Sustainability of Global Health Interventions

by Daphne Wang

One aspect of global health intervention programs highlighted by Dr. Prakalapakorn’s lecture was sustainable development. In the field of global eye health, there is concrete knowledge on the interventions to prevent or treat visual impairment, and the overwhelming cost-effectiveness of these treatments. When tackling such global health challenges with known effective treatments, it is even more imperative to focus efforts on creating intervention programs that are locally sustainable, for both cost-effective and ethical reasons.

A common theme observed across many organizations that provide ophthalmological care in low-income settings is a focus on training local eye care professionals. The Aravind Eye Care System is one of the most productive eye care center and teaching facility in the world. In order to help replicate the radical “McDonald” model of eye care elsewhere, Aravind offers both clinical and non-clinical courses on topics such as management, community outreach, and instrument maintenance. In this way, Aravind not only trains the local workforce to sustain the growth of the institute itself, but also encourages the development of similar facilities in other underserved areas. Another organization, Orbis International, is well-known for their Flying Eye Hospital, a fully equipped eye hospital and surgical teaching facility. Orbis targets the adequate training for healthcare professionals to build eye care capacity in the places that it works. By providing the training from a team approach, Orbis improves the efficiency of the surgical team and the health outcomes for the patients. Education and training are essential aspects for creating a sustainable global health intervention by building the local workforce and sharing proven methods for increased healthcare efficiency and better patient outcomes.

Another consideration when creating a sustainable healthcare model in a low-resource setting is the acquisition and management of donated goods. Many instruments required during vision exams and surgeries are expensive and complex. To ensure that donated instruments have the most benefit, the Community Eye Health Journal developed guidelines: “Donations of consumables and surgical instruments: how to ensure you really benefit.” One informing principle is to consider the standards of eye care and the ease of maintaining the donated goods. Donated medicine should be of comparable quality to those used in other parts of the country. Eye care facilities receiving donated instruments should be able to maintain, fix, and use the instruments. It is not sustainable to simply accept items unless these items will be used and maintained reliably, and that the healthcare outcomes of the donated medicine are comparable to the results of medicines in the native country.

Perhaps even more importantly compared to concerns of cost-effectiveness, sustainable global health interventions have ethical impacts. Would an intervention provide more harm than good if a patient was diagnosed with a treatable condition, but was unable to receive treatment due to program sustainability reasons? If the benefits of the short-term intervention end with the end of the intervention, is the program still beneficial to the local population? If a donated medication arrives only intermittently, should this treatment be offered to the patients? There are fewer ethical concerns if treatments are sustainable and available in the long-term. Until additional guidelines can be developed for sustainable eye care in low-resource settings, interventions that provide training for local eye care professional and practice effective management of donated resources are crucial aspects of a sustainable program targeting the reduction of visual impairment in underserved regions.

Reference

Cordero, I. (2011). Donations of consumables and surgical instruments: how to ensure you really benefit. Community Eye Health,24(76), 41.

Eye Health Disparity

by Yujung Choi

What I loved about Dr. Prakalapakorn’s guest lecture was her incorporation of the anatomy and physiology of the eye to describe how certain dysfunctions of the eye can lead to different ophthalmological diseases. And of course, listening to her incredible experiences with the Orbis Flying Eye Hospital was inspiring, too!

During her lecture, Dr. Prakalapakorn mentioned some statistics regarding the global burden of ophthalmological disease. I think it is worth mentioning them again to reiterate how the burden of eye disease disproportionately affects the global poor especially in the time of significant population growth and aging worldwide. According to the WHO, about 285 million people are visually impaired around the world. Of those, over 90% live in low and middle income countries. More disconcertingly, about 80% of all visual impairment can be prevented or cured (WHO, 2014).

Although most ophthalmological diseases such as cataract, uncorrected refractive error, glaucoma and age related macular degeneration are not life threatening conditions, they remain serious global health problems as poor eye health affects people’s income, livelihoods, nutrition, development and access to basic services such as education and healthcare. Jaggernath et al. further argue that eye diseases are both the cause and consequence of poverty; a lack of sanitation, poor or inadequate water supply, malnutrition and a lack of education cause the majority of preventable vision impairment and blindness while severely vision impaired and blind individuals are also limited from accessing and utilizing available public services (Jaggernath et al., 2014).

