March 01, 2002
8 min read
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India’s government tackles challenges of eye care

The government has closed inefficient eye camps, waived equipment taxes and created programs to relieve the backlog of surgeries.

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In India, a country of 1.27 billion people, nearly 15 million are blind, mostly due to cataract, one of the most easily treatable causes of blindness and low vision.

In the early 1970s, a number of nongovernmental organizations (NGOs), along with the private sector, began aggressively spreading awareness on the prevention and treatment of blindness throughout underdeveloped nations. At that time, India led these countries with the largest number of people who are blind, and it still does today. With 16% of the world’s population, India accounts for nearly 25% of worldwide blindness.

In 1999, the World Health Organization (WHO) teamed up with the International Agency for the Prevention of Blindness (IAPB) to launch Vision 2020: The Right to Sight campaign, with the mission to stamp out world blindness by 2020. WHO estimates that by 2020 the number of blind and visually impaired people will soar to approximately 180 million, twice its current level. With India contributing disproportionately to this figure, it is estimated that in 20 years India will have nearly 30 million people who are blind unless more aggressive measures are taken.

With numerous international agencies supplying money, resources and manpower to India, many are left to wonder, “What is the Indian government doing to help its blind people?” The answer is, quite a bit.

A plan of action

“Recognition of the magnitude of blindness has really dawned on people in recent times. India is taking a major initiative to look at its problems and address them in a serious way,” said Gullapalli N. Rao, MD, director of the L.V. Prasad Eye Institute in Hyderabad.

With the help of The World Bank, the Indian National Program for the Control of Blindness (NPCB) launched the Cataract Blindness Control Project (CBCP) in 1994. The government of India joined with the state governments of Uttar Pradesh, Madhya Pradesh, Andhra Pradesh, Rajasthan, Maharashtra, Tamil Nadu and Orissa to upgrade the quality of cataract surgery and expand coverage of blindness prevention, education and treatment in tribal and isolated areas.

The CBCP was projected to last for 7 years, but an evolving system of reform is progressing, according to Dr. Rao.

“In the last 7 years, since the CBCP project began, we have tripled the rate of cataract surgeries being done yearly. This is a remarkable feat by any standard,” he said.

“We are working around the clock to solve the problems of our people,” said Amar Agarwal, MS, FRCS, FRCOphth(Lon), of Dr. Agarwal’s Eye Hospital in Chennai, Bangalore and Dubai. At Dr. Agarwal’s hospitals, and in all government hospitals, cataract surgery is performed day and night.

“We work six-and-a-half days a week at my center. A high-volume surgeon will perform about 200 to 250 surgeries per week. It’s a lot, but we have no choice,” Dr. Agarwal said.

To reach the most poor areas, all government hospitals and some privately owned centers send ambulances to rural villages and small towns daily. There the needy are examined and brought back to the hospital to receive free treatment.

In India, the government provides free health care to the public, but many are too poor even to pay for bus fare to travel to the hospitals, Dr. Agarwal said. This is why transportation is provided.

“Insurance companies are now entering into the health care industry. I expect the health care industry to start booming in the next 5 years,” he said.

Dr. Agarwal plans to expand his hospitals into other cities. There, too, the poor will be provided for. In addition to free surgery, patients are given food and clothing before they are returned to their villages a few days later.

No more camps

Today 90% of surgeries are performed in the hospitals as opposed to eye camps, which are now a thing of the past, Dr. Rao said.

“Eye camps are being cut short now. It’s more about bringing the patients to the hospital, operating on them and then returning them after recovery,” said H. K. Tewari, MD, general secretary of the All India Ophthalmic Society.

“There is a government mandate that prohibits surgery in makeshift facilities,” Dr. Rao said. He said this change has occurred in the past 2 years.

Performing surgery in hospitals and centers rather than makeshift facilities in rural areas decreases the chance for complications and sterilization problems and increases the quality of care, according to Dr. Agarwal.

“Our past experience shows that the outcome of surgery in these camps has been very poor,” Dr. Rao said.

“The advantage now is that you’re giving high-quality treatment to the patient at an affordable cost or at no cost. We do phaco with IOL implantation for these people, as well as LASIK,” Dr. Agarwal said.

Dr. Rao said uncorrected refractive errors account for 16% of all blindness in the country. LASIK is performed in a number of government centers, free of charge, for the needy. For cultural reasons as well, Dr. Agarwal performs LASIK for young people.

“In my country, some people think that a girl is not fit for marriage if she has a high error of –10 D and wears glasses,” he said.

Access to high technology

As part of the CBCP, in the early 1990s the Indian government began waiving all custom taxes on sight-saving equipment. According to those interviewed for this article, the law had a tremendous affect on ophthalmology.

“We have improved as far as technology is concerned. We do photodynamic therapy, transpupillary thermotherapy, LASIK, vitreoretinal surgery, use multifocal IOLs — everything available in the Western world,” Dr. Tewari said.

“There has been a great positive influence on the quality of health care in India because of this law,” Dr. Rao said.

“Before this regulation, I had to pay 100% to 200% duty to the government on an instrument,” Dr. Agarwal said. “In a country that has economic problems, this just killed us. You can imagine the cost for a $20,000 machine.”

Today in India, any ophthalmologist — even in a small town — can order a piece of machinery duty-free, he said.

Even with the government mandate of duty-free equipment, there is still a limitation because of economics.

“Some microsurgical procedures are implemented, the use of slit lamps adapted, but most of the machinery you see in small towns is low-cost equipment supplied by local Indian manufacturers,” Dr. Rao said.

