Access to eye care, uptake of services are issues in India

Debate over the incidence of blindness has been raised. Available eye services are underused by potential recipients.

Global Notebook India is one of the most densely inhabited countries of the world, with an estimated population of 1 billion in an area about one-third the size of China. Despite its huge middle class, India also has one of the largest populations of poor people. Millions are blind, mainly from untreated cataracts. The high incidence of cataract blindness is partially attributable to the lack of access to quality care in rural areas and, a recent study has shown, also is partially attributable to the unwillingness of prospective patients to take advantage of available care.

For India’s poor, the government provides free health care. But most government-run health facilities are located in major metropolitan areas, with few hospitals to serve rural areas. But even when services are available in rural areas, the study shows, there is a high proportion of people with eye problems who could benefit from treatment who do not seek it out. Others do not accept recommendations that they undergo treatment.

In a country as vast as India, one would expect to find contradictory ideas about how eye health care should be handled. While ophthalmologists interviewed for this article agreed that there are problems with government-sponsored health and eye care, they said they are hopeful and see signs of improvement. Government efforts to increase the volume of cataract surgery, while well-intentioned, may be misdirected, some said. One study suggests that the incidence of cataract blindness may not be as high as previously thought.

Levels of care

“The health care system is the government’s lowest priority,” Gullapalli N. Rao, MD, of the L.V. Prasad Eye Institute in Hyderabad, told Ocular Surgery News. “Only about 2% to 2.5% [of the budget] is spent on health care.” Dr. Rao said there is little private insurance and no managed care yet in the country.

Still, there is reason to be optimistic, said Dr. Rao, who lived in the United States and has been back living in India for the past 13 years. There has been some change. “I have seen a major shift and a lot of changes in eye care in the past 13 years and it is going to get better,” Dr. Rao said. “We have a long way to go, but I think we seem to be getting on the right track.”

photograph

“There is still a lot of disparity between the rich and the poor and between the urban and rural areas of India,” Abhay R. Vasavada, MBBS, MD, of the Iladevi Cataract and Intraocular Lens Research Centre in Ahmedabad, told Ocular Surgery News. “There is no uniformity in this country, and the medical system here can be best described as a polarized system.”

Dr. Vasavada said a small minority of the population in India receives the best treatment, while the average person struggles to receive average medical care.

The government is the dominant dispenser of medical care. But the caliber and the style of that care “leave a lot to be desired,” according to Dr. Vasavada. It is those with no money who end up in the state-run hospitals and care systems. Those who have some money prefer to go to private sector facilities. Dr. Vasavada ranked the levels of care from best to worst, starting with private health care, followed by non-governmental semi-charitable institutes, followed by government-run health care facilities.

Ravi Thomas, MD, a professor of ophthalmology at the Christian Medical College, Vellore, Tamil Nadu, notes that in theory every citizen in the country is entitled to free care. In practice, unfortunately, the health care system in India is overburdened and does not work as well as it should, he said. Staffing of government-run facilities in remote areas is poor, while pharmaceuticals and some medical instruments are just not on hand.

Dr. Thomas said he believes that government funding could be better utilized. For example, even when instrumentation is provided to hospitals, he said, necessary maintenance and repair are neglected.

“The quality of care in many instances is far superior in the private sector,” Dr. Thomas told Ocular Surgery News. “Having said that, the government is trying to improve their services.” Dr. Thomas said a World Bank-funded cataract project currently under way is one attempt at improvement. Dr. Thomas went on to say that there are some government health institutions that are as good as private sector facilities. But the problem is that these institutions are located in major cities. It is the remote areas of the country that lack adequate government-supported care, he said.

Causes of blindness

One of the country’s objectives is to reduce the incidence of blindness. Nearly 12 million people in India are blind. Estimates say 80% of the blindness would be avoidable if adequate care were available. Untreated cataract accounts for 40% to 80% of all cases of blindness in India. Most people with untreated cataracts live in rural areas with limited access to modern health care. Injury has been identified as a major cause of cataract in addition to old age and poor nutrition.

Other causes of blindness include uncorrected refractive errors, glaucoma, corneal opacity, trachoma, vitamin A deficiency, diabetic retinopathy and age-related macular degeneration (AMD). Blindness is more prevalent in women than in men. And blindness, of course, is more prevalent among the poorest segments of India’s society.

More does not mean better

In India, there are an estimated 9,000 to 10,000 ophthalmologists, a ratio of one ophthalmologist to 100,000 population. This is well below the World Health Organization’s recommended ratio of 1 ophthalmologist per 20,000 population, a serious shortage of manpower.

