Determining the National Cataract Surgical Rate in Pakistan.

PURPOSE: Cataract surgical rate (CSR) (cataract surgeries performed per million population) is an eye health indicator that helps assess the state of eye care services. A survey in 2002 revealed a CSR of 2254. The current survey aimed to establish a new and sustainable development goal compliant baseline for the volume of cataract surgery performed by different service providers in Pakistan at district, provincial, and national levels.
METHODS: The survey was commissioned by the National Committee for Eye Health under the Ministry of National Health Services, Regulations and Coordination. The methodology used for the survey included identification and mapping of all service providers by district and category and data collection from all districts in the country.
RESULTS: There were more cataract surgeries performed in women than men with a male-to-female ratio of 0.95. About 98.9% of all cataract surgeries were performed with intraocular lenses, while 63.9% were performed by phacoemulsification. About 17.7% of cataract surgical services were provided in the government sector (including Forces), while nongovernmental organizations and the private sector contributed to 82.3%. Pakistan achieved a national CSR of 5307 which is almost double the CSR determined in 2002.
CONCLUSION: In order to achieve a CSR of 7500+ by 2030, there is a need for at least 1,840,000 cataract surgeries to be performed annually. If there is no change in the current annual cataract surgical output, the CSR will drop to 4628 by 2030. Copyright:

Introduction

There is no up-to-date and documented estimate of cataract surgeries being performed in Pakistan. This imposes limitations in planning because existing data on number of cataract surgeries in the country are 17 years old.

Planning eye health programs in the sustainable development goal (SDG) era requires recent data about burden of disease to inform service development to achieve universal eye health coverage. Cataract surgical rate (CSR) (cataract surgeries performed per million population) is an eye health indicator that helps assess the state of eye care services. This article provides the most recent information available on CSR in Pakistan.

Background

In 1987–1990, the prevalence of blindness was found to be 1.78% in Pakistan with cataract as the most common cause of blindness.[1] In 1993, the annual cataract surgical output was estimated at 140,000 according to the First National Plan for Prevention and Control of Blindness 1994–1998.[2] In view of the national launch of Vision 2020 – The Right to Sight in Pakistan in 2001, the development of district comprehensive eye care programs, and the Second National Blindness Survey, it was considered vital to have a more recent estimate of district cataract surgical output and the CSR at the time. The Second National Blindness Survey was conducted in 2002–2004, which found a prevalence of blindness of 0.9% with cataract again as the most common cause of avoidable blindness.[3]

The first mapping of cataract surgical services was conducted under the auspices of the National Committee for Prevention of Blindness in 2002.[4] The 2002 survey revealed the estimated Cataract Surgical Output of 310,572 per year at the time. This gave a CSR of 2254 per million population in 2002.

Since the surveys from 1987 and 2002 indicated cataract as a major cause of blindness in Pakistan, the national prevention of blindness plans prioritized the elimination of cataract by upgrading cataract surgical services at district level.

Since then, there has been a marked increase in the following:

Continuous stream of ophthalmologists produced from over 30 tertiary teaching centers across the country

Over 70% of district eye units in district hospitals in the public sector upgraded and operational

Mushroom growth in the number of nongovernment organization run eye hospitals

Strategic support from international eye care partners to strengthen cataract surgical services in the last 20 years

Marked increase in eye care services provided by the private sector

Increase in the population from 138 million in 2002 to over 209 million (2017 population census).

The purpose of this survey was to determine the volume and type of cataract surgery being performed by different service providers in Pakistan. The survey aimed to establish a new and SDG compliant baseline for the volume of cataract surgery being performed at subdistrict, district, provincial, and national levels and to determine the readiness of cataract surgical services for the SDGs.

The main objectives of the survey were to:

Determine the volume and type of cataract surgery being performed in each province at sub-district and district levels.

Determine the type of service providers and their volume of work.

Estimate the annual cataract surgical output and the CSR for each district, province, and a national mean.

Identify priority districts that have low CSRs.

Estimate the number/proportion of phacoemulsification surgeries being performed presently.

Estimate the number/proportion of intraocular lens (IOL) surgeries being performed annually

Chart the progress in CSR over the last 17 years and make projections for the next decade.