“The real high-cost technology is confined to the big centers or urban practices,” he added.

India is divided into a large middle class and an even larger low-income — or no-income — class.

“In our country, we just have the ‘haves’ and the ‘have-nots’,” Dr. Agarwal said. The wealthy people in the cities pay top dollar for the latest foldable lenses, sophisticated equipment and high-quality care.

“This is why the cities are booming. We even have clients from neighboring countries who come to receive care in our big centers,” he added. Unfortunately, the rural areas lack the funds, support and wealthy client base.

Depressed development

Poor infrastructure and a lack of education for students and trained surgeons also contributes to poor eye care in depressed areas.

“The major cities are flourishing with new technology, resources, money and aid from the government and NGOs,” Dr. Rao said. The rural areas, too far from the cities by bus, need more attention.

India is ranked 115th in the Index of Human Development among the 162 depressed countries of the world, according to a 2001 report from the United Nations Development Program. The country is working to address infrastructure problems, especially in the areas of health and education, to improve the status of human development, the report said.

The Blindness Control Project, administered by the government’s Ministry of Health and Family Welfare, has been set up to assist human development matters not addressed by the NPCB.

“We now have the equipment, the supplies are relatively inexpensive, and there is no research required to solve our medical problems. What we do need is well-trained manpower and infrastructure,” Dr. Rao said.

Infrastructure and manpower lacking

In a country of over 1 billion people, there should be at least one ophthalmologist for every 20,000 people, according to WHO. India has only an estimated 10,000 surgeons. The same is true with optometrists; 20,000 are needed, but there are only 2,000 available to practice.

“For the number of surgeons we have, it works out to be between 80,000 to 100,000 people per doctor,” Dr. Rao said.

“There are only about 4,000 ophthalmic assistants in India. In other surgical and administrative personnel we fall short of the required number,” Dr. Rao said. Ideally, a ratio of five assistants to one doctor would be necessary for proper management, but there is not even a one-to-one ratio in rural areas or the cities.

“Once we get the paramedical support, we will be much more efficient. A medical team would relieve the surgeon of extraneous tasks, so he or she can concentrate on the medical and surgical aspects of eye care,” he added.

Training and education

Free or low-cost education programs have been set up by many NGOs to train ophthalmic assistants and paramedical workers. Also, the government offers a degree in ophthalmology to train doctors in 3 years, so they can be sent to depressed areas in a minimal amount of time.

The Diplomatic National Board (DipNB) program offers 3 years of hands-on training in a government hospital. At the end of the course, a student takes a government certification exam and becomes a recognized ophthalmologist once the test is passed.

“My hospital takes four DipNB students a year. They are trained on high-tech machinery, learning from top surgeons in the field,” Dr. Agarwal said. “It’s quite a big advantage for the country to get a larger amount of ophthalmologists graduating every year.”

In addition to the DipNB program, students may get a traditional degree in medicine from a private or government medical college, and then specialize in ophthalmology. The standard program takes 8 years, Dr. Agarwal said. Dr. Tewari added that the government subsidizes continued education for those who cannot afford it.

“We get many fellows from Nepal, Pakistan, Afghanistan and surrounding countries who come to our universities to learn about specialties in corneal, cataract, refractive, retinal surgery,” Dr. Tewari said.

However, some feel the educational programs still need improvement.

“At the moment, most of the residency training is of sub-optimum quality. We have to correct that,” Dr. Rao said.

By enforcing a nationwide curriculum that would be standard for all universities, Dr. Rao believes the education situation could be vastly improved. Currently, he and his colleagues are developing a curriculum that would enable all doctors to be equally trained in the basics.

“It’s difficult, because you have to change the mindset of teachers, instructors and practicing doctors,” he said. In addition to new doctors, Dr. Rao and colleagues are working on refining and enhancing the skills of certified ophthalmologists.

Programs sponsored by the All Indian Ophthalmic Society and the Intraocular Implant and Refractive Society of India provide workshops, often monthly, to help keep surgeons up to date. Live surgeries are performed and often telecast to other parts of the world so doctors can learn and communicate with other surgeons.

“The issue is not only a few surgeons becoming high-tech, but all the surgeons who must become high-tech,” Dr. Agarwal said.

“Once we teach our doctors how to tackle the difficult problem of backlog cataract and refractive errors, then they can address the regional diseases, like glaucoma, corneal opacity, age-related macular degeneration and trachoma,” Dr. Rao said. He added that 35% of blindness in India is due to these conditions.

“In the last 7 years, there have been a lot of positive changes, but we are still battling some old problems. What we’ve done, and continue to do, has definitely made a change in the right direction,” he said.

For Your Information
  • Gullapalli N. Rao, MD, can be reached at the L.V. Prasad Eye Institute, L.V. Prasad Marg, Banjara Hills, Hyderabad 500 034, India; +(91) 40-354-8098 / 354-8267; fax: +(91) 40-354-8271; e-mail: gnrao@lvpeye.stph.net.
  • Amar Agarwal, MS, FRCS, FRCOphth(Lon), can be reached at Dr. Agarwal’s Eye Hospital, 19 Cathedral Road, Chennai-600086, India; +(91) 44-811-6233; fax: +(91) 44-811-5871; e-mail: dragarwal@vsnl.com.
  • H. K. Tewari, MD, can be reached at the Dr. R.P. Centre For Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India, +(91) 68-648-5158; fax: +(91) 116-852-919; e-mail: hktewari1@yahoo.com.