To help overcome this personnel shortfall, India’s government has undertaken projects dedicated to the eradication of blindness. To attempt to reduce the backlog of untreated cataract, the government has set up a program in which 500 nonstop hours of cataract surgery are to be performed at selected centers across the country. In these centers, teams of ophthalmologists continue operating for 500 hours at a time in shifts.

But one concern is that in this effort to meet targets set by the government, “the quality of this surgery is mediocre,” Dr. Vasavada said. “It is not comparable to those surgeries performed in private hospitals or nothing compared to the modern techniques of phacoemulsification.”

According to Dr. Rao, the government became so focused on doing more and more cataract surgery procedures that the quality of those surgeries was lost. “They are concentrating on numbers and that has created a lot of problems,” Dr. Rao said. “In recent years, India’s government got a major loan from the World Bank for cataract surgery. That did increase the amount of cataract surgery, which has almost doubled over the last 4 or 5 years.”

Additionally, about 200,000 IOLs have been provided by the government, free of cost, to district and town hospitals. This is in an attempt to shift all cataract surgery to microsurgical techniques with IOL implantation, according to Dr. Rao. Additionally, there is a major effort to bring surgeries performed at eye camps into hospital-based facilities.

The goal of cataract surgery is restoration of sight. “Unfortunately, somewhere along the line, this goal seems to have been substituted by the act of inserting an IOL,” Dr. Thomas said. “We seem to have reached a stage where if an IOL is inserted, irrespective of the resultant eyesight, that person is considered ‘cured.’ The person may remain blind, but as long as an IOL has been inserted, the statistics reflect one less blind Indian.”

A study by researchers from the Liverpool School of Tropical Medicine backs up Dr. Thomas’ assertion. The study, published in The Lancet, says that India’s government-run mobile cataract camps, set up by the National Blindness Control Program, fare badly compared with cataract hospitals run by grass roots groups and state medical facilities. Almost one-half of eye camp patients interviewed were unhappy with their results, with 36% blind in the operated eye. In two-thirds of the blind eyes, poor quality surgery was to blame, and postoperative care was faulted in another 16%.

According to the researchers, patient satisfaction was much higher after treatment at a local non-governmental organization hospital, where patients were brought in from satellite clinics, and at a walk-in state medical college hospital.

Overestimation?

A study by Dr. Thomas and J. Muliyil, MD, DrPH, in which they recalculated the incidence of cataract and cataract blindness, suggests that the incidence of cataract usually cited may be overestimated by about 60%. Their study suggests that some diagnostic tests used in previous surveys may have distorted the projected figures. This has implications for addressing the backlog of cataracts. Dr. Thomas and Dr. Muliyil’s study recalculated the projections after adjusting for the sensitivity and specificity of distant direct ophthalmoscopy.

Previous studies estimated an annual incidence of about 3.8 million cataracts and more than 9 million total cataract blind in India. These studies were based on data obtained from surveys using distant direct ophthalmoscopy with an undilated pupil for the detection of cataracts. These earlier studies also implied that about 1.8 million sight-restoring surgeries were performed per year. According to Drs. Thomas and Muliyil, assuming that the average life expectancy is 7.5 years after cataract blindness, in India there should be a backlog of about 15 million people blind from cataract. If life expectancy is 10 years after cataract blindness, the backlog should be about 20 million.

According to Dr. Thomas and Dr. Muliyil, a recent survey has shown that the backlog of blind people in India is 12 million, of which 80% is due to cataracts. This leaves a discrepancy of 5 to 10 million; therefore, they argue, an overestimation in the incidence of cataract is evident. Drs. Thomas and Muliyil also point out that in the area where the previous studies were conducted, the prevalence of trachoma and other conditions causing corneal opacities was probably high and would further decrease the specificity of screening tests. The method of distant direct ophthalmoscopy has good interobserver reliability, but reliability does not reflect test accuracy, Drs. Thomas and Muliyil said.

Drs. Thomas and Muliyil said that if the incidence is lower than previously believed, then the goal of eliminating the backlog might be achievable. Another ramification of their study is that if the incidence is less, perhaps the distribution of funding might be proportionately decreased. Drs. Thomas and Muliyil argue for using the allocated resources for delivery of quality eye care with a minimum of iatrogenic blindness.

Low utilization of services

According to a study by A.E. Fletcher, PhD, et al in rural areas of India, even when eye care services were made available, potential patients underused them.

