Journal of the College of Physicians and Surgeons Pakistan
ISSN: 1022-386X (PRINT)
ISSN: 1681-7168 (ONLINE)
Affiliations
doi: 10.29271/jcpsp.2023.08.833The evidence obtained through a population-based Pakistan National Blindness and Visual Impairment Survey in 2002-2004 which revealed that the prevalence of overall blindness and visual impairment was 0.9% (all ages), while the prevalence of blindness for age 30 years and above was 2.7%. The common causes of blindness and visual impairment in Pakistan were cataracts, corneal opacity, glaucoma, and uncorrected refractive errors.1
Recent data of the Rapid Assessment of Avoidable Blindness surveys (RAABs) indicate that the prevalence of blindness is likely to be 0.6% - 0.7%, suggesting a 22% reduction in blindness rates from 2004. Using the higher figure of 0.7%, there are likely to be over 1.5 million blind people in Pakistan and three to four times that number who are visually impaired.
The Mapping of Cataract Surgical Services in Pakistan – 2019 report revealed that Pakistan achieved a national CSR of 5307.2 But as per this report there are strong inequalities in different geographic locations and communities nationwide.2 Cataract surgical services are more developed in big cities and also not affordable for the most marginalised and poor segments of society. Despite all the efforts by Ministry of Health and other non-governmental stakeholders, including International NGOs for improved service delivery services, nearly one in ten adults are visually impaired due to un-operated cataracts. Similarly, other treatable causes of blindness such as refractive error and other common ailments are still causing blindness in Pakistan due to lack of awareness, inequitable distribution of services in different geographies, inaccessible and unaffordable care for marginalised communities such as women, children, older people, transgender, ethnic/religious minority groups, and people with disabilities, etc.
According to the World Report on Disability – 2011 by WHO, there is a strong relationship between disability and poverty; disability can increase the risk of poverty, whilst poverty can increase the risk of disability.
Communities from poverty-stricken socio-economic backgrounds are at high risk of facing poor nutrition, unsafe working conditions, and unhealthy living environment. The WHO Disability Report also reveals that access of healthcare by the poor and marginalised becomes challenging and complex when there is a general lack of information/education regarding the causes of disabilities.3
People with disabilities including those with visual impairment face real obstacles in accessing healthcare. It is essential that these services are available to them in an enabling environment, based on three important elements. The first is the accessible physical infrastructure of healthcare provider facilities with disability-friendly access for all types of disabilities. The second is the friendly and enabling attitudes of the healthcare professional staff towards diverse needs of people with disabilities. The third is an affordable, accessible, and acceptable delivery of care in a dignified manner to all beneficiaries including people with disabilities. According to the World Report on Vision by WHO, the two main challenges faced by marginalised segments of society are the non-affordability of eye care and inaccessible distance and transportation from home to healthcare facilities. The severity of this challenge can be further analysed by the estimates, indicating that from low-income countries, where the uptake of health services for non-disabled people is 32 - 33%, compared to 51 - 53% by people with disabilities.4
Regarding Pakistan people with disabilities are the most neglected and challenges are profound for them. Disability can increase the risk of poverty not only for the person with specific disabilities but for the entire family. This can be alleviated through effectively designed and well-informed services, and this would be only possible by adopting inclusive and equitable interventions while designing healthcare programmes that can address the needs of women and men with disabilities and other marginalised groups.
