Community based eye care in India - Reconciling quality and quantity - The ACOIN prescription.

Unity in Diversity

India is a unique country with diverse geographical location, weather and people with different languages, culture, prejudice level of literacy and overall economic condition. With great demand for better facilities for ophthalmic problems, community eye care is a step in the right direction.

Eye Care Delivery Systems in India – A Transition

For centuries together, medical practice in India was based mainly on domiciliary service, which later changed to hospital or clinic based practice. Couching of cataract at the doorstep—the traditional method for cataract surgery—is the vivid example. Limited literacy and lack of efficient manpower and infrastructure were the main obstacles for better treatment. Charitable eye hospitals and cataract camps were the popular community eye health services available in India for several years. Modern allopathic treatment of ocular morbidities became available during the Colonial rule. After independence, Indian National Trachoma Control Programme was the first initiative in the prevention of blindness as part of the 5-year plans from 1955 onwards. Vitamin A supplementation and instillation of antibiotic eye drops at birth under the National Family Planning and Welfare Programme, and later under the “Health and Family Welfare Programme”, and currently the “Reproductive and Child Health Programme”, contributed in combating nutritional blindness and in prevention of ophthalmia neonatorum. The influx of refugees from Bangladesh in 1970 pushed India to tackle the burden of malnutrition and subsequent corneal blindness among children. Eye care for the community was revolutionised by the National Programme for Control of Blindness (NPCB), 1976 (now known as the National Programme for Control of Blindness and Visually Impairment) with the slogan, “Eye clinic at your door”, in keeping with the preamble of the programme, “To preserve the eyesight of every citizen is a national duty”. It began with the “Eye Camp Approach” with 80 mobile eye units for 80 divisions of India evolved into “Comprehensive Eye Health Care Camps” and culminated in a “Base Camp Approach”. The programme is helmed by the Centres of Excellence at the apex Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi and 20 Regional Institutes along with numerous upgraded departments of Ophthalmology in medical colleges and Block Health Centres. Aravind Eye Care System, L V Prasad Eye Institute and Sankara Nethralaya are a few of the WHO Collaborative Advanced Centres for the management of eye diseases with the state of the art tools and technology for teaching and training. At present, there are different eye care delivery systems in India: practice by optometrists and ophthalmic assistants, individual ophthalmic practice, group practice charitable hospitals, Lions Club eye hospitals, private and corporate hospitals (such as Sankara Eye Hospitals, Centre for Sight, Disha Eye Hospitals, Pushpagiri Eye Hospital etc) and Government and private medical college hospitals.

Association of Community Ophthalmologists of India (ACOIN)

ACOIN is the only professional ophthalmic association in India which includes the diverse strata of community eye health care personnel. From its initiation as a group of ophthalmologists being trained in community ophthalmology, it has now turned into a brigade of community eye health personnel from all of the cadres of Prevention of Blindness Programme. ACOIN aims to achieve the ultimate goal of “reaching the unreached” with an aim to provide “affordable, accessible and accountable eye care for both curable and incurable blindness”.

Acoin at the Forefront

ACOIN works through various community eye health advocacy and awareness models, so as to materialise its goal, “Advocacy in Community Eye Health in Indian Subcontinent” guided by the mantra of Swami Vivekananda “Arise, Awake and Attain”. In 2001, ACOIN started with a CME during the Annual Conference of the AIOS. That academic exercise gradually took the shape of weekly CMEs, numerous surveys and screening camps with graded referrals. Forum of Ophthalmology Professors of India (FOPI) was organised to assemble teachers to train the next generation of young ophthalmologists The motive was to teach the postgraduate students by taking them to the unreached tribal and downtrodden communities for door-to-door survey, screening camps, regular visits to blind schools and patients with blindness following systemic diseases like leprosy. SAARC Association Community Ophthalmology has been entrusted by SAARC Academy of Ophthalmology for services beyond the border with workshops and eye camps with colleagues from the neighbouring countries. One example is the Diabetic Retinopathy Screening Camp in Kurseong Darjeeling, West Bengal. Dristi Rath Yatra (Vision Chariot) in Uttar Pradesh in September-October 2019 was like the lava of awareness flowing from the mountain of knowledge (ACOIN) to the masses [Fig. 1]. It attracted people on a large scale and opened their eyes to several unknown facets such as childhood blindness, rehabilitation of patients with cortical blindness, diabetic retinopathy, eye donation, glaucoma, refractive errors with special attention to amblyopia, blind school education, eye care of leprosy patients and cataract care in different Governmental and non-governmental set up under the Pradhan Mantri Jan Arogya Yojana (Community Health Care Programme), Ayushman Bharat, Government of India.

Figure 1

Vision chariot at Moradabad district of Uttar Pradesh, carrying clear messages related to community eye health

ACOIN believes that in this fight for sight, only the soldiers (ophthalmologists) are not enough, but the para-military forces (ophthalmic assistants and optometrists) must be included. Proper orientation of the latter will prepare them to work efficiently. The optometrists, refractionists and ophthalmic assistants are the of the community eye health practice and they should ideally be involved in all ophthalmology events. ACOIN wishes to prepare an “ACOIN District Community Eye Health Care Team” in each of the 730 districts of India with the participation of one member each from the Indian Medical Association, All India Ophthalmological Society and ACOIN of that particular district, and empowered by the District Collector, Chief Medical Officer and Zilla Sabhadhipati. To celebrate Vision 2020 Right to Sight, we present the “ACOIN Prescription” to reach out to the blind population in India [Table 1].

Table 1

The ACOIN Prescription

1. Dristi Rath Yatra (break the barrier of ignorance about preventable blindness)

2. Prepare the Generation-Next to take up the cause of community-oriented ophthalmic services

3. ACOIN District Community Eye Health Care Team in each of the 730 Districts of India

4. ACOIN Community Eye Hospital in Taluk (Block Level) as a Base Hospital

5. Observation of “National Community Eye Health Care Day”

The transition of medical education in institutions to the era of community medical practice started from 1960 following the declaration at Alma Ata and gave birth to community medicine. The Alma Ata Declaration of “Health for all by 2000” has specifically turned into “Vision 2020 Right to Sight” in 2000. At the dawn of 2020, we have reframed our agenda to “Universal Health Care”. Our journey into light and vision will continue under the strong, generous, broad and inclusive umbrella of ACOIN.

Charaibeti, Charaibeti, Charaibeti (march along until the fulfilment of our Goal).

About the author

Prof. Swapan Samanta

Professor Swapan K Samant, trained in Community Ophthalmology at the ICEH, London, is currently the Head of the Department of Ophthalmology at the ICARE Institute of Medical Sciences, Haldia, West Bengal. From 1983 to 1999, he was in charge of the Central Mobile Eye Unit attached to the Bankura Medical College, providing community eye health care services to a 10 million population from the five districts of Southern Bengal. He joined the West Bengal Medical Education Services in 1999 and worked at almost all the Medical colleges in West Bengal. He is the founder Honorary Secretary of the Indian Alumni Group of International Centre for Eye Health, which is now known as the Association of Community Ophthalmologists of India. He is the Chair of SAARC Association of Community Ophthalmology under SAARC Academy of Ophthalmology. Prof. Samanta is the recipient of Dr. E V Srinivasan Gold Medal from AIOS, Dr. PN Avasthi Memorial Oration Award from UPSOS, Gold Medal from UKSOS, Dr. Alim Chowdhury Award from Bangladesh Community Ophthalmological Society, Dr. RC Meher Oration from EIZOC and APAO Outstanding Achievement Award in Prevention of Blindness from APAO.