The study by Fletcher et al was set up to investigate service uptake in rural Indian populations served by outreach eye camps and to identify barriers to uptake. The study analyzed 749 adults, representing 13% of all households and 4% of all adults who were identified by their community as having eye problems. Only 6.8%, or 51, of these adults attended the eye camp. Of those, 13 accepted treatment, 12 did not and 26 had trivial eye problems for which no significant treatment was recommended.

Fear was the reason most commonly given for not taking advantage of free eye care. Fears ranged from a common belief that treatment would damage a patient’s eyes to the fear of death in some patients. Others expressed fear of surgery, even those whose eye problems did not require surgery. Another cause for non-use of eye care services was word-of-mouth from community members who had previously had poor outcomes from treatment.

For about one-quarter of those studied, not attending the eye camps was related to treatment costs. Other barriers included the time and expense involved in leaving day-to-day responsibilities. Some with eye problems said they did not need treatment or thought they could cope without treatment.

Men were twice as likely as women to attend the eye camps. Nonetheless, attendance rates in men represented only 10% of those found to have eye problems.

According to the study, living in a village with direct transportation to the camp, living nearer to the eye camp and being from a village with one or more people with poorly surgically treated vision affected eye camp attendance. Being male and distance to the camp were significant attendance predictors. Age, literacy, publicity, presence of people with good postop outcomes within a village and economic status showed no correlation with attendance.

For Your Information:
  • Gullapalli N. Rao, MD, can be reached at the L.V. Prasad Eye Institute, Road No. 2 Banjara Hills, Hyderabad, India 500034; +(91) 40-248-098; fax: +(91) 40-248-271; e-mail: gnrao@lvpeye.stph.net.
  • Ravi Thomas, MD, can be reached at Schell Eye Hospital, Christian Medical College, Arni Road, Vellore, Tamil Nadu, India 632001; +(91) 416-232-921; fax: +(91) 416-232-035; e-mail: ravi@cmcvellore.ac.in.
  • Abhay R. Vasavada, MBBS, MD, can be reached at Iladevi Cataract & Intraocular Lens Research Centre, Gurukul Road, Memnagar, Ahmedabad, India 380052; +(91) 272-745-3303; fax: +(91) 272-741-1200. None of the doctors has a direct financial interest in any products mentioned in this article, nor are they paid consultants for any companies mentioned.
References:
  • Fletcher A. E., et al. Arch Ophthalmol. 1999;117:1393-1399.
  • Thomas R., Muliyil J.P. Natl Med J India. 1998;4:182-184.

Global Notebook India is one of the most densely inhabited countries of the world, with an estimated population of 1 billion in an area about one-third the size of China. Despite its huge middle class, India also has one of the largest populations of poor people. Millions are blind, mainly from untreated cataracts. The high incidence of cataract blindness is partially attributable to the lack of access to quality care in rural areas and, a recent study has shown, also is partially attributable to the unwillingness of prospective patients to take advantage of available care.

For India’s poor, the government provides free health care. But most government-run health facilities are located in major metropolitan areas, with few hospitals to serve rural areas. But even when services are available in rural areas, the study shows, there is a high proportion of people with eye problems who could benefit from treatment who do not seek it out. Others do not accept recommendations that they undergo treatment.

In a country as vast as India, one would expect to find contradictory ideas about how eye health care should be handled. While ophthalmologists interviewed for this article agreed that there are problems with government-sponsored health and eye care, they said they are hopeful and see signs of improvement. Government efforts to increase the volume of cataract surgery, while well-intentioned, may be misdirected, some said. One study suggests that the incidence of cataract blindness may not be as high as previously thought.

Levels of care

“The health care system is the government’s lowest priority,” Gullapalli N. Rao, MD, of the L.V. Prasad Eye Institute in Hyderabad, told Ocular Surgery News. “Only about 2% to 2.5% [of the budget] is spent on health care.” Dr. Rao said there is little private insurance and no managed care yet in the country.

Still, there is reason to be optimistic, said Dr. Rao, who lived in the United States and has been back living in India for the past 13 years. There has been some change. “I have seen a major shift and a lot of changes in eye care in the past 13 years and it is going to get better,” Dr. Rao said. “We have a long way to go, but I think we seem to be getting on the right track.”

photograph

“There is still a lot of disparity between the rich and the poor and between the urban and rural areas of India,” Abhay R. Vasavada, MBBS, MD, of the Iladevi Cataract and Intraocular Lens Research Centre in Ahmedabad, told Ocular Surgery News. “There is no uniformity in this country, and the medical system here can be best described as a polarized system.”

Dr. Vasavada said a small minority of the population in India receives the best treatment, while the average person struggles to receive average medical care.