The National Health Vision of Pakistan 2016-2025, endeavours to develop a well-informed and gender-responsive national plan to tackle several health challenges, maintaining and prioritising UHC as its ultimate goal.5 The document clearly mentions that disability due to blindness or other causes is also high, and services for the disabled population are limited, including the provision of assistive devices to improve their quality of life. This policy document acknowledges UHC as one of the key priorities among other competing priorities and is in complete alignment with other government plans and policies such as the Poverty Alleviation Programmes and other social protection initiatives, such as EHSAS programme.5
Inclusive Eye Health (IEH) is an emerging new concept that aims to ensure the provision of eye care services within an accessible and enabling environment, where gender and disability mainstreaming is possible and services are sustainable and can be accessed by all neglected groups, particularly people with disabilities, women, and children.6 Sightsavers’ piloted the IEH model in Pakistan, for the first time in 4 districts in partnership with LRBT hospital networks, from 2018-2022. The Key objective was to ensure that inclusive and equitable eye health services are available to everyone, including the most marginalised groups such as people with disabilities. Moreover, the purpose of piloting IEH model was to demonstrate solutions for accessible and inclusive eye care delivery in a way that governments and other stakeholders can adapt the same model as part of their health policies.
This pilot project was based on the learnings of the Sightsavers IEH project already tested in Bhopal, India,1 Special interventions were planned to make sure that the approaches are in complete alignment of the principles of the United Nations globally agreed agenda 2030 and the Sustainable Development Goals (SDGs),1 and “Leave No One Behind.”7
Sightsavers is currently scaling up the IEH approaches as a cross-cutting theme in selected projects with potential provincial government partners such as the Sindh Institute of Ophthalmology and Visual Sciences (SIOVS). SIOVS is not only the state-of-the-art training institute for sub-specialities in the field of ophthalmology and allied vision sciences but also recognised as the provincial coordinating body/unit of the National Blindness Control Programmes under the patronage of the National Committee for Eye Health.8 It currently implementing health systems strengthening through primary healthcare (PHC) reforms and projects in districts Mirpurkhas and Qambar Shahdadkot of interior Sindh. This project is working for the successful integration and institutionalisation of primary eye care (PEC) into primary healthcare (PHC) to achieve Universal Healthcare (UHC) in Pakistan.
Most importantly this project is addressing to reduce the challenges faced by people with disabilities to access eye care within the public health system. The measures include removing physical infrastructural barriers at health facilities by creating reasonable accessibility adaptations, staff trained on disability equality training programmes, and key staff provided with basic sign language skills to be able to communicate with deaf patients. Most importantly the project is collaborating with organisations of people with disabilities (OPDs) and other local civil society organisations (CSOs) to identify the pockets of the disabled population in the projects’ geographical locations and then arrange outreach screening camps for early detection and referral of eye care problems among people with disabilities. Later, they are facilitated for transportation to and from the hospital to their homes.
The key expected outcome of the project is that project creates evidence for the wider replication, and the provincial government is convinced and supportive for the need to adapt national and the provincial integrated people-centred eye care plans (IPEC) into their eye care approach as well as to reflect disability and gender disaggregation in provincial government’s Health Management Information System (HMIS), District Health Information System (DHIS) and within referral and reporting tools and mechanisms in place.
Recently, Pakistan has developed 5-year Integrated People Centred Eye Care (IPEC) plans 2020 - 2025 at national and provincial levels. These plans are now endorsed at Federal Level and Sindh province is the first province endorsing the 5-year IPEC plan by the provincial government. The 5-year Sindh Provincial IPEC Plan 2020 - 2025 is a mid-term strategic plan that is designed to contribute towards a 10-year perspective outlook with longer term goals, outcomes, and milestones. The aim is to achieve Universal Eye Health Coverage by 2030.
The National IPEC Plan 2020 - 2025 is to be used as a guiding planning document by the provincial health department for all long term and short terms eye health initiatives, resulting in services that are inclusive and comprehensive. These services must be designed in a way that can capture health promotion, disease prevention, curative medical and surgical services, and rehabilitative, services including access to all assistive devices for people with visual impairments.
Provincial primary and secondary healthcare departments and other stakeholders need to bring Primary Eye Care within their domain, hence bringing services closest to the communities at the nearest possible first-level health facilities through deployment of trained optometrists and training other allied health professionals in primary eye care. Last but not the least, there is a dire need to undertake a contextual and operational review of the new provincial health sector strategies to identify opportunities for disability inclusion that can be integrated with specified objectives and implementation plans.
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