Abstract

Problem

Visual impairment affects nearly 285 million people worldwide. Although there has been much progress in combating the burden of visual impairment through initiatives such as VISION 2020, barriers to progress, especially in African countries, remain high.

Approach

The Rwandan Ministry of Health has formed partnerships with several nongovernmental organizations and has worked to integrate their efforts to prevent and treat visual impairment, including presbyopia.

Local setting

Rwanda, an eastern African country of approximately 11 million people.

Relevant changes

The Rwandan Ministry of Health developed a single national plan that allows key partners in vision care to coordinate more effectively in measuring eye disease, developing eye care infrastructure, building capacity, controlling disease, and delivering and evaluating services.

Lessons learnt

Collaboration between stakeholders under a single national plan has ensured that resources and efforts are complementary, optimizing the ability to provide eye care. Improved access to primary eye care and insurance coverage has increased demand for services at secondary and tertiary levels. A comprehensive strategy that includes prevention as well as a supply chain for glasses and lenses is needed.

Résumé

Problème

Près de 285 millions de personnes dans le monde présentent des déficiences visuelles. Bien que les efforts pour réduire la charge qu'elles représentent aient beaucoup progressé, grâce à des initiatives telles que VISION 2020, les obstacles au progrès, en particulier dans les pays d'Afrique, restent importants.

Approche

Le Ministère de la Santé rwandais a établi des partenariats avec plusieurs organisations non gouvernementales en tâchant d'intégrer leurs efforts pour prévenir et traiter les déficiences visuelles, notamment la presbytie.

Environnement local

Le Rwanda, un pays d'Afrique de l'Est comptant environ 11 millions d'habitants.

Changements significatifs

Le Ministère de la Santé rwandais a mis en place un plan national qui permet une coordination plus efficace entre les partenaires clés de l'ophtalmologie, pour dépister les maladies des yeux, développer des infrastructures de prise en charge des affections oculaires, renforcer les capacités, contrôler les maladies, fournir des services et évaluer ces derniers.

Leçons tirées

La collaboration entre les différents acteurs, dans le cadre d'un plan national unique, a permis d'assurer la complémentarité des ressources et des efforts et d'optimiser les capacités de prise en charge des affections oculaires. L'amélioration de l'accès aux soins oculaires de base ainsi qu'aux assurances a intensifié la demande de services aux niveaux secondaire et tertiaire. Une stratégie globale de prévention et d'acquisition de lunettes et de lentilles est maintenant nécessaire.

Resumen

Situación

La discapacidad visual afecta aproximadamente a 285 millones de personas en todo el mundo. Si bien se han hecho muchos avances en la lucha contra la carga de la discapacidad visual mediante iniciativas como el programa VISIÓN 2020, las barreras hacia el progreso siguen siendo altas, especialmente en los países de África.

Enfoque

El Ministerio de Salud de Rwanda ha establecido colaboraciones con varias organizaciones no gubernamentales y ha trabajado para integrar sus esfuerzos para prevenir y tratar la discapacidad visual, incluida la presbicia.

Marco regional

Rwanda, un país del África oriental con aproximadamente 11 millones de habitantes.

Cambios importantes

El Ministerio de Salud de Rwanda desarrolló un único plan nacional que permite a los colaboradores clave que trabajan en la atención oftálmica coordinar de una manera más efectiva la medición de las enfermedades oculares, el desarrollo de una infraestructura para la atención oftálmica, la generación de capacidades, el control de las enfermedades y la prestación y evaluación de servicios.

Lecciones aprendidas

La colaboración entre las partes interesadas bajo un único plan nacional ha garantizado que los recursos y esfuerzos sean complementarios, optimizando la capacidad de proporcionar servicios de atención oftálmica. La mejora del acceso a la atención oftálmica primaria y la cobertura del seguro ha incrementado la demanda de servicios a nivel secundario y terciario. Se necesita una estrategia exhaustiva que incluya la prevención y una cadena de suministro de gafas y lentes.

ملخص

المشكلة يؤثر ضعف البصر على ما يقرب من 285 مليون شخص على مستوى العالم. وبالرغم من وجود تقدم كبير في التغلب على عبء ضعف البصر من خلال مبادرات مثل VISION 2020، فإن العوائق الموجودة أمام التقدم، خاصةً في البلدان الأفريقية، لا تزال مرتفعة.

الأسلوب لقد شكلت وزارة الصحة الرواندية مبادرات شراكة مع العديد من المنظمات غير الحكومية وعملت على إدماج جهودها للوقاية من ضعف البصر وعلاجه، بما في ذلك قصور البصر الشيخوخي.

