Resources for eye care at secondary and tertiary level government institutions in Saudi Arabia.

PURPOSE: To evaluate the number of healthcare personnel and equipment resources for eye care at government institutions in different administrative zones of the Kingdom of Saudi Arabia (KSA) and to recommend measures for increasing resources to address deficiencies.
MATERIALS AND METHODS: Data on resources (personnel and equipment) for eye care were collected from all governmental eye units in 2012. The data was regrouped by zones and administrative areas. The mid-2012 population projections were used to calculate the ophthalmologist to population ratio and optometrist to population ratio. The equipment available for eye care was reviewed.
RESULTS: All 60 institutions in 13 administrative areas and five zones of KSA participated in this study. There were 407 ophthalmologists and 147 optometrists. The ophthalmologist to population ratio was 1:43,000 (1:12,900 in the northern zone to 1:80,300 in the western zone). By 2015, 700 ophthalmologists will be required, and by 2020, 1,100 ophthalmologists will be required. The optometrist to population ratio was 1:95,000 (1:34,100 in the northern zone to 1:146,700 in the western zone). Nearly 2,800 and 4,400 allied eye care personnel will be needed by 2015 and 2020. Diagnostic and treatment equipment such as lasers, electrophysiologic and ultrasound equipment, and fundus cameras were not available at all institutions.
CONCLUSIONS: Data from the private sector need to be included to draw conclusions on the human resource index for eye care in the Kingdom. An unequal distribution of resources in different zones and administrative areas requires attention. Better utilization of available resources is recommended before fulfilling the demand for additional resources.

INTRODUCTION

Saudi Arabia and other Gulf Cooperation Council (GCC) countries have endorsed their commitment to adopt the ‘VISION 2020’ initiative and prioritized its efforts to eliminate avoidable blindness. One of the recommendations of the global and regional ‘VISION 2020’ document is to undertake a situation analysis of eye healthcare and recommend effective allocation of resources.1 The 2012 population of the Kingdom of Saudi Arabia (KSA) was estimated at 27 million people (including 6 million non-Saudis). Females and children less than 15 years of age constitute 49 and 50% of the Saudi population, respectively. Saudi adults aged 40 years and older comprise of 14.5% of total population. KSA has a rapidly evolving robust economy in the last 3 decades. The gross domestic product (GDP) of the Kingdom was 15,836 US$ per capita in 2011.2 The Kingdom spends 4% of its GDP on health services.3 This expenditure has not increased despite an increase in population. Hence, optimum utilization of available resources and improved performance are essential to reach the short-term national health objectives. The Global Human Development report ranked Saudi Arabia at 56 among 187 countries.4 Hence, the Kingdom has great potential to build the capacity of Saudi youth and professionals to make eye care sustainable.

The exact magnitude of blindness and visual impairment in the Kingdom remains unknown. If estimates from other Eastern Mediterranean countries are applied, then there are potentially 27,000 blind individuals and another 197,000 individuals with low vision disability in the Kingdom.5 With an increasing burden of disease due to congenital anomalies in children and metabolic syndromes in the adult population in the Kingdom, visual disabilities related to complications of these conditions are likely to remain high in the near future.6 Hence, eye care services will need to be appropriately allocated and there were will a greater demand for skilled personnel for pediatric eye care, geriatric eye care, and rehabilitation experts. Eye care is delivered at government institutions with the help of Saudi professionals as well as experts from other countries. Eye care has undergone rapid changes due to emerging technology and innovation in diagnosis and treatment. Therefore, both manpower and updated technology are essential in providing high quality eye care. An analytical approach to determine the current status of resources and preparing evidence-based policy briefs for enhancing resources to address any deficiencies and plan for 2020 is crucial for the Kingdom.

This report is an evaluation of eye care resources in the governmental institutions, in order to determine the current status, identify the gaps, and propose corrective measures that might be required to address blindness and visual impairment in Saudi Arabia.