The government is the dominant dispenser of medical care. But the caliber and the style of that care “leave a lot to be desired,” according to Dr. Vasavada. It is those with no money who end up in the state-run hospitals and care systems. Those who have some money prefer to go to private sector facilities. Dr. Vasavada ranked the levels of care from best to worst, starting with private health care, followed by non-governmental semi-charitable institutes, followed by government-run health care facilities.

Ravi Thomas, MD, a professor of ophthalmology at the Christian Medical College, Vellore, Tamil Nadu, notes that in theory every citizen in the country is entitled to free care. In practice, unfortunately, the health care system in India is overburdened and does not work as well as it should, he said. Staffing of government-run facilities in remote areas is poor, while pharmaceuticals and some medical instruments are just not on hand.

Dr. Thomas said he believes that government funding could be better utilized. For example, even when instrumentation is provided to hospitals, he said, necessary maintenance and repair are neglected.

“The quality of care in many instances is far superior in the private sector,” Dr. Thomas told Ocular Surgery News. “Having said that, the government is trying to improve their services.” Dr. Thomas said a World Bank-funded cataract project currently under way is one attempt at improvement. Dr. Thomas went on to say that there are some government health institutions that are as good as private sector facilities. But the problem is that these institutions are located in major cities. It is the remote areas of the country that lack adequate government-supported care, he said.

Causes of blindness

One of the country’s objectives is to reduce the incidence of blindness. Nearly 12 million people in India are blind. Estimates say 80% of the blindness would be avoidable if adequate care were available. Untreated cataract accounts for 40% to 80% of all cases of blindness in India. Most people with untreated cataracts live in rural areas with limited access to modern health care. Injury has been identified as a major cause of cataract in addition to old age and poor nutrition.

Other causes of blindness include uncorrected refractive errors, glaucoma, corneal opacity, trachoma, vitamin A deficiency, diabetic retinopathy and age-related macular degeneration (AMD). Blindness is more prevalent in women than in men. And blindness, of course, is more prevalent among the poorest segments of India’s society.

More does not mean better

In India, there are an estimated 9,000 to 10,000 ophthalmologists, a ratio of one ophthalmologist to 100,000 population. This is well below the World Health Organization’s recommended ratio of 1 ophthalmologist per 20,000 population, a serious shortage of manpower.

To help overcome this personnel shortfall, India’s government has undertaken projects dedicated to the eradication of blindness. To attempt to reduce the backlog of untreated cataract, the government has set up a program in which 500 nonstop hours of cataract surgery are to be performed at selected centers across the country. In these centers, teams of ophthalmologists continue operating for 500 hours at a time in shifts.

But one concern is that in this effort to meet targets set by the government, “the quality of this surgery is mediocre,” Dr. Vasavada said. “It is not comparable to those surgeries performed in private hospitals or nothing compared to the modern techniques of phacoemulsification.”

According to Dr. Rao, the government became so focused on doing more and more cataract surgery procedures that the quality of those surgeries was lost. “They are concentrating on numbers and that has created a lot of problems,” Dr. Rao said. “In recent years, India’s government got a major loan from the World Bank for cataract surgery. That did increase the amount of cataract surgery, which has almost doubled over the last 4 or 5 years.”

Additionally, about 200,000 IOLs have been provided by the government, free of cost, to district and town hospitals. This is in an attempt to shift all cataract surgery to microsurgical techniques with IOL implantation, according to Dr. Rao. Additionally, there is a major effort to bring surgeries performed at eye camps into hospital-based facilities.

The goal of cataract surgery is restoration of sight. “Unfortunately, somewhere along the line, this goal seems to have been substituted by the act of inserting an IOL,” Dr. Thomas said. “We seem to have reached a stage where if an IOL is inserted, irrespective of the resultant eyesight, that person is considered ‘cured.’ The person may remain blind, but as long as an IOL has been inserted, the statistics reflect one less blind Indian.”

A study by researchers from the Liverpool School of Tropical Medicine backs up Dr. Thomas’ assertion. The study, published in The Lancet, says that India’s government-run mobile cataract camps, set up by the National Blindness Control Program, fare badly compared with cataract hospitals run by grass roots groups and state medical facilities. Almost one-half of eye camp patients interviewed were unhappy with their results, with 36% blind in the operated eye. In two-thirds of the blind eyes, poor quality surgery was to blame, and postoperative care was faulted in another 16%.

According to the researchers, patient satisfaction was much higher after treatment at a local non-governmental organization hospital, where patients were brought in from satellite clinics, and at a walk-in state medical college hospital.

Overestimation?

