of the range) and this was then added to the number available for the total responding districts in the state to obtain the low projection. For the high projection, the upper end of the range (district with the largest number of reported ophthalmologists/beds) was extrapolated to the population residing in the non-responding districts, by assuming that all the non-responding districts had the maximum possible eye care services (i.e. upper end of the range) and this was then added to the number available for the total responding districts in the state to obtain the high projection (the most ‘optimistic’ estimate) for the state. The total estimates for the country were obtained by summating the estimated numbers from the individual states (based on the median and upper and lower ends of the range). It was decided to use the median value of each state’s distribution rather than the mean because the median would be less affected by the outlying values and would therefore be more accurate in the projections. This was necessary because the range was wide due to the differences between the districts. Comparison with global standards To compare the results with global standards, available norms for eye care infrastructure and human resources were used. The Global Advisory Committee of Vision 2020 recommended norms for human resources and infrastructure based on expert consensus on the number of cataract procedures that could be performed by a surgeon per year under optimal conditions, and the number of beds required for the same per million population.7 It was assumed that at least 50 procedures/bed/year could be optimally performed. Based on these assumptions, the following norms were recommended: • Ophthalmologists: 1 per 50 000 population • Ophthalmic assistants: 1 per 50 000 population • Eye beds: 1 per 20 000 population Eye care facilities were defined as any healthcare facility where specialist eye care services were available (working ophthalmologist) irrespective of whether they had provision for eye beds or not. In some states ophthalmologists are posted at primary health centres (PHCs) also and this information was collected. Because of the scope of the definition, the eye facilities were not used as a denominator as they represented a wide range of facilities— PHCs, community health centres, dispensaries, secondary and tertiary care hospitals. Institutions were categorized as government institutions if they were funded by the government or other public sources such as universities and public sector undertakings. NGO institutions were those where there was no government funding and the hospital functioned on a no-profit, no-loss basis. Hospitals with a profit motive, irrespective of whether owned by an individual, or a group of people/agency were categorized as private enterprises. RESULTS Of the 591 districts covered under the study, information could be obtained from 528 districts (89.3%). Completed questionnaires were received initially from 467 districts (79%) and the response
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was improved further by utilizing other data sources and by constant follow up. This level of response is excellent for extrapolating to the entire country. A total of 4889 eye care facilities were enumerated in the respondent districts; 52% (2559) were private nursing homes or eye hospitals where patients were admitted for eye surgery. 1%
Another 18% (883) were in the NGO sector. In addition, private medical colleges accounted for 1% (56). Overall, 71.5% (3498) of facilities were in the private/NGO sectors. Among all facilities, 28.5% (1391) were in the government sector. District hospitals and mobile ophthalmic units were the commonest types of facilities in the government sector (Fig. 1). 3%
10%
9% 3%
7% 10%
2%
10%
5%
43%
52%
5%
18% 22%
District hospital Govt medical college NGO Private medical college
Mobile units Other govt organization Private hospital
FIG 1. Distribution of eye care facilities in India NGO non-governmental organization
Govt government
District hospital CHC/ PHC Private hospital
Mobile unit Other govt organization Private medical college
FIG 2. Distribution of practising ophthalmologists Govt government NGO non-governmental organization CHC/PHC community health centre/primary health centre