MATERIALS AND METHODS

This was a situation analysis related to eye care that evaluated healthcare personnel and equipment available at different ministry institutions in KSA. The Institution Research Board (IRB) approved this study. This study was performed between May 2012 and January 2013. Information from King Khaled Eye Specialist Hospital (KKESH) was excluded as it is a referral institution and draws patients from other governmental institutions that were already included in this review.7

The administrator of KKESH sent a letter to the heads of ophthalmology departments in KSA. The number of ophthalmologists and optometrists present in the institution were noted. Data were collected on the number of diagnostic machines and therapeutic equipment.

There are 13 administrative areas and five administrative zones in the Kingdom. “The population of these areas in 2012 was estimated based on the last census result and the annual growth rate.8 For the population projections for 2015 and 2020, estimates from the United Nations were referred.9 The data from each institute were regrouped by the administrative area and zones of the Kingdom. The ophthalmologist to population ratio and optometrist to population ratio for each area and zone were calculated.

The equipment available to diagnose and manage important blinding eye diseases (e.g., glaucoma, diabetic retinopathy, cataract, childhood blindness, posterior segment pathologies, refractive error, and corneal diseases) such as digital fundus camera, visual field machines, A- and B-scan ultrasound, refraction facilities, contact lens related equipment, optical coherence tomography machines, and different types of laser for ocular disease management were grouped by administrative areas and zones to calculate the equipment per 100,000 population.

The eye care provider indices from our study were compared to World Health Organization (WHO) and Gulf Cooperation Council's (GCC) recommendations.1011

RESULTS

All 60 eye care governmental institutions of the Kingdom provided the data. The response rate after frequent communication was 100%.

The status of qualified ophthalmologists and optometrists in the governmental institutions per administrative zone and areas is presented in Table 1. The Central and Eastern zones had more than 60% of the ophthalmologists. The ophthalmologist and optometrist to population ratios by zones of the Kingdom are mapped in Figure 1.

Table 1

Distribution of ophthalmologists and optometrists in administrative areas and zones in the Kingdom of Saudi Arabia

Figure 1

Distribution of ophthalmologists and optometrists in different administrative zones in the Kingdom of Saudi Arabia

The allied eye care personnel include optometrists, ophthalmic assistants, and ophthalmic photographers. The proportion of allied eye care personnel to ophthalmologist was less than 1:4. The need in the Kingdom for eye care in 2020 was also calculated.

Ophthalmic equipment for basic workup for chronic and blinding eye diseases in the different zones is presented in Table 2.

Table 2

Status of equipment for care of blinding eye diseases by zone in the Kingdom of Saudi Arabia in 2012

DISCUSSION

To our knowledge, this is the first report of eye care resources at government institutions in Saudi Arabia. To effectively implement the ‘Action Plan for the Prevention of Blindness 2014-2019’, the results published in this paper could be used by the national planners and public health policy analysts.12 The ophthalmologist to population ratio recommended by the WHO has been achieved in Saudi Arabia. But, there is wide variation in the administrative zones. To ensure each zone and administrative area is adequately self-sufficient for eye care needs, both human resources and technological support have to be provided in view of the increasing population.

A global exercise to review the distribution of practicing ophthalmologists showed that there is a wide gap between the need and the existing human resource both in high and low income countries.13 The WHO has recommended that there should be one ophthalmologist per 50,000 population in Asian countries by the year 2020.10 In other gulf countries, this rate varies from 1:26,000 in Oman and Qatar, 1:32,000 in Kuwait, and 1:60,000 in Bahrain. In 2003, researchers reported that the ophthalmologist to population ratio in Saudi Arabia was 1:71,227.10 The rate found in our study in 2012 is better, compared to previous reports. The ophthalmologist to population ratio in the Kingdom exceeds that of some countries that report wide gaps in the healthcare personnel needed to adequately provide care for a population. For example, a Nigerian study reported an ophthalmologist to population ratio of 1:300,000.14 Pakistan had reported an ophthalmologist to population ratio of 1:85,000.15

Ophthalmologists are generally categorized as ophthalmic surgeons and medical ophthalmologists, depending on their job responsibilities.16 Medical ophthalmologists (also termed specialist ophthalmologists) could support consultant ophthalmologists in comprehensive eye assessment (basic work up) and medical treatment of chronic, age-related diseases such as diabetic retinopathy, glaucoma, dry eye syndrome, etc., Consultant ophthalmologists, thus, could focus on surgical management of avoidable blinding eye diseases.17 Thus, future evaluation of manpower for eye care should gather information on medical ophthalmologists and ophthalmic surgeons to ensure a rational distribution of both subgroups.