المواقع المحلية رواندا، وهي بلد تقع في شرق أفريقيا ويسكن بها قرابة 11 مليون نسمة.

التغيّرات ذات الصلة قامت وزارة الصحة الرواندية بإعداد خطة وطنية منفردة تسمح للشركاء الرئيسين في مجال رعاية الإبصار بالتنسيق بشكل أكثر فعالية في قياس الأمراض العينية، وإعداد البنية التحتية للرعاية العينية، وإمكانية بناء القدرات، ومكافحة الأمراض، وتقديم الخدمات وتقييمها.

الدروس المستفادة لقد ضمن التعاون بين الجهات المعنية في إطار خطة وطنية منفردة أن تكون الموارد والجهود متكاملة، مما يؤدي إلى تحسين إمكانية توفير الرعاية العينية. أدى تحسين فرص الحصول على الرعاية العينية الأولية وتغطية التأمين على زيادة الطلب على الخدمات في المستويات الثانوية وفوق الثانوية. وهناك حاجة إلى استراتيجية شاملة تتضمن الوقاية بالإضافة إلى سلسلة الإمداد للنظارات والعدسات.

摘要

问题

视力受损影响了全球近 28.5 亿人口。尽管我们已通过"视觉 2020"(VISION 2020) 等举措在消除视力受损带来的负担方面取得了很大的进步，但是前进的道路仍然充满障碍，这种情况在非洲国家尤为明显。

方法

卢旺达卫生部已与多个非政府组织建立了合作伙伴关系，并且共同致力于预防和治疗视力受损，包括老花眼。

当地状况

卢旺达是东非国家，拥有约 1.1 亿的人口。

相关变化

卢旺达卫生部制定出全国统一的计划，允许与重要的视力保健合作伙伴一起在测定眼疾、开发眼科护理基础设施、培养能力、控制疾病以及提供和评估服务方面开展更加有效的合作。

经验教训

利益相关者依据全国统一的计划而开展的合作能够确保资源和精力互补，以优化提供眼科护理服务的能力。初级眼科护理普及率提高以及保险覆盖面的改善增加了对中级和高级服务的需求。我们需要制定出一项涵盖预防举措和眼镜及镜片供应链的全面战略。

Резюме

Проблема.

От нарушений зрения страдают около 285 миллионов человек во всем мире. И хотя благодаря таким инициативам, как VISION 2020, в борьбе с расстройствами зрения был достигнут немалый прогресс, на этом пути сохраняются значительные препятствия, особенно в странах Африки.

Подход.

Министерство здравоохранения Руанды в партнерстве с несколькими неправительственными организациями стремится объединить усилия этих организаций по профилактике и лечению нарушений зрения, включая старческую дальнозоркость.

Местные условия.

Руанда - восточноафриканское государство с населением около 11 миллионов человек.

Осуществленные перемены.

Министерство здравоохранения Руанды разработало единый национальный план, который позволяет ключевым партнерам в области офтальмологической помощи более эффективно координировать друг с другом работу по мониторингу нарушений зрения, разработке необходимой медицинской инфраструктуры, расширению своих возможностей, контролю заболеваний, а также оказанию услуг и оценке их качества.

Выводы.

Сотрудничество между заинтересованными сторонами в рамках единого национального плана позволило объединить их усилия и ресурсы для оказания оптимальной офтальмологической помощи. Благодаря упрощению процесса получения первичной офтальмологической помощи и страховому покрытию увеличился спрос на услуги на вторичном и третичном уровнях. Необходима комплексная стратегия, которая включала бы профилактику, а также учитывала бы цепь поставок линз и очков.

