Editorial

An infrastructure model for the implementation of VISION 2020: the Right to Sight

Blindness is a serious public health problem globally. Eighty percent of this problem is avoidable, i.e., either preventable or treatable; 90% of the problem manifests in the developing countries of the world. Over the past 30 years the magnitude of blindness has steadily increased, with southeast Asia carrying
the greatest burden (disproportionate to the size of its population), followed by the western Pacific region, sub-Saharan Africa, Europe, and the eastern Mediterranean and Latin American regions. The risk of blindness increases significantly with poverty and older age and in women.

In light of these observations, all the major groups and organizations involved in the prevention of blindness around the world realized that a major shift was warranted in the strategies to control blindness. This led to the development of the Global Initiative for the Elimination of Avoidable Blindness, which was given the name “VISION 2020: the Right to Sight.” This is a joint program of the World Health Organization, which represents the governments of the world, and the International Agency for the Prevention of Blindness, which represents the international nongovernmental development organizations, professional organizations, institutions and the corporate sector. The goal of this initiative is to control blindness and to reverse the present trend of increasing global blindness. The three strategic components of this program are effective disease control aimed at controlling the major causes of blindness, human resource development, and development of infrastructure and appropriate technology. The three components must be developed in parallel to ensure the success of this program.

One of the major limiting factors in the combat against blindness in the developing countries is the lack of appropriate infrastructure for delivery of eye care. The proposed model envisages delivery of comprehensive eye care at all levels, namely, primary, secondary, tertiary and advanced tertiary, through a pyramidal structure.

At the base of the pyramid are vision centres, which are intended to deliver primary eye care to a population unit of 50 000. The functions at this level include screening of the communities to detect potentially blinding diseases, refraction and dispensing services, linkage with all community services and appropriate referrals, both horizontally and vertically. The problems that can be handled effectively at this level (in collaboration with other local primary health care organizations) are refractive errors, vitamin A deficiency, trachoma and onchocerciasis. Based on our experience, the initial capital investment required to set up such a centre is around US$10 000 (20¢ per person). The staff required is a vision technician, a high school graduate who has undergone a year of special training.

At the next level are service centres, whose main purpose is to provide predominantly secondary-level eye care, including comprehensive diagnostic evaluation, cataract surgical services, other minor surgical procedures, low-vision services, community-based rehabilitation and an eye donation centre, for a population unit of 500 000. The initial investment for such a centre in the developing countries is US$100 000 (20¢ per person). The staff required includes one or two ophthalmologists supported by a team of 25 to 30 people to
cover medical, administrative and other support services. These centres may be district hospitals in the government sector, rural hospitals run by nongovernmental organizations or private hospitals. The idea is to integrate all sectors of eye care delivery to bring about a good public–private partnership for better coordination and more optimal use of available resources.

At the third tier in the pyramid are the training centres, one for each unit of 5 million people. The main functions at this level include secondary and basic tertiary eye care, good-quality residency training, training of all other ophthalmic personnel, lowvision and rehabilitation services, and appropriate
clinical research. Essentially at this level the problems of cataract, glaucoma, diabetic retinopathy and corneal scar can be handled along with difficult cataracts and refractive errors. The dominant activity should be training of eye care personnel. The initial investment for the creation of such a centre is around US$1 million (20¢ per person). This tertiary level could develop on the existing base of departments of ophthalmology in medical schools and teaching hospitals as well as tertiary care hospitals in the voluntary and private sectors.

At the apex of the pyramid are centres of excellence, one for every 50 million people, with the functions of advanced tertiary care and new methods of
treatment, training of trainers, appropriate clinical, laboratory, public health and operations research, advanced management training, low-vision rehabilitation
and product development. In all these areas, service delivery, training and research will be emphasized. The total cost of each of these units is around
US$10 million (20¢ per person). The centre of excellence will be staffed by the complete complement of eye care personnel to cover the entire gamut of functions, both medical and nonmedical.

The total initial investment in setting up this pyramidal infrastructure is only 80¢ per person. With an additional cost of about 20¢ per person for the training needed to make this infrastructure functional, the total cost per person is just around US$1. In most parts of the world, a sizeable portion of the required
infrastructure already exists, and all that is required now is upgrading of these facilities. The main additions will be in terms of focused training and upgrading
the facilities.

All the various centres of excellence can then contribute to the development of national and regional programs where common functions, such as program planning, resource mobilization, development of curriculum for various training programs, distribution of education materials, development of systems and
identification of appropriate research areas, can be tackled. This will eliminate unnecessary duplication and help avoid wasteful expenditure.

It is possible to create this model in most developing countries with appropriate local modifications. This then will provide the necessary framework for the creation of a sustainable eye care delivery system beyond the year 2020 so that everyone in the world has that fundamental Right to Sight.

Gullapalli N. Rao, MD
L.V. Prasad Eye Institute
Hyderabad, India

Dr. Rao is President-elect of the International Agency for the Prevention of Blindness. He will be in Canada the first 2 weeks of November on a speaking tour organized by Operation Eyesight and sponsored by Shoppers Optical.
Ophthalmologists are invited to meet him at one of five evening receptions in these cities: Vancouver, Calgary, Winnipeg, Toronto and Ottawa. He will also be speaking in Montreal on Nov. 12, at a noon-hour public luncheon at the Novotel Montreal Centre Hotel. For event information please visit www.operationeyesight.ca or call (800) 585-8265.

This editorial was previously published in the Saudi Journal of Ophthalmology (2004;18[Special Issue]:3–4) and is reprinted with permission from the Saudi
Ophthalmological Society.