A study by Dr. Thomas and J. Muliyil, MD, DrPH, in which they recalculated the incidence of cataract and cataract blindness, suggests that the incidence of cataract usually cited may be overestimated by about 60%. Their study suggests that some diagnostic tests used in previous surveys may have distorted the projected figures. This has implications for addressing the backlog of cataracts. Dr. Thomas and Dr. Muliyil’s study recalculated the projections after adjusting for the sensitivity and specificity of distant direct ophthalmoscopy.

Previous studies estimated an annual incidence of about 3.8 million cataracts and more than 9 million total cataract blind in India. These studies were based on data obtained from surveys using distant direct ophthalmoscopy with an undilated pupil for the detection of cataracts. These earlier studies also implied that about 1.8 million sight-restoring surgeries were performed per year. According to Drs. Thomas and Muliyil, assuming that the average life expectancy is 7.5 years after cataract blindness, in India there should be a backlog of about 15 million people blind from cataract. If life expectancy is 10 years after cataract blindness, the backlog should be about 20 million.

According to Dr. Thomas and Dr. Muliyil, a recent survey has shown that the backlog of blind people in India is 12 million, of which 80% is due to cataracts. This leaves a discrepancy of 5 to 10 million; therefore, they argue, an overestimation in the incidence of cataract is evident. Drs. Thomas and Muliyil also point out that in the area where the previous studies were conducted, the prevalence of trachoma and other conditions causing corneal opacities was probably high and would further decrease the specificity of screening tests. The method of distant direct ophthalmoscopy has good interobserver reliability, but reliability does not reflect test accuracy, Drs. Thomas and Muliyil said.

Drs. Thomas and Muliyil said that if the incidence is lower than previously believed, then the goal of eliminating the backlog might be achievable. Another ramification of their study is that if the incidence is less, perhaps the distribution of funding might be proportionately decreased. Drs. Thomas and Muliyil argue for using the allocated resources for delivery of quality eye care with a minimum of iatrogenic blindness.

Low utilization of services

According to a study by A.E. Fletcher, PhD, et al in rural areas of India, even when eye care services were made available, potential patients underused them.

The study by Fletcher et al was set up to investigate service uptake in rural Indian populations served by outreach eye camps and to identify barriers to uptake. The study analyzed 749 adults, representing 13% of all households and 4% of all adults who were identified by their community as having eye problems. Only 6.8%, or 51, of these adults attended the eye camp. Of those, 13 accepted treatment, 12 did not and 26 had trivial eye problems for which no significant treatment was recommended.

Fear was the reason most commonly given for not taking advantage of free eye care. Fears ranged from a common belief that treatment would damage a patient’s eyes to the fear of death in some patients. Others expressed fear of surgery, even those whose eye problems did not require surgery. Another cause for non-use of eye care services was word-of-mouth from community members who had previously had poor outcomes from treatment.

For about one-quarter of those studied, not attending the eye camps was related to treatment costs. Other barriers included the time and expense involved in leaving day-to-day responsibilities. Some with eye problems said they did not need treatment or thought they could cope without treatment.

Men were twice as likely as women to attend the eye camps. Nonetheless, attendance rates in men represented only 10% of those found to have eye problems.

According to the study, living in a village with direct transportation to the camp, living nearer to the eye camp and being from a village with one or more people with poorly surgically treated vision affected eye camp attendance. Being male and distance to the camp were significant attendance predictors. Age, literacy, publicity, presence of people with good postop outcomes within a village and economic status showed no correlation with attendance.

For Your Information:
  • Gullapalli N. Rao, MD, can be reached at the L.V. Prasad Eye Institute, Road No. 2 Banjara Hills, Hyderabad, India 500034; +(91) 40-248-098; fax: +(91) 40-248-271; e-mail: gnrao@lvpeye.stph.net.
  • Ravi Thomas, MD, can be reached at Schell Eye Hospital, Christian Medical College, Arni Road, Vellore, Tamil Nadu, India 632001; +(91) 416-232-921; fax: +(91) 416-232-035; e-mail: ravi@cmcvellore.ac.in.
  • Abhay R. Vasavada, MBBS, MD, can be reached at Iladevi Cataract & Intraocular Lens Research Centre, Gurukul Road, Memnagar, Ahmedabad, India 380052; +(91) 272-745-3303; fax: +(91) 272-741-1200. None of the doctors has a direct financial interest in any products mentioned in this article, nor are they paid consultants for any companies mentioned.
References:
  • Fletcher A. E., et al. Arch Ophthalmol. 1999;117:1393-1399.
  • Thomas R., Muliyil J.P. Natl Med J India. 1998;4:182-184.