Introduction

Visual impairment - both preventable and treatable - affects an estimated 285 million people globally. Most of the people affected (87%) live in low- and middle-income settings.¹1 . Draft action plan for the prevention of avoidable blindness and visual impairment 2014-2019. Geneva: World Health Organization; 2013. Available from: http://www.iapb.org/sites/iapb.org/files/A66_11-en.pdf [cited 2015 Feb 20].
http://www.iapb.org/sites/iapb.org/files... ²2 . International agency for the prevention of blindness: 2010 Report. London: International Agency for the Prevention of Blindness; 2010. Available from: http://www.iapb.org/sites/iapb.org/files/State%20of%20the%20World%20Sight_2010.pdf [cited 2015 Feb 20].
http://www.iapb.org/sites/iapb.org/files... In Africa, an estimated 32 700 people per million are visually impaired.³3 . Global data on visual impairments 2010. Geneva: World Health Organization; 2012. Available from: http://www.who.int/blindness/GLOBALDATAFINALforweb.pdf [cited 2013 Nov 22].
http://www.who.int/blindness/GLOBALDATAF... A variety of eye disorders contribute to visual impairment, including cataract, glaucoma, trachoma and refractive error.³3 . Global data on visual impairments 2010. Geneva: World Health Organization; 2012. Available from: http://www.who.int/blindness/GLOBALDATAFINALforweb.pdf [cited 2013 Nov 22].
http://www.who.int/blindness/GLOBALDATAF... Nearly 80% of impairments are preventable or treatable.⁴4 . New IAPB report on 'universal eye health' launched on world sight day [Internet]. London: International Agency for the Prevention of Blindness; 2013. Available from: http://www.iapb.org/news/new-iapb-report-%E2%80%98universal-eye-health%E2%80%99-launched-world-sight-day [cited 2015 Feb 20].
http://www.iapb.org/news/new-iapb-report... Presbyopia - difficulty focusing on nearby objects - is a common feature of ageing, as the ocular lens loses elasticity. The ageing population and the lack of national plans to address the effect of visual impairment on people's productivity and quality of life, will likely increase the burden of eye disease in many African countries.⁵5 . Patel I, Munoz B, Burke AG, Kayongoya A, McHiwa W, Schwarzwalder AW, et al. Impact of presbyopia on quality of life in a rural African setting. Ophthalmology. 2006 May;113(5):728-34. http://dx.doi.org/10.1016/j.ophtha.2006.01.028 PMID:16650665
http://dx.doi.org/10.1016/j.ophtha.2006....

Providing eye care services to mitigate visual impairment is an important dimension of delivering comprehensive primary health care. It also contributes to economic growth and development by helping reduce injuries and by improving access to education and employment.⁶6 . PricewaterhouseCoopers and Three Rivers Consulting. The global cost of eliminating avoidable blindness. Sydney: Fred Hollow Foundation; 2013. Available from: https://www.hollows.org.au/sites/default/files/pdfs/research/FHF_Price_of_Sight_Report_final_201302.pdf [cited 2015 Feb 20].
https://www.hollows.org.au/sites/default... Investment in eye care services has a benefit-to-cost ratio of more than two to one.⁴4 . New IAPB report on 'universal eye health' launched on world sight day [Internet]. London: International Agency for the Prevention of Blindness; 2013. Available from: http://www.iapb.org/news/new-iapb-report-%E2%80%98universal-eye-health%E2%80%99-launched-world-sight-day [cited 2015 Feb 20].
http://www.iapb.org/news/new-iapb-report... ⁷7 . Armstrong KL, Jovic M, Vo-Phuoc JL, Thorpe JG, Doolan BL. The global cost of eliminating avoidable blindness. Indian J Ophthalmol. 2012 Sep-Oct;60(5):475-80. http://dx.doi.org/10.4103/0301-4738.100554 PMID:22944763
http://dx.doi.org/10.4103/0301-4738.1005...

While there is multilateral organizational support for integrating eye care services into health systems - including the launch of the VISION 2020 Right to Sight Initiative - there are barriers to progress, especially in low-income settings.²2 . International agency for the prevention of blindness: 2010 Report. London: International Agency for the Prevention of Blindness; 2010. Available from: http://www.iapb.org/sites/iapb.org/files/State%20of%20the%20World%20Sight_2010.pdf [cited 2015 Feb 20].
http://www.iapb.org/sites/iapb.org/files... In many African countries, there is a shortage of eye care personnel, a lack of standardized training, inadequate coordination among eye care stakeholders and for those in need of eye care, the cost of equipment and treatment can be an obstacle.⁴4 . New IAPB report on 'universal eye health' launched on world sight day [Internet]. London: International Agency for the Prevention of Blindness; 2013. Available from: http://www.iapb.org/news/new-iapb-report-%E2%80%98universal-eye-health%E2%80%99-launched-world-sight-day [cited 2015 Feb 20].
http://www.iapb.org/news/new-iapb-report... ⁸8 . Palmer JJ, Chinanayi F, Gilbert A, Pillay D, Fox S, Jaggernath J, et al. Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards VISION 2020. Hum Resour Health. 2014;12(1):44. http://dx.doi.org/10.1186/1478-4491-12-44 PMID:25128163
http://dx.doi.org/10.1186/1478-4491-12-4... Challenges with data collection and measurement of the burden of visual impairment complicate efforts to generate support for effective health policy development.⁸8 . Palmer JJ, Chinanayi F, Gilbert A, Pillay D, Fox S, Jaggernath J, et al. Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards VISION 2020. Hum Resour Health. 2014;12(1):44. http://dx.doi.org/10.1186/1478-4491-12-44 PMID:25128163
http://dx.doi.org/10.1186/1478-4491-12-4... Here we summarize ongoing efforts to overcome barriers to addressing the burden of visual impairment in Rwanda.

