In its 2010 estimate, the World Health Organization (WHO) reports that globally, 39 million people are blind and over 285 million people are visually impaired. However, in 2005, it was projected that without additional interventions, the number of blind individuals would have increased from 44 million in the year 2000 to 76 million in 2020. This trend reversal has been made possible by focused efforts of blindness prevention and cure. The coordinated efforts of service providers, supporting agencies and policy makers in several developing countries under the global initiative, VISION 2020: The Right to Sight has made this change possible. This demonstrates the potential inherent in bringing together the right group of people and organizations to enhance eye care services – done through the sustained alignment of the different stakeholders at every level.
Advocacy is a strategy that has the potential to significantly improve the way eye care is provided by influencing the involvement and behavior of key stakeholders. Identification of the right stakeholders or ‘advocates’ can create sustainable partnerships in the delivery of eye care and such advocates can contribute at different levels to advance eye care service delivery. Advocacy can be used to ensure:
- Better service delivery at the operational level.
- An enabling environment for effective service delivery to take place.
- That necessary resources are available for effective service delivery to take place.
This article explores how advocacy can be used to achieve these objectives – the stakeholders it reaches out to at every level, the focus of the advocacy strategy, and the mutually beneficial paradigm that contributes to a successful advocacy program. Since what really matters ultimately is the number of people getting served, we will begin by exploring the role of advocacy at the service delivery level.
Improving Service Delivery at the Operational Level
In order to ensure better service delivery at the operational level, one must draw the attention and commitment of those who can influence the effectiveness of the service delivered – and this begins with reaching out to those who need eye care.
Creating access: How advocacy can help you reach the patient
In most country settings a significant proportion of the population comes under some easily accessible formal structure.
- Close to a third of the population will be below 20 years and many of them could be reached through academic institutions.
- Focus of Advocacy: Access to this segment of the community can be facilitated by officials and policy makers in the education sector
- A significant proportion of those in the 20–60 years age group (about 50% population) would be working in industries or other organized sectors (farm estates, banks, etc.) which can become access points.
- Focus of Advocacy: Here again the policy makers in the economic and industrial community can facilitate access to the workforce for providing eye care.
Such existing community structures and segments can be leveraged to target awareness creation and outreach services. However, in order to reach them it is essential to enlist the support of those in authority within these structures.
Focus of Advocacy: This is best done by articulating how eye care services can directly impact, for example, the education of a child or the productivity of an employee in addition to overall quality of life. In advocating to policy makers in the community or in the government, it is thus important to recognize such areas of converging interest that makes it mutually beneficial to partner with an eye care service provider to facilitate eye examination of students and the workforce by giving necessary permissions or instructions as appropriate.
Creating acceptance: How advocacy can help uptake and compliance to services
Once we have access to the community, it is essential to gather their trust in order to ensure uptake of our services and compliance to the treatment advised. Often, this is best achieved when the eye care services are championed by someone from within the community. Community leaders and opinion makers are in direct contact with the community and can exercise significant influence on them. Eye care service providers should seek the support of elected community leaders, local industrialists, village elders, heads of service organizations such as Lions and Rotary Clubs as they can significantly impact activities such as community-based screening and eye care services.
Focus of Advocacy: Advocacy for this group needs to focus on the magnitude and impact of visual impairment and blindness; its causes, the treatment options, cost, and benefits. Once they have the overall appreciation of the problem of visual impairment and blindness as well as the benefits of addressing them they can be easily persuaded to support such work. This group would also directly benefit from eye care services, and often their interest and support can be sought when they approach as patients. They also have a direct interest in the community that they represent as their position of influence comes through acts of helping the community.
As an outcome one can expect that some of them will become proactive in promoting eye care and their support can be counted upon to mobilize resources including human resources and infrastructure for setting up periodic eye camps or permanent primary eye care facilities. They also can support the development of a community-based referral system and play a significant role in encouraging eye donations.
Creating a referral network: How advocacy can widen your circle
A significant range of eye conditions are not self-diagnosable by the patient. Moreover, apart from cataract and refractive error, many conditions are not amenable to community-based screening – either due to the low levels of prevalence or the specialized skills and technology required to screen for such conditions. These include conditions such as diabetic retinopathy and eye care needs in children. In these conditions timely, appropriate intervention is critical to retain or restore vision.