Methods

The methodology for this survey involved five phases:

Preparatory phase

A consultative/planning meeting was convened with the National and Provincial Coordinators of the National Eye Health Programme, and key stakeholders for the survey. A data collection tool for mapping service providers was developed and shared with the provincial coordinators. They were requested to populate the list of service providers in their respective provinces and regions. This was further refined in Phase 1.

Formal approval for the cataract mapping survey was provided by the Federal Ministry of National Health Services, Regulations and Coordination, who also conveyed the approval to the provincial health authorities and requested for their assistance and facilitation in the survey. The provincial health departments conveyed the information about the survey to all respective district health administration, district health facilities, and relevant units in the provincial health departments.

Phase 1 – Identification and mapping of service providers by district and category

Government and nongovernment service providers

A comprehensive list of service providers was prepared by the provincial eye health coordinators according to each district and included the name of the facility, type of facility, and names and contacts of key informants. Each key informant was contacted to confirm the contact details and inform them of a planned survey. Where it was readily available, data on cataract were collected at this stage.

Private sector

A list of ophthalmologists working in the private sector and private eye hospitals for each district was prepared by the provincial eye health coordinators. Key informants were identified from the list who provided useful information and estimates about the status of cataract surgery in the private sector in their respective districts. Where it was readily available, data on cataract were collected at this stage.

Forces hospitals

Topline provincial-level information from all Forces hospitals was obtained through the courtesy and facilitation of the Armed Forces.

Private sector intraocular lens companies and suppliers

A list of all main IOL suppliers in Karachi, Lahore, Peshawar, Quetta, Gilgit-Baltistan, and Azad Jammu and Kashmir was prepared with names and contacts of key informants. Where it was readily available, topline national-level data on IOLs distributed in 2018 were collected at this stage.

District Health Information System

The Provincial Comprehensive Eye Care (CEC) Cells were requested to establish contact with their respective District Health Information System (DHIS) units and brief them about the survey and the need to obtain data on cataract surgeries reported in DHIS for each district.

Development of data collection tools and data management system

Data collection instruments and tools were developed appropriate to the service provider. The data collection instruments were pilot tested to ascertain the ease of communicating to key informants, inputting information, submitting the completed questionnaire by e-mail, tracking of missing respondents, data reconciliation, and data analysis.

Development of a master checklist

The key informant contact data were entered onto a master checklist by province and district and used to build the profile of prospective respondents for data collection.

Phase 2 – Data collection

First communication

A first communication was sent by the provincial coordinators to all listed respondents (excluding private sector and Forces). This informed them about the forthcoming survey, the type of data to be collected, and what they needed to do. They were requested to submit their data to the respective Provincial CEC Cells.

Second communication

The second communication was sent after 1 month as a reminder in case there were any nonrespondents or missing entries from the respective provincial master lists.

Third communication

If there were missing respondents from the master checklist, a repeat communication was sent after 1 month. This was also followed by telephonic follow-up requesting them to complete the form and submit it.

Fourth communication

If there were still any missing respondents, a repeat communication was sent after another 1 month. This was also followed by telephonic follow-up requesting them to complete the form and submit it.

DHIS, private sector, and Forces

All information obtained from these sources was entered manually by the consultants onto the Excel database.

Lot quality assurance sampling

The Provincial CEC Cells visited a sample of 10% district eye units in the government sector to validate data on cataract surgery by reviewing operation theater records. The districts were selected randomly in each province.

A data collection team comprising two optometrists was deployed in each province. They were provided orientation on data collection and the use of the data collection tool. The team then visited the sample of 10% district eye units to validate data.

Phase 3 – Data analysis

Data cleaning

All forms submitted to the database were reviewed and data cleaning was done. Any missing entries were noted and followed up with the respective provincial coordinators and respondents. Data from different sources were triangulated to obtain as robust a situational status as possible. Once data cleaning had been completed, the data were analyzed and tabulated by district, province, and category of service provider.

Population census data for 2017 were used. A growth rate of 1.0193% was used to determine the mid-2018 population for each district. This was then used to estimate the CSR. Statistical analysis was performed as appropriate. Graphs and maps were generated with color coding for different levels of CSR by province and district.