As with many diseases around the world, women bear the additional burden of health inequalities of eye diseases. Women suffer from visual problems at rates about 1.5 times greater than men, adjusted for age and irrespective of biological attributes (Stevens et al., 2013; See Fig. 1). This gender disparity can be explained by frequent exposure to causative factors such as infectious diseases and malnutrition as well as less access to treatment and care for women when compared to men. For instance, women were found to utilize eye care services 40% less than men (Fouad et al., 2004). How do we explain this phenomenon? A couple reasons may include: 1) women tend to have less control of finances than men. This makes the cost of surgery and transportation to the hospital more prohibitive for women. Not to mention the financial burden from the loss of work while staying in the hospital and/or accompanying the patient; 2) women may be less likely than men to travel outside of their village for a surgical facility; 3) women may perceive that there is a higher value for men to have surgery than for themselves because men are the breadwinners of households; 4) there is a lack of access to information and resources because community-based education about eye care has not been initiated in many areas (Lewallen and Courtright, 2002); 5)  there could be a fear of a poor outcome.

Figure 1. Bar graph of the ratio of female-to-male age-standardized prevalence of blindness and of moderate and severe vision impairment (MSVI) in adults 50 years of age and older.

Stevens, G. A., White, R. A., Flaxman, S. R., Price, H., Jonas, J. B., Keeffe, J., ... & Vision Loss Expert Group. (2013). Global prevalence of vision impairment and blindness: magnitude and temporal trends, 1990–2010. Ophthalmology, 120(12), 2377-2384.

Because women are less likely to seek ophthalmological care than men, they are more negatively affected in school participation and literacy levels. Women also experience higher rates of violence and less assistance with abuse and have limited decision making power in and outside household. More importantly, women’s low status in low and middle income countries—as evidenced by lower levels of education, literacy and income—is the root cause of the gender disparities in ophthalmological health. Some questions I have are: how well do you think the trend of women playing more prominent roles in household and society in the future will decrease the gap of prevalence of blindness and of MSVI between women and men? Looking at Figure 1, how do you explain the female-to-male prevalence of blindness in high-income and Central/Eastern Europe compared to the one in Sub-Saharan Africa? Why is there such a big difference between the blindness ratio and of MSVI ratio in East and Southeast Asia and Oceania? What factors contribute to this difference? And why is there hardly any difference between blindness ratio and of MSVI ratio in Sub-Saharan Africa?

Fortunately, visual impairment worldwide has decreased since the 1990s despite the aging population. The WHO states that this is because of overall socioeconomic development in low and middle income countries, concerted public health action, increased availability of eye care services and awareness of general population about solutions such as surgery and refraction devices to the visual impairment problems (WHO, 2014). Globally, there has also been an increase in telemedicine. Taking advantage of the increase in access to mobile phones in low and middle income countries, eye surgeons such as Dr. Andrew Bastawrous created Peek, a smart phone app into a comprehensive, easy-to-use, accurate eye-exam device. Perhaps this app can bridge the gaps in eye health disparity and gender inequality in eye health. Moreover, perhaps the WHO’s multidisciplinary methods to combat eye diseases can serve as a good model for prevention and control of other diseases around the world.  

      

For your reference, here is the link to Dr. Bastawrous’ TedTalk discussing his eye exam smart phone app: http://www.ted.com/talks/andrew_bastawrous_get_your_next_eye_exam_on_a_smartphone?language=en

References

Fouad, D., Mousa, A., & Courtright, P. (2004). Sociodemographic characteristics associated with blindness in a Nile Delta governorate of Egypt. British Journal of Ophthalmology, 88(5), 614-618.

Jaggernath, J., Øverland, L., Ramson, P., Kovai, V., Chan, V. F., & Naidoo, K. S. (2014). Poverty and eye health. Health, 2014.

Lewallen, S., & Courtright, P. (2002). Gender and use of cataract surgical services in developing countries. Bulletin of the World Health Organization, 80(4), 300-303.

Stevens, G. A., White, R. A., Flaxman, S. R., Price, H., Jonas, J. B., Keeffe, J., ... & Vision Loss Expert Group. (2013). Global prevalence of vision impairment and blindness: magnitude and temporal trends, 1990–2010. Ophthalmology, 120(12), 2377-2384.

World Health Organization. (2014). Visual impairment and blindness. Fact sheet, (282), 2009-2010.