Improving Primary Eye Care Services in Urban Settings: A Case Study from Bihar, India

Photo Caption: Providing Primary Eye Care Services in one of the Urban Primary Health Centre in Bihar, India.

Authors: Suharsha Bhagat, I.A.S is the Executive Director of the State Health Society, Government of Bihar. Masood Alam is a state program manager for the National Urban Health Mission at the State Health Society, the Government of Bihar. Anand is senior state program officer at Urban Health in Jhpiego, India. Sanjeev Kumar is a public health professional based in New Delhi, with more than ten years of experience working with multiple states health systems in India.

Introduction

India has made significant strides in reducing the prevalence of blindness, particularly through improving cataract surgical rates (CSR) . This success, however, is not without its challenges, as the aging population and weak primary eye care systems continue to pose significant obstacles. India, like many other countries, bears a disproportionate burden of global blindness and visual impairment. In 1976, India became the first country to implement the National Program for Blindness Control, with the ambitious goal of reducing the prevalence of blindness to 0.3% by 2020 . This was followed by WHO’s Vision 2020: The Right to Sight in 1999, which aimed to eliminate avoidable blindness by 2020. The World Health Assembly then adopted the Universal Eye Health: Global Action Plan 2014-19, with a target of a  25%  reduction in avoidable visual impairment by 2019  compared to the 2010 baseline. These initiatives underscore the situation’s urgency and the need for collective action to improve primary eye care services.

Globally, the main causes of blindness are cataracts, refractive error, diabetic retinopathy, glaucoma, and age-related macular degeneration (WHO). In India, the majority of blindness and visual impairment cases are due to avoidable causes, specifically cataracts, refractive error, diabetic retinopathy, and glaucoma, accounting for 92.9% and 96.2%   respectively. These are significant, as a large proportion of these cases are treatable, with 68.1% of blindness cases and 85.7% of visual impairment.

Under the comprehensive primary healthcare, the Union and state governments have been implementing various strategies collaboratively through the National Program for Control of Blindness and Visual Impairment, including the establishment of vision centres in primary health care settings (Health and Wellness centres). However, the implementation of these centres varies across India, with Bihar identified as needing a new strategy to strengthen primary eye care through vision centres. As a result, with support from development partners, the government of Bihar launched the initiative to operationalize fixed-day vision centres in urban primary health care settings in Patna district on September 17, 2019.

Vision Centre

To ensure primary eye care services in the community, the Government of Bihar initially prioritized the Urban Primary Health Centres (U-PHCs) equipped with functional vision centres in the Patna district. Six components were identified: service provisions, human resources, data system, instruments/equipment, Medical products, Information, Education, and Communication (IEC).  Under the service provision, it was decided to provide 19 services, including screening for blindness and refractive errors, conjunctivitis, Acute red eye, and eye care trachoma, etc. (Refer to Figure 1).

For human resources, it was decided to deploy trained Optometrists or Ophthalmic Assistants in the centre who will work under the close supervision of that health facility’s Medical Officer. Before deploying, it was ensured to provide refresher training for the provisioned services. Data systems help the initiative to improve the services, for which a register was formulated to record OPD services with detailed information, such as Visual Impairment, cataracts, and other provisioned services. For eye services, identified instruments/equipment include a Trial set with trail frame, tonometer, direct ophthalmoscope, self-illuminated Visio testing drum, and others (Refer to Fig 1 for details). Additionally, it was identified that medical products include eye drops of methyl cellulose, sodium cromoglycate 2%, and lignocaine 4%, among others. To better prepare the health workforce and generate demand for eye care in the community, counselling sessions were organized in families, social groups, and Mahila Arogya Samitis (MAS) in slums and non-slum areas. For auxiliary nurses and midwives (community health workers), flip charts were also developed on the importance of Eye Symptoms of cataracts, Glaucoma and its symptoms, Diabetic retinopathy, and the importance of spectacles and sunglasses. As an Accredited Social Health Activist (ASHA), a community mobilizer is the linkage of health services with the community; it also developed a pictorial illustrative guide on child eye care.

Figure 1: Vision Centre-Critical Components

Since the launch of the Vision Center on September 17, 2019, until March 31, 2024, these centers have provided a total of 119048 outpatient consultations. Over time, there has been a steady increase in the services provided, with 11501, 17711, 24200, 31061, and 34575 patient consultations in fiscal years 2019-20, 20-21,21-22, 22-23, and 23-24, respectively (Refer to Figure 2).

Figure 2: Number of OPD Patients Provided Consultation from 17th September 2019 to 31st March 2024 (Source-State Health Society, Government of Bihar)

It was also recorded that 28% of the consultations were for refraction cases, while the remaining 72% were attributed to other cases (Refer to Figure 3). Refraction cases mainly fall into three subcategories: refractive errors, cataracts, and presbyopia. Over the years, approximately 55084

spectacles were provided to patients with refractive errors, and 19611 patients with cataracts were referred to higher facilities.

Figure 3: Refractive and Non Refractive OP Patients Distribution

Learnings and Way Forward

Vision centres established within Urban Primary Health facilities serve the urban population, with a specific focus on the elderly and marginalized groups. They play a crucial role in detecting refractive errors and other eye conditions early, which helps prevent avoidable blindness. Setting up a primary eye care unit faces challenges, but local solutions and phased implementation can help overcome them. This model of low-resource Vision centres has the potential to be replicated across Bihar and other resource-stressed areas in India and around the world.