Phase 4 – Report writing

Draft provincial-level data tables were submitted to the provincial coordinators for review, checking for any errors, and provision of any additional data. Once all data had been tabulated and statistical analysis performed, the findings were submitted to the National Coordinator, National Eye Health Programme for review, who then approved them for publication.

Validation

Four sources of information were used to validate information obtained from the survey.

Primary data collection using the survey instrument

Secondary data from the DHIS for government service providers by district

Tertiary data from IOL suppliers/distributors in the country

In addition to the above, lot quality assurance sampling was used to validate the information obtained from the survey; 10% cataract surgery statistics available from district headquarter hospitals were verified. Most data showed no difference between reported and verified, while overall all data were within ±10% of the reported figure.

The total number of cataract surgeries using IOLs that were reported in the survey accounted for 94.09% (Confidence Limits: 94.05%–94.13%) of the total number of IOLs supplied in Pakistan by distributors in 2018. This indicates a very high response rate achieved in the survey.

Limitations

There were a few limitations encountered in the survey.

District-wise population data were not available for Gilgit-Baltistan and some newly created districts in Balochistan, Khyber Pakhtunkhwa, and Sindh. However, province-wise population data were available

Complete sex- and age-disaggregated data were not available for all districts

It was envisaged that DHIS data would provide the second source of information to triangulate data. There was much variance in the quality of data provided through the DHIS – in some cases, it matched the data obtained from the survey; in other instances, it was incomplete and therefore not very useful

The third source of information used was that from IOL suppliers. For reasons of client confidentiality, they were only able to provide a total national figure for 2018. IOL supply data disaggregated by province or service provider were not available

Since there were 70,960 cataract surgeries with IOLs (5.91%) unreported in comparison to national IOL data (1.2 million IOLs in 2018) provided by IOL suppliers, it is likely that there was some element of underreporting or missed data from the private sector, as yet unidentified service providers and unused IOL stock available in hospital stores

The cataract surgery data from the Forces hospitals were only available as combined data for all services’ hospitals and disaggregated at provincial level due to administrative reasons. Islamabad Capital Territory data were combined with Punjab data

The initial project completion time had been estimated at 3 months. However, owing to the diversity of service providers, verification procedures requiring onsite field visits, and follow-up of missing entries, the whole process took 6 months.

Results

Cataract surgeries and gender

The survey revealed that there were more cataract surgeries performed in women than men with a male-to-female ratio of 0.95 [Table 1]. Balochistan and Gilgit-Baltistan had higher male-to-female ratios of 1.14 and 1.41, respectively. Sex-disaggregated data for the former Federally Administered Tribal Areas (FATA) were not available.

Table 1

National, regional, and provincial profile of cataract surgical rate (2018)

	Population 2017	Population mid-2018	Total cataract surgery	CSR	Number of cataract surgeries performed					Male/female
					Government	Forces	NGOs	Private sector	Total
Islamabad Capital Territory	2,006,572	2,045,299	14,686	7180	3923	0	0	10,763	14,686	0.98
Balochistan	12,344,408	12,582,655	24,765	1968	7156	1017	7532	9060	24,765	1.14
Gilgit-Baltistan	922,745	940,554	2083	2215	1099	357	48	579	2083	1.41
Khyber Pakhtunkhwa	30,522,371	31,111,453	163,689	5261	40,230	2728	57,713	63,018	163,689	0.93
Former FATA	5,001,676	5,098,208	1790	351	800	0	0	990	1790
Punjab	110,012,442	112,135,682	662,161	5905	95,916	11,946	269,717	284,582	662,161	0.96
Sindh	48,760,006	49,701,074	264,583	5323	31,281	4088	117,488	111,726	264,583	0.92
National	209,570,220	213,614,925	1,133,757	5307	180,405	20,136	452,498	480,718	1,133,757	0.95
Proportion of cataract surgeries by service provider (%)					15.9	1.8	39.9	42.4	100.0
Azad Jammu and Kashmir	4045,000	4,123,069	10,029	2432	2298	2075	3319	2337	10,029	0.95

CSR: Cataract surgical rate, NGOs: Nongovernmental organizations, FATA: Federally Administered Tribal Areas

Intraocular lens and phaco surgeries

About 98.9% of all cataract surgeries were performed with IOLs. About 63.9% of all cataract surgeries were performed by the phacoemulsification (phaco) technique with the highest in Islamabad Capital Territory at 93.4%. Azad Jammu and Kashmir data indicated that at least half (52.6%) of all cataract surgeries were performed using phaco, while Gilgit-Baltistan and Khyber Pakhtunkhwa have comparatively lower rates of 12.5% and 14.3%, respectively. In Punjab and Sindh provinces, the rates were 79.3% and 58.7%, respectively. The provincial and national figures are likely to be higher as complete data on phaco were not available from all districts and service providers.