Setting

Rwanda has 10.5 million inhabitants. Over the past two decades, mortality caused by infectious diseases has dropped, for instance, mortality related to acquired immunodeficiency syndrome fell by 82% between 2000 and 2012. Consequently, life expectancy has nearly doubled since the 1990s and is now at 63 years of age.⁹9 . Binagwaho A, Farmer PE, Nsanzimana S, Karema C, Gasana M, de Dieu Ngirabega J, et al. Rwanda 20 years on: investing in life. Lancet. 2014 Jul 26;384(9940):371-5. http://dx.doi.org/10.1016/S0140-6736(14)60574-2 PMID:24703831
http://dx.doi.org/10.1016/S0140-6736(14)... In the population older than 49 years, in 2006, the overall prevalence of visual impairment was 5.3% (not including presbyopia) and the prevalence of blindness was 1.8%.¹⁰10 . Mathenge W, Nkurikiye J, Limburg H, Kuper H. Rapid assessment of avoidable blindness in Western Rwanda: blindness in a postconflict setting. PLoS Med. 2007 Jul;4(7):e217. http://dx.doi.org/10.1371/journal.pmed.0040217 PMID:17608561
http://dx.doi.org/10.1371/journal.pmed.0... In 2006, more than 80% of the eye conditions were considered preventable or treatable - including cataract, refractive error and trachoma.¹⁰10 . Mathenge W, Nkurikiye J, Limburg H, Kuper H. Rapid assessment of avoidable blindness in Western Rwanda: blindness in a postconflict setting. PLoS Med. 2007 Jul;4(7):e217. http://dx.doi.org/10.1371/journal.pmed.0040217 PMID:17608561
http://dx.doi.org/10.1371/journal.pmed.0... Other estimates suggest that more than 65 000 people (0.6%) in Rwanda are blind in both eyes and 12% of the population - including those with presbyopia - have a correctable refractive error and are therefore in need of corrective lenses.¹¹11 . National strategic plan for eliminating needless blindness: Five year plan (2009-2013). Rwanda: Ministry of Health; 2009.

While Rwanda has experienced substantial economic growth, nearly 50% of the population still lives below the poverty line, especially in rural areas. This means that most people are not able to afford private eye care services.¹²12 . Data, Rwanda [Internet]. Washington: World Bank; 2015. Available from: http://data.worldbank.org/country/rwanda [cited 2014 Apr 26].
http://data.worldbank.org/country/rwanda... Moreover, most eye care resources are located in the capital of Kigali, a situation which has resulted in public-private partnerships aiming to ensure equity in access to eye care services.

Forming partnerships

In 2002, Rwanda signed the VISION 2020 initiative and created a national vision plan to end needless blindness. The plan has been updated regularly in collaboration with stakeholders.¹¹11 . National strategic plan for eliminating needless blindness: Five year plan (2009-2013). Rwanda: Ministry of Health; 2009. As part of the plan, the Ministry of Health partners with various nongovernmental organizations (NGOs) and private providers to address the preventable and treatable burden of visual impairment, especially at the primary care level. Here we describe partnerships between the Ministry of Health and three international non-profit partners: Vision for a Nation, the Christoffel Blinden Mission and the Fred Hollows Foundation. We categorize these partnerships in four pillars: (i) measurement of disease prevalence and evaluation of services (e.g. funding disease burden studies); (ii) infrastructure development (e.g. building of eye care clinics); (iii) human resources development (e.g. standardizing the eye care curriculum for nurses); and (iv) disease control and service delivery (e.g. providing low-cost or free eye glasses to those in need; Table 1).

Guiding principles

Three principles have guided these changes in the way eye care services are delivered in Rwanda: prioritizing geographic equity of service delivery, reducing the cost of access to services, and coordinating all partners under a single national plan.

The Rwanda health system aims to provide eye care services at primary, secondary and tertiary levels (Fig. 1) in a decentralized and evenly distributed manner. Primary health care is delivered through a network of 45 000 community health workers and 502 health centres. In 2010 the Rwandan government launched a comprehensive primary eye care programme with the support of the organization Vision for a Nation. This programme includes creating a permanent primary eye care curriculum at all eight nursing schools in Rwanda, educating 1250 existing health centre nurses in primary eye care services and improving referral guidance. To date, the programme has administered approximately 200 000 vision assessments nationally and created a sustainable nationwide supply chain for eye glasses. National campaigns are run to inform people that they can access these services.