The facilities in the Kingdom have capacity to train 30 ophthalmologists a year. This is inadequate if the gap of 293 and 700 additional ophthalmologists is to be filled by 2015 and 2020, respectively. Until local manpower is available, the Kingdom will need to depend on professionals hired from other countries. In addition, private sector ophthalmologists in the Kingdom could contribute to eye care at government institutions. Senior Saudi ophthalmologists will retire in the next 7 years and this will result in a serious shortfall of experienced surgeons and clinicians. Unfortunately in this study, we could not collect data on the duration (years) an eye care professional is likely to work at government institutions. Further studies are recommended to generate this vital information.

Ophthalmic care in industrialized countries has changed in the past decades. Increasingly, day care surgeries and short hospital stays are preferred. The diagnostic and treatment modalities have also become more sophisticated and less invasive. These technologies need to be handled by trained assistants, technicians, and optometrists. Hence, more support staff is required. This will enable ophthalmologists to spend less time in performing measurements and focus on providing therapeutic or surgical eye care.18

Countries such as Saudi Arabia are at crossroads. On one side, they are in the process of developing high quality human resources; and on the other side, they have to address avoidable blindness due to eye diseases on urgent basis in order to mitigate a substantial backlog. To some extent, this could be addressed by hiring trained allied eye care personnel. Additionally, experts could manage blinding eye diseases at state of the art institutions. A proposal for establishing five medical cities in each zone is a step towards improving eye care.19 Satellite eye care centers staffed with allied eye care professionals, outreach eye screening programs, implementation of teleconsultation (teleophthalmology), and enhancing primary eye care through primary health centers are fundamental for addressing the problem of the limited number of ophthalmologists in the Kingdom.20212223

Equipment, both for diagnosis and management of eye diseases, appear to be available in all zones. However, in order to ensure each administrative area of the Kingdom has adequate resources to manage cases without referral for additional investigation, further support is required.

To ensure long-term sustainability and cost-effectiveness of eye care services, it is essential that certain productivity benchmarks are established.24 We recommend a similar review as performed for the current study, to monitor the progress and enhancement in eye care resources periodically in the Kingdom. Additionally a review of the quality of eye care delivery should be performed. This review will ensure optimal utilization of the resources available in zones and nationwide, prior to considering additional demands for both human resources as well as equipment.

There are some limitations of this study. Our estimation of resources was focused on secondary level eye care services in the government sector only. There are 660 ophthalmologists in the private sector. *If we include data from the private sector to calculate the ophthalmologist to population (Saudi + non-Saudi) ratio, it is 1:23,000. Unfortunately, the data on subspecialist ophthalmologists in the private sector is not available, so it is assumed that all of them provide comprehensive eye care. Data on the resources at KKESH were not included in the government sector data. With most of the services offered in this institution is related to subspecialty eye care, hence it is difficult to assess the contribution to comprehensive eye care by ophthalmologists at KKESH. However, in view of nearly 22,554 surgeries in last 2 years, [#]inclusion of ophthalmologists in the anterior segment unit at KKESH could have provided a more accurate status of resources for eye care in the Kingdom.

In conclusion, if we include those working in the private sector, the number of ophthalmologists seems to be adequate for the population of the Kingdom. But their distribution in the zones outside the central zone (mainly capital) should be planned. Optometrists and other allied eye care personnel are too few for standard eye care in the ministry of health institutions. Training and hiring more optometrists and other allied eye care personnel is proposed.