Cataract surgeries and service providers

The proportion of cataract surgical services provided in the government sector ranged from 11.8% in Sindh to 52.8% in Gilgit-Baltistan. The nongovernment and private sectors jointly contributed to two-thirds (67.0%) to over four-fifths (86.6%) of all cataract surgeries in Islamabad Capital Territory, Balochistan, Khyber Pakhtunkhwa, Punjab, and Sindh. The findings also indicated that Layton Rahmatullah Benevolent Trust with its network of eye hospitals is the single largest service provider in the nongovernment sector (38.7% of all cataract surgeries performed by nongovernmental organizations [NGOs]). It performs 17.0% of all cataract surgeries in Pakistan and exceeds the proportion of cataract surgeries performed by the government sector in Punjab and Sindh provinces and by the government sector nationally.

The proportion of cataract surgeries by service provider nationally was (i) government (govt.) – 15.9%, (ii) forces – 1.8%, (iii) NGOs including charities and faith based – 39.9%, and (iv) private sector – 42.4%.

Cataract surgical rate

Table 1 illustrates the national, provincial, and regional profile of total cataract surgeries performed and CSR for 2018. CSR is defined as the number of cataract surgeries performed per million population in a given year. The data indicate that Pakistan achieved a national CSR of 5307.

Azad Jammu and Kashmir is an autonomous administrative region and is presented separately from the rest of Pakistan.

Based on comparison of cataract surgery data in the 2002 and 2018 surveys, the statistical analysis indicates a rate ratio of 2.367% increase in cataract surgeries (CL: 2.358–2.376) which incorporates an increase in population during this period. The rate ratio is highly significant at P < 0.0000001.

The survey revealed a response rate of 94.09% (CL: 94.05%–94.13%). There were 70,969 cataract surgeries with IOLs (5.91%) unreported in the survey in comparison to the national IOL data (1.2 million IOLs in 2018) provided by IOL suppliers.

Childhood cataract surgical rate

Table 2 presents the provincial trends in childhood cataract surgery (age: 0–15 years). The survey data indicates that the childhood CSR (CCSR) per million population ranged from a low of 18 in Balochistan to a high of 184 in Islamabad Capital Territory (ICT) and a national rate of 43. There is no data for former FATA, but it is believed that the parents bring their children to the larger cities in Khyber Pakhtunkhwa for treatment.

Table 2

National, regional, and provincial profile of childhood cataract surgical rate

	Population mid-2018	Childhood population 0-15 years (31.4%)	Cataract surgery in children 0-15 years	CCSR per million childhood population (age 0-15 years)	CCSR per million total population
Islamabad Capital territory	2,045,299	642,224	376	585	184
Balochistan	12,582,655	3,950,954	223	56	18
Gilgit-Baltistan	940,554	295,334	70	237	74
Khyber Pakhtunkhwa	31,111,453	9,768,996	786	80	25
Former FATA	5,098,208	1,600,837	0	0	0
Punjab	112,135,682	35,210,604	6034	171	54
Sindh	49,701,074	15,606,137	1752	112	35
National	213,614,925	67,075,086	9241	138	43
Azad Jammu and Kashmir	4,123,069	1,294,644	138	107	33

CSR: Cataract surgical rate, CCSR: Childhood CSR, FATA: Federally Administered Tribal Areas

Discussion

The World Health Organization launched its “World Report on Vision” in 2019, which introduced the concept of “Integrated, People-Centred Eye Care” (IPEC).[5] It stated that IPEC provides a continuum of health interventions that address the full spectrum of eye conditions, according to people's needs and throughout their life course. Cataract was identified as the second most common cause of vision impairment after refractive errors. Member states will be required to develop national IPEC plans in the coming years. Determining CSR provides a very useful and credible baseline indicator to determine future impact as eye care services are remodeled according to the IPEC strategy in the coming years.