In almost all these situations the primary point of contact is often not an eye care professional but other health professionals. Hence their role in eye care becomes pivotal in addressing these conditions which now are priorities under VISION 2020–The Right to Sight initiative in many regions and countries. Without their involvement it is not possible to have cost-effective case finding and consequently eliminating avoidable blindness. This is also essential to deliver services such as low vision and blindness rehabilitation, which in many countries are still considered outside the scope of eye care services.
Here are a few examples of how networking with appropriate partners can ensure a targeted approach to reach patients by widening one's circle:
- Diabetic Retinopathy (DR): Diabetes is often diagnosed by the physician and care is provided by them or by other specially trained professionals such as diabetologists and endocrinologists. Most health professionals lack knowledge relating to ocular complications in diabetics and the treatment options. Thus the referral of diabetic patients for ocular examinations is poor.
- Focus of Advocacy: This knowledge and practice gap must be filled through advocacy. Here advocacy can take the form of structured education and sensitization of physicians, covering the magnitude and trends in diabetes, clinical manifestations of DR and treatment options. Today, equipment placed at these physician clinics enables remote diagnosis of DR. Training should be tailored for the different groups who are in regular contact with diabetics – physicians, health workers, pharmacy owners, and laboratory technicians. Such advocacy can increase referral and attendance of diabetics in eye clinics, lead to partnerships in community-based eye examinations of diabetics and facilitate health education to the diabetic community.
- Pediatric Eye Care: Children who have an eye problem are rarely brought directly to an ophthalmologist – because parents often fail to detect it. It is the pediatrician who generally has access to children. They would be in a position to first recognize any eye condition such as squint, congenital cataract, congenital glaucoma, and nystagmus. With the increasing proportion of institutional deliveries, it is the obstetrician who will first know that the baby was delivered prematurely and grossly underweight – leading risk factors for Retinopathy of Prematurity (RoP). Many of these conditions can be addressed with timely referral and intervention.
- Focus of Advocacy: Pediatricians, primary health workers, obstetricians, and mid-wives should be educated about the causes and clinical manifestations of pediatric eye conditions and their management, resulting eventually in a drop in childhood blindness.
- Corneal Infections: Field trials have shown that in instances of corneal abrasions, the immediate use of antibiotics and referral to an eye hospital has dramatically reduced the progression into ulceration and subsequent loss of vision. Today it is mostly farmers who get corneal abrasions, and who often turn to traditional healers or primary health physicians. The interventions of these healers can worsen the condition either due to wrong treatment or delays, sometimes leading to loss of vision.
- Focus of Advocacy: The advocacy should focus on education and awareness creation on etiology and progression of corneal infections and on what they can do at the primary level. This should significantly reduce the incidence of corneal blindness.
- Low Vision and Blindness Rehabilitation: Rehabilitation of the blind is not seen as an integral part of eye care and is often perceived as falling in the realm of the rehabilitation team. "Low Vision" has been a neglected field and is only now getting some attention following its inclusion within the disease priorities of VISION 2020. While these patients often have contact with the eye care professionals, they are usually not counseled for rehabilitation services. This is the change that needs to happen to ensure that these individuals are able to lead a near normal life and become productive members of the community.
- Focus of Advocacy: Here the advocacy has to be directed primarily at ophthalmologists and optometrists so that they refer such patients to appropriate Low Vision or Blindness Rehabilitation services.
Operational excellence through disseminating best practices: Advocating among peers
While advocating to key stakeholders such as community leaders and other healthcare professionals we can facilitate better penetration of eye care into the community. However, among service providers there is a huge variation in the quality of service provided. By sharing innovative ideas and gathering and disseminating supportive evidence, it is possible to help service providers adopt best practices.
Through consistent and sustained promotion of use of intraocular lens (IOLs) in cataract surgery by educating the surgeons about the vast improvement in quality of outcomes, along with appropriate training, there has been a dramatic increase from a mere 5% of surgeries done with IOL implants in 1995 to 75% in 2002 and is currently well over 95%.
Creating an Enabling Environment for Effective Service Delivery
Delivery of eye care services is directly dependent on several factors such as access to patients, availability of resources such as manpower, infrastructure, and supplies. This is often influenced by settings in the external environment. This has to be addressed by advocating to policy makers and this often requires dealing with those who are not directly associated with eye care.
It is important to study the barriers in the community that hinder patients from accessing care.
- Do physical barriers such as poor roads or public transportation make it difficult for patients to reach the hospital?
- In several countries, a strict bureaucratic system that dictates how patients should be referred for care may act as an artificial barrier that could discourage health-seeking behavior.