TABLE I. Ophthalmologists and eye beds in responding districts State Andamans Andhra Pradesh Assam Arunachal Pradesh Bihar Chandigarh Chhatisgarh Delhi Daman and Diu Dadra and Nagar Haveli Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Lakshadweep Madhya Pradesh Manipur Maharashtra Meghalaya Mizoram Nagaland Orissa Pondicherry Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttaranchal Uttar Pradesh West Bengal India
Ophthalmologists per 100 000 population Mean 95% CI Range 0.6 0.6 1.1 0.6–1.5 0.6 0.3–0.9 0.8 0.1–1.6 0.3 0.2–0.4 7.1 7.1 0.5 0.3–0.7 3.8 3.8 2.4 0.1–4.8 Data not available 2.2 0–4.8 1.2 1.0–1.5 1.1 0.7–1.4 1.0 0.6–1.5 0.8 0.4–1.2 0.3 0.1–0.5 1.5 1.0–2.0 1.2 0.9–1.5 1.6 1.6 0.7 0.4–0.9 0.5 0–1.2 1.2 0.6–1.7 0.4 0–0.9 0.9 0.1–1.6 0.7 0–1.4 0.4 0.3–0.6 4.0 0.7–7.3 1.6 1.0–2.2 0.6 0.4– 0.7 0.5 0–1.5 1.3 0.8–1.7 0.7 0–2.2 0.6 0.4–0.9 0.6 0.4–0.7 0.7 0.2–1.3 0.9 0.77–0.94
Govt. medical collage college NGO
Eye beds per 100 000 population Mean 95% CI Range
0.6–0.6 0.3–5.7 0.1–2.6 0–2.9 0–1.1 7.1–7.1 0.1–1.1 3.8 2.3–2.6
2.8 6.1 3.0 3.1 1.6 15 3.5 11.6 18.5
2.8 3.8–8.4 1.3–4.6 0–9.6 0.5–2.8 15 2.3–4.7 11.6 0–51.4
2.8 0.7–27.6 0 – 12 0–28.8 0–13.7 15 0.5–7.7 11.6 15.9–21.1
2.0–2.4 0.1–2.9 0.2–2.6 0–2.4 0.2–1.7 0–1.4 0.3–6.7 0.7–2.4 1.6 0–3.2 0–2.0 0.2–9.4 0.0–0.9 0–1.5 0–1.0 0–2.1 2.7–7.1 0.3–4.4 0.1–1.5 0–1.2 0.2–4.0 0.3–1.4 0–1.4 0–4.0 0.1–4.7 0–9.4
7.9 10.9 8.2 5.6 3.5 1.1 9.6 4.8 8.3 4.5 1.4 5.0 1.4 3.6 2.0 3.8 15.8 6.4 4.1 2.2 15.8 2.2 5.2 4.9 2.9 5.4
0–20.6 7.6–14.2 4.6–11.9 3.2–8.1 0.8–6.3 0.2–2.0 6.6–12.6 2.1–7.5 8.3 2.9–6.1 0–4.1 3.5–6.5 0–3.4 0–7.7 0–5.0 2.6–4.9 0–37.2 4.6–8.3 3.0–5.2 0–8.0 9.0–22.5 0–4.9 2.9–7.6 3.2–6.5 0.7–5.1 4.9–6.0
6.9–8.9 1.3–28.9 0–22.7 0–11.9 0–9.4 0–4.7 1.7–36.5 1.5–14.4 8.3 0.5–25.7 0–8.9 0.1–17.9 0.0–3.8 0.0–7.9 0–4 0–13.1 0–27.1 0.7–12.4 0.5–11.2 0–7.6 0.6–70.4 1.3–3.4 0–11.3 0–42.5 0.3–17.8 0–70.4
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A count of ophthalmologists working in eye care facilities showed that there were an estimated 9031 ophthalmologists in the country; 69% (6235) were working in the private and NGO sectors, while 31% (2796) were working in the government sector. The largest concentration of practising ophthalmologists was in the private sector (Fig. 2). A fair proportion of practising ophthalmologists (1188) were working in medical colleges (13.1%). In fact, in the government sector there were more ophthalmologists in medical colleges than in district hospitals. The different eye care institutions in India reported a total of 57 263 eye beds. The largest proportion of beds were in the private and NGO sectors (71%; 40 648) and 23 972 (41.9%) beds were contributed solely by the NGO sector (Fig. 3). Overall, there was nearly 1 ophthalmologist (95% CI: 0.77– 0.94) and 5 beds (95% CI: 4.9–6.0) per 100 000 population (Table I). However, there were wide variations across the states. The smaller states and union territories had better human resources and infrastructure for eye care.
10%
26%
14%
5%
42% District hospital Other govt organization Private hospital
Govt. medical college NGO Private medical college
FIG 3. Distribution of inpatient facilities (eye beds) Govt government NGO non-governmental organization
TABLE II. Projected number of ophthalmologists and eye beds in India State
Total population Surveyed
No data available
Andamans 356 265 0 Andhra Pradesh 75 679 541 0 Assam 26 656 325 0 Arunachal Pradesh 875 482 215 635 Bihar 62 202 667 18 835 521 Chandigarh 900 914 0 Chhatisgarh 15 951 911 1 325 235 Delhi 13 782 976 0 Daman and Diu 158 059 0 Dadra and Nagar Haveli NA 220 451 Goa 1 343 998 0 Gujarat 42 735 439 4 545 764 Haryana 15 753 547 5 329 442 Himachal Pradesh 5 322 279 684 969 Jammu and Kashmir 6 604 088 3 465 829 Jharkhand 20 315 909 6 593 519 Karnataka 52 733 958 0 Kerala 27 953 614 3 885 005 Lakshadweep 60 595 0 Madhya Pradesh 58 121 798 2 263 320 Manipur 2 388 634 0 Maharashtra 94 565 379 2 186 868 Meghalaya 2 014 169 291 900 Mizoram 767 922 123 136 Nagaland 1 264779 723 857 Orissa 36 059 008 647 912 Pondicherry 973 829 0 Punjab 20 337 324 3 951 972 Rajasthan 56 473 122 0 Sikkim 540 493 0 Tamil Nadu 53 870 165 8 240 674 Tripura 1 660 637 1 530 531 Uttaranchal 8 479 562 0 Uttar Pradesh 164 027 486 2 025 373 West Bengal 77 779 347 2 441 824 India
Reported
2 858 180 7 171 64 108 529 4 NA 29 566 165 53 55 73 884 374 1 479 23 1128 10 9 8 178 59 319 363 4 740 11 66 977 534 9031
