Self-Sustaining Community-Based Primary Eye Care

Introduction : The FOCOMETER and InFOCUS

Four years ago the FOCOMETER was described as a new refractive device for developing countries.¹ The instrument was designed to provide accurate and reliable determinations of visual refractive errors, including correction for astigmatism, for people in poor and remote areas, with-out the need for complicated procedures or electricity. A non-profit primary eye care development organisation, InFOCUS (Interprofessional Fostering of Ophthalmic Care for Underserved Sectors) was established in 1995. Its purpose was to distri-bute the FOCOMETER, to train users and to help create access to affordable primary eye care for large, medically underserved populations.

Through the generous efforts of numerous volunteer and goodwill organisations massive vision screening and primary eye care ‘camps’ have been conducted throughout the developing world. In spite of this, very large populations remain with-out access to primary eye care, and with serious consequences due to uncorrected refractive errors. Among the medically underserved, at least 400 million people – or, as expressed by the late Joe Taylor, about 30 of every 100 patients² – are still in need of visual refractive correction in order to carry on productive lives. The capacity of eye care specialists (ophthalmologists, optometrists, ophthalmic nurses and technicians) to provide the necessary care is limited. The main problems are an insufficient number of health care workers capable of delivering primary eye care; poor distribution of eye care specialists practising in remote or urban poverty areas, and a lack of or inadequate equipment and supplies (spectacles and pharmaceuticals). Many excellent projects have shown that primary eye care can be delivered to the most difficult-to-serve communities (FOCOMETERs are currently being used in over 40 countries). However, the vast majority in virtually every developing country, and many in medically isolated areas of wealthy countries, remain outside the reach of reliable, permanent services.

Tanzania VPEP's (Village Primary Eye Care Providers) learning Focometry protocols from Optometry Professor Vlerian Lyimo and Dr Simon Gould

Photo: IB Berger & BR Kadzan

Strategies : Target Populations

The strategy InFOCUS uses is to equip village and community heath workers, primary eye care providers and other community-based interested individuals with the knowledge and skill to improve vision, prevent blindness and improve health, while earning an income in the process through the sale of eye glasses. This approach was developed in direct response to the World Health Organization Bamako Initiative, a recommendation for income-generating efforts to be estab-lished in local communities.³ Programmes recently begun in India, Tanzania, Thailand, Mexico and Brazil illustrate different models for InFOCUS strategies. All involve village-based primary eye care providers trained to assess eye health, offer eye health education, prescribe and dispense eye glasses, and treat or refer individuals presenting certain eye and systemic diseases. InFOCUS programmes, therefore, include standardised training and supervision of village-based primary eye care providers by local eye care professionals or public health authorities. It has been found that each primary eye care worker can earn an adequate income by serving a population of around 10,000. The Table shows the target populations for trained village-based primary eye care providers.

Table.

Examples of Primary Eye Care Programmes utilising Village-Based Self-Sustaining InFOCUS Strategies (see Footnotes)

Programme	Location	Number of village-based primary eye care providers trained	Target patient population
Lori Nayanjyot, Pvt. Ltd.	Jalgaon District, Maharashtra State, India	16	160,000
Tanzania Healthy Eyes & Clear Vision Program	Kilimanjaro Region, Tanzania	11	110,000
Thailand	Refugee villages along Thai-Burma border	220	2,200,000
Mexico	Texas-Mexico border towns	50	50,000 (children)
Brazil	Selected remote and poor towns throughout the country	20	20,000

Karen refugees from Burma using the FOCOMETER

Photo: IB Berger and BR Kadzan

Lori Nayanjyot (India) is a private company where the eye care workers are paid a salary. It is expected that after one year of operation, the 16 Lori Nayanjyot primary eye care providers will each be examining about 20 patients per day, (i.e., 6,000 per year) and dispensing about 2,000 spectacles per year. At this rate, 1.6 years are required by the Nayanjyot team to examine the entire target population. In Tanzania, the programme is run by optometrists and the Ministry of Health. InFOCUS trained 11 village-based eye care technicians, who receive a salary from the district optometrists. In Thailand, a large refugee population is served by village medics trained to incorporate primary eye care into their health care programme. In communities along the Texas-Mexico border, Rotary Club members examine children and sell affordable eye glasses to those who need them. In Brazil, opticians from the eastern part of the country establish eye care outlets in interior towns and villages, supplying both the FOCOMETER, training and ‘wholesale’ affordable spectacles to village-based workers. This approach is now embraced by almost 200 vision and health care agencies, missionary groups, volunteer eye care professionals and government agencies, who have acquired FOCOMETERs and are providing training to support permanent programmes.

Economic Initiatives: Appropriate Technologies : Preventive Protocols

Economic incentives from the sale of affordable eye glasses motivate village-based providers and encourage expansion into neighbouring communities. The availability of affordable spectacles from existing suppliers (primarily in India) is increasing due to the increased volume of dispensing at the village level. InFOCUS is also investigating new and appropriate technologies (e.g., generating lenses from liquid monomers and polymerization) which can be brought closer to the target populations. In addition, preventive protocols (e.g., ivermectin and vitamin A distribution, dry eye protection, and health education for sanitation and control of eye infections) are gradually being incorporated into the InFOCUS training curriculum.

The programmes described above are demonstrating that even in the poorest areas, people are willing and able to pay for eye care services when they are available in their own villages. Equipped with the FOCOMETER, training and a reliable source of low-cost spectacles, community-based providers are helping several underserved populations become substantially self-reliant for primary eye care services. These programme models may serve as prototypes for replication in areas with large unmet needs for basic vision services.

For further information about InFOCUS or to obtain a FOCOMETER, contact InFOCUS, 327 Tealwood Drive, Houston, Texas 77024, USA or by e-mail: rady@ibm.net.

InFOCUS has also established the Center for Primary Eye Care Development in conjunction with several universities to promote training and research for organisations involved with international health development.