To ensure that services are affordable, the Rwandan community-based health insurance scheme, which enrols most of the population,⁹9 . Binagwaho A, Farmer PE, Nsanzimana S, Karema C, Gasana M, de Dieu Ngirabega J, et al. Rwanda 20 years on: investing in life. Lancet. 2014 Jul 26;384(9940):371-5. http://dx.doi.org/10.1016/S0140-6736(14)60574-2 PMID:24703831
http://dx.doi.org/10.1016/S0140-6736(14)... now includes vision care services, including reimbursement for consumables.

The Ministry of Health coordinates partners by ensuring that their activities align with the national vision plan. A technical working group - consisting of partners and Ministry of Health representatives - advises on implementation. The working group provides planning and ensures that each partner is providing the most appropriate services, given their available resources and expertise. For example, through the primary eye care programme, efforts to increase awareness and attention to vision care at the primary level have increased demand for more advanced vision care at the secondary and tertiary care levels, including cataract surgery. Therefore, other partners - such as the Fred Hollows Foundation and the Christoffel Blinden Mission - have provided their expertise to create curricula, support scholarship programmes to train eye-care specialists, deliver specialty care and develop critical health-care infrastructure at these more resource-intensive levels. These efforts complement private eye care clinics and hospitals that also provide more advanced eye care services in Rwanda.

Next steps

Although these non-profit collaborations have helped to orchestrate the development of eye care delivery infrastructure, human resource capacity and quantity of services, formal assessments will be necessary to document improvements in population health. Evaluation of the primary eye care programme is ongoing and the next population survey to assess the burden of avoidable blindness will be done this year. However, evidence from the Rwandan electronic health management information system suggests that demand for eye care services may be increasing: eye disease was the second leading reason for seeking care in 2014. In 2009, eye diseases were not among the 10 leading reasons for seeking care. Additional indicators - such as the number of cataract operations done and the number of people presenting with glaucoma - recently added to the electronic information system will help to monitor progress and identify remaining gaps, especially for more advanced eye care.

The World Health Organization has set a target of 2000 operations per million population per year for cataract surgery in Africa. The cataract surgery rate in Rwanda was estimated at 300 operations per million population per year in 2007.¹⁴14 . Courtright P, Murenzi J, Mathenge W, Munana J, Müller A. Reaching rural Africans with eye care services: findings from primary eye care approaches in Rubavu District, Rwanda. Trop Med Int Health. 2010 Jun;15(6):692-6. http://dx.doi.org/10.1111/j.1365-3156.2010.02530.x PMID:20374559
http://dx.doi.org/10.1111/j.1365-3156.20... Also, despite the gradual increase in human capacity, there continues to be a shortage of trained eye care specialists across sub-Saharan Africa.⁸8 . Palmer JJ, Chinanayi F, Gilbert A, Pillay D, Fox S, Jaggernath J, et al. Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards VISION 2020. Hum Resour Health. 2014;12(1):44. http://dx.doi.org/10.1186/1478-4491-12-44 PMID:25128163
http://dx.doi.org/10.1186/1478-4491-12-4... In 2014, there were only 18 ophthalmologists in Rwanda, most of whom resided in the capital, leaving rural areas underserved.¹⁰10 . Mathenge W, Nkurikiye J, Limburg H, Kuper H. Rapid assessment of avoidable blindness in Western Rwanda: blindness in a postconflict setting. PLoS Med. 2007 Jul;4(7):e217. http://dx.doi.org/10.1371/journal.pmed.0040217 PMID:17608561
http://dx.doi.org/10.1371/journal.pmed.0... Policies to promote task shifting, such as through the Rwandan three-year ophthalmic technician training course, has helped to address this gap, yet more trained professionals will be needed. Other east African countries, such as Uganda, are also investigating task shifting to bolster workforce capacity through its ophthalmic clinical officers' programme.¹⁵15 . Kaggwa G. Ophthalmic clinical officers: developments in Uganda. Comm Eye Health Vol. 2014;27(86):34. Available from: http://www.cehjournal.org/article/ophthalmic-clinical-officers-developments-in-uganda/ [cited 2014 Dec 17].
http://www.cehjournal.org/article/ophtha...

Collaborations between the Ministry of Health and key partners have improved the capacity to manage visual impairment in Rwanda (Box 1). Though advanced eye care services need more development, we are optimistic that continued collaboration will provide opportunities to overcome the remaining challenges.

References

Publication Dates

History