Ophthalmologists Eye beds Projection for total population based on Projection for total population based on Mean Median Range Reported Mean Median Range (medium Low High (medium Low High estimate) estimate estimate estimate) estimate estimate 2 858 180 9 228 64 115 529 4 0 29 621 224 60 83 93 884 421 1 495 23 1154 11 10 13 181 59 382 363 4 847 22 66 989 551 9572
2 858 180 8 209 64 115 529 4 5 29 625 208 60 83 86 884 413 1 488 23 1148 11 10 14 181 59 378 363 4 822 16 66 985 546 9478
2 858 180 7 171 64 109 529 4 5 29 571 176 53 62 73 884 401 1 479 23 1132 10 9 8 178 59 331 363 4 756 16 66 985 536 9134
2 858 180 13 378 64 123 529 4 6 29 698 304 69 114 165 884 467 1 551 23 1334 13 11 15 192 59 493 363 4 1070 32 185 1058 649 10 940
10 4743 787 12 1127 135 689 1601 31 NA 104 4373 1290 310 221 287 5003 1668 5 3035 80 4503 39 41 22 1336 223 1483 2626 13 9673 36 567 9126 2064 57263
10 4743 787 19 1428 135 735 1601 31 0 104 4868 1727 348 342 360 5003 1854 5 3137 80 4612 43 45 36 1361 223 1736 2626 13 10975 70 567 9225 2135 60 986
10 4743 787 12 1165 135 731 1601 31 41 104 4828 1626 346 294 287 5003 1773 5 3103 80 4597 43 45 37 1359 223 1764 2626 13 10497 67 567 9189 2096 59 828
10 4743 787 12 1127 135 696 1601 31 35 104 4432 1290 310 221 287 5003 1726 5 3046 80 4505 39 41 22 1336 223 1511 2626 13 9722 56 567 9126 2071 57 539
10 4743 787 74 3708 135 791 1601 31 47 104 5687 2500 391 547 597 5003 2227 5 3617 80 4894 50 51 51 1421 223 1973 2626 13 15474 88 567 9987 2499 72 602
Median calculated from surveyed population was extrapolated to population where data were not available to construct medium estimate; district with least reported ophthalmologists/ eye beds (lower end of range) was used to extrapolate to population where no data were available to construct low estimate, while district with highest reported ophthalmologists/eye beds (upper end of range) was used to extrapolate to population where no data were available to construct high estimate. For estimating services available in Dadra and Nagar Haveli, rates of Daman were used, as the two are part of the same administrative cluster. NA not available
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0.7/50 000 population 0.2–0.39/50 000 population
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0.4–0.69/50 000 population < 0.2/50 000 population
FIG 4. Ophthalmologist:population ratios in different states of India
Among the available ophthalmologists in the country, more than half (4697) were practising in just 5 states (Maharashtra, Uttar Pradesh, Karnataka, Andhra Pradesh and Tamil Nadu). Together with another 5 states (Gujarat, West Bengal, Delhi, Madhya Pradesh and Kerala), 81% of ophthalmologists in the country could be accounted for (Table II). This shows the disparity in the availability of ophthalmologists in India. Very few states in India are near the Vision 2020 norm of 1 ophthalmologist per 50 000 population (Fig. 4). Only the states of Punjab, Delhi, Gujarat and Goa have a good ratio of ophthalmologists per 50 000 population. However, a large number of states have 1 ophthalmologist per 100 000 population (norm set for 2010 under Vision 2020) and these states would be in a good position to achieve the final norms over the next decade. Of all the eye beds in India, 18.3% were in Tamil Nadu alone (Table II). Six states (Tamil Nadu, Uttar Pradesh, Karnataka,
Gujarat, Andhra Pradesh and Maharashtra) accounted for 67.9% (38 857) of all the eye beds in India. There was a wide disparity in the distribution of eye beds within the country. Many states in the country had good infrastructure for admitting patients for surgery (Fig. 5). Only Bihar, Jharkhand, Manipur, Meghalaya and Nagaland reported a bed capacity that was less than onethird of the anticipated need of the population. Presently, in India there is 1 bed per 20 000 population (suggested norm under Vision 2020). We estimated that there are 9478 practising ophthalmologists in India based on extrapolation of the median (Table II). Using conservative methods (lower end of the range), it was estimated that there were at least 9134 practising ophthalmologists; while using the upper end of the range the estimate was 10 940. Similarly, it was projected that there were 59 828 dedicated eye beds in the country (Table II) based on the median,
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1/20 000 population 0.33–0.49/20 000 population
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0.5–0.99/20 000 population