Our study demonstrates that Pakistan has almost doubled its CSR to 5307 in the last two decades. According to CSR data presented in the Vision Atlas of the International Agency for the Prevention of Blindness, Pakistan now ranks with countries with median CSRs alongside Central Europe, Eastern Europe, and Central Asia (according to data available in the Vision Atlas) [Figure 1].[6]

Figure 1

Cataract surgical rate and cataract blindness (Credit: Vision Atlas, International Agency for the Prevention of Blindness)

There is no standardized indicator to monitor the rate of cataract surgery in children. However, researchers in Tanzania used a “Childhood Cataract Surgical Rate” per million total population and found that regional rates varied from 5.4 to 32.3 with a national rate of 9.9 per million population.[7] The data from Pakistan indicate that the national CCSR was four to five times higher than that found in Tanzania. Our study provides useful baseline data for determining the impact of pediatric ophthalmic services in the future.

Population projections indicate that by 2090,[8] Pakistan's population structure will gradually change from a pyramidical one to a cylindrical one. This has serious implications for health care since Pakistan will have a growing elderly population with greater dependency and vulnerable to chronic and noncommunicable diseases. This also means that there will be an increase in adult cataracts and chronic eye diseases such as glaucoma, age-related macular degeneration, and diabetic retinopathy.

Figure 2 indicates the CSR trends from 2002. In order to achieve a CSR of 7500+ by 2030, there is a need for at least 1,840,000 cataract surgeries to be performed annually by 2030. If there is no change in the current annual cataract surgical output, the CSR will drop to 4628 by 2030. At least 58,000–60,000 additional cataract surgeries will need to be performed every year over and above the rate of each previous year to achieve a CSR of 7500+ by 2030.

Figure 2

Projection of cataract surgical rate and annual cataract surgeries

On analysis of the Human Development Index (HDI) by district in Pakistan,[8] the highest HDI in 2015 was 0.875 for Islamabad, a federally administered territory and the capital of the country, followed by Azad Jammu and Kashmir with an HDI score of 0.734. The lowest HDI was 0.216 for the FATA (which has now been merged into Khyber Pakhtunkhwa), a very low human development category. Among the provinces, Balochistan had the lowest HDI of 0.421 falling in the category of low human development. Punjab had the highest, 0.732, placing it in a high medium human development category. The other two provinces, Sindh and Khyber Pakhtunkhwa, performed relatively better and fell in the medium human development category.

On analysis of HDI and CSR trends, a perfect correlation of r = 1.0 was noted at the provincial level suggesting that as HDI improved, a corresponding improvement in CSR was also noted (Figure 3). This is likely to be a combination of increased state funding for eye care, increased availability and deployment of human resources for eye health, especially ophthalmologists, and a large nongovernment and private sector involved in provision of cataract surgical services.

Figure 3

Correlation between cataract surgical rate and the Human Development Index

Conclusion

The key recommendations emerging from this study include:

Update the data frameworks for each province, especially for missing entries for sex and age, phaco surgeries, human resources for eye health, and eye beds

Conduct a comprehensive survey on human resources for eye health to determine the status by district, service provider, and category of human resources

Complete the data on pediatric cataract surgeries where there are missing entries so that a more realistic status is obtained

Prioritize districts with CSRs of <2000 for district comprehensive eye care program

Strengthen district eye care services with CSRs >2000–4000 to transition to the next tier of >4000–6000.

Conduct capacity building of statistical officers/ophthalmic technicians for accurate data reporting so that monthly data provided to the DHIS achieve a high rate of reliability. Monitor compliance rates and verify all monthly reports until 100% compliance is achieved. Include tertiary teaching hospitals in the data collection and reporting capacity building initiative

Utilize data frameworks for biennial monitoring of cataract surgery and update the list of service providers as appropriate

Pilot introduction of disability-inclusive data reporting on cataract surgery at facility level and implement at scale.

Financial support and sponsorship

This study was commissioned by the National Committee for Eye Health and funded by Sightsavers.

Conflicts of interest

There are no conflicts of interest.