Focus of Advocacy: It is evident that these barriers can only be addressed by appealing to policy makers at higher levels of authority. If it is recognized that improvement of logistics is vital in order to make eye care services to reach the community, then one must appeal to the government authorities.
Eye care human resource
Sufficient numbers of persons with the appropriate skill sets are critical to deliver eye care effectively:
- Often, eye care services suffer where countries do not have the infrastructure to produce or attract eye care workers in the required numbers
- In some others, the quality of training is not adequate to deliver quality eye care services
- In still others, there is a gross disparity in the distribution of the manpower - most of them are concentrated in a few eye care institutions making the reach of their services limited.
Focus of Advocacy: It is essential to advocate for the institution of training programs that can produce competent eye care workers of all cadres. Sometimes it is essential to advocate for a certifying body that will ensure the quality of the training and the competence of the candidates it produces. Policies pertaining to distribution of health care services should be reviewed for equitable distribution.
Availability of eye care supplies
Critical to the delivery of eye care are medicines, surgical consumables and spectacles in addition to equipment and instruments required for examination and treatment. Government regulations, such as import duty on supplies, can sometimes increase the cost of care. Inability to procure supplies often stifles the delivery of care
Focus of advocacy: It is essential to advocate for the easing of taxation of critical supplies that are needed to offer eye care services at a large scale – where most of the patients may not be able to pay for the services. Alternatively, local entrepreneurs may be approached to consider indigenous production of supplies and equipment.
Mobilizing Necessary Resources for Effective Service Delivery to Take Place
Providing eye care in developing countries where income from patient revenues would not sufficiently cover the expenses of the service provider – especially the capital expenditure on equipment and infrastructure and in many cases for patient care as well. Where a majority of patients cannot pay for the services – especially for specialty eye care services – indicates that support for such services may have to be sought from external sources.
Besides providing monetary support for providing patient care, funders will have to be approached to support other essential activities such setting up and running training programs, research and dissemination. Such support, in the form of financial or other resources, can be garnered through advocacy.
Focus of advocacy: In such situations it is important to mobilise resources from external sources (other than the patient). WHO's 5 year Action Plan directs eye care providers to enlist the “political, financial and technical commitment” of the country. Besides governments, international funding agencies can be approached to support eye care services – especially those working for education, human resource development, and general health care. In addition, there are NGOs that work exclusively in eye care.
The Indian National Program for Control of Blindness (NPCB) successful cataract subsidy program is an example of how national commitment can be gathered through focused advocacy. This has helped to reduce the cataract burden in the country from 1.49% in 1986–1989 to 1.1% today. Last year, this program support stimulated an overall performance of over 6 million cataract surgeries across the country.
Another such example has been the Australian Government's allocation of over AUS $100 million for eye care in the year 2007. VISION 2020 Australia worked with its global partners to produce a comprehensive proposal to eliminate blindness and visual impairment in the Southeast Asia and Pacific region. The fierce competition between political parties during the run-up to the 2007 elections provided an opportunity for VISION 2020 Australia to secure more than AUS $100 million in funding for eye health and vision care.
Invest in evidence
We have seen, through the many examples, that the advocacy requires one to educate the advocate, sensitize them about the magnitude of the problem and the impact of the recommended intervention, including outcomes that are of benefit and interest to the advocate. This is best illustrated with evidence and through case studies that demonstrate the impact of the intervention. The demonstration of the loss of productivity due to visual impairment can influence the government to make a political commitment toward a national eye care program.
Whether at national program level or at a hospital level advocacy has been recognized as a key strategy for success. Advocacy efforts are generally not a one-time exercise. Rather it is an on-going process that ultimately aims at developing the identified advocates into long-term partners in the process. For this to happen the “Advocates” have to be eventually involved in the design of the health intervention activity.
Partnerships should also be forged with others like ourselves – beginning with those in one's own region. Such alliances can make for a more formidable force in advocacy rather than striving to do it on one's own.
Support arising out of advocacy efforts can sustain only when the “Advocate” groups see a benefit for them. The education officials see a reduction in school drop-outs; the diabetologists see a better compliance to follow-up and so on. Hence, advocacy cannot be manipulative where the design of the intervention or programs benefits not only the eye care provider; rather, it should be a “win-win” solution. It is the articulation of the benefits that are of interest to the advocate and this is what leads to successful advocacy.
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Source of Support: Nil
Conflict of Interest: None declared