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Subspecialties Health Economics and Policy, Pediatric, Professional Development

Within Arm's REACH

Orbis has recently launched the See My Future appeal, with the aim of preventing sight loss in Nepalese children. All public donations received for the appeal before June 23 this year will be matched by the UK government – thus, donors may double the impact of their gifts, in turn allowing Orbis to double the appeal’s effectiveness. Please donate now and help to save a child’s sight – and change a child’s future.

https://gbr.orbis.org/en/see-my-future

What is your background, and how did you become the Orbis Country Director for India?

The journey that led me to Orbis, where I have been for a little over six years now, stems from seeing the wonderful work done by my ophthalmologist father in remote Indian villages. Throughout my years at school and then into my time at medical school, the family routine included accompanying my father to community eye camps in various pockets of Central India. I’m sure this was deeply embedded into my subconscious and led me to complete my medical training and pursue a career as an ophthalmologist. Going on from there to study public health and business, and even work in the corporate sector for a few years, provided a more holistic picture. Now, as the Country Director for India, I lead Orbis International’s efforts in India, Nepal and Indonesia.

What’s your experience of working on eye care projects in India?

I’ll begin with how Orbis started out in India; building India’s capacity for pediatric eye care presented itself as a mammoth challenge. Examining children requires special skills and their treatment protocols require specific training, knowledge and equipment. This meant that we had to build the infrastructure for service delivery, including equipping the facilities and supporting community work, along with development of all cadres of human resources. Having the right people in the right place is the cornerstone of any successful public health program. Keeping this in mind, in 2002, the India Childhood Blindness Initiative  was launched by Orbis to help ensure that India’s children have access to quality eye care for generations to come.

The program began by identifying tertiary level eye hospitals where Children’s Eye Centers (CECs) could be established. Further, a country-wide survey generated evidence for human resource and infrastructure requirements for elimination of avoidable childhood blindness – the first time that such an extensive survey was performed in India.

The easier part was the development of infrastructure and systems. The challenging aspect was identifying staff and creating the pediatric ophthalmology teams at a time when pediatric ophthalmology was not recognized as a distinct subspecialty in India. When we started, there were limited career options and therefore initially not many people were willing to undergo training.

Once people were identified for training, “where” and “how” they would be trained continued to remain a challenge. To address this, three of the existing tertiary level pediatric facilities in the country were developed as pediatric ophthalmology learning and training centers (POLTCs) by providing infrastructure as well as technical support. This included standardization of the curricula for different cadres of eye health professionals for the CECs and community work. POLTCs offer fellowships in pediatric ophthalmology, short/long-term training programs, and periodically conduct workshops/refresher training as well as continuing medical education.

To aid continuing education and support, Orbis creates customized hands-on opportunities through the Flying Eye Hospital and hospital-based training  to increase clinical and surgical abilities of eye care providers. These trainings are tailored to address the requirements of the trainee as well as the community they will be serving.

At present, Orbis India has created the largest national network of CECs in the world – 33 CECs in 17 states; the most recent one was inaugurated at Akhand Jyoti Eye Hospital in Bihar – the CEC is the state’s first such center. Apart from that, it also initiated the Refractive Error Among Children (REACH) program in 2016.

What are India and Nepal’s unique needs when it comes to developing tailored eye care projects? 

India and Nepal both have a large population in need of eye care. However, infrastructure, as well as the human resource for delivery of eye health, are both scant. India also has demographic challenges (in terms of our diversity of population), while Nepal has geographic challenges. The silver lining? Both countries have a vibrant not-for-profit eye care ecosystem. At least seventy percent

of eye care services in both countries are provided by the private and not-for-profit sector. These institutions go beyond the walls of their eye care facility and reach out to people in need.

Can you tell us more about the REACH program?    

In short, REACH is a technology-enabled, innovative model for comprehensive delivery of school eye health. India’s REACH program began serving 15 districts through 11 partner hospitals on July 1, 2016. The aim of the program is to reduce visual impairment caused by uncorrected refractive error among school-going children. REACH addresses the fact that most school-based refractive error programs in the country end with spectacle delivery and do not include follow-up – neither for spectacles given nor for children referred for other ocular problems. In addition, parents of children with ocular problems often have limited awareness related to eye care services and refractive error. To address these issues, REACH also raises awareness through the development of evidence-based information, education and communication materials.

At present, REACH serves children in the states of Bihar, Madhya Pradesh, Maharashtra, Kerala, Odisha, Rajasthan, Tamil Nadu, and West Bengal. From July 2016 until April 2019, we have performed 4,575,014 screenings, given 136,223 prescriptions and delivered 93,773 spectacles.

More recently, the REACH model has been replicated in Nepal through Orbis partner Nepal Netra Jyoti Sangh, with implementing partner hospitals operating in Jhapa and Sunsari districts.

And how does REACH function “on the ground?”

Orbis, along with its hospital partners, develops teams of ophthalmic personnel and supports them with digital and clinical equipment to perform vision screening, prescription and provision of spectacles, as well as referral of children to a fixed facility for further examination and treatment. REACH also monitors children’s compliance to spectacle wear and encourages a favorable eye health seeking behavior. There is a very strong focus on data management at all levels and at all steps of REACH. To that end, Orbis has developed REACHSoft, a purpose-built software solution. REACHSoft is designed to support every step of the planning, implementation and management (including monitoring and evaluation) of the program.

All school-going children who are identified with problems through the REACH program’s primary screening undergo detailed evaluation. Children who require spectacles are prescribed and given glasses through the program. Children who require intervention beyond the need for spectacles are referred to the base hospital for further management, which could include cycloplegic refraction, further examination/investigations, treatment or surgery. And this cycle is repeated on an annual basis to provide continued access to the eye care services these school children need.

How will the See My Future appeal (and the UK government’s donation matching) impact the projects that you oversee?

In many parts of the world, including Nepal, avoidable blindness leads to children dropping out of school – either because of issues with their own eye health or because they are caring for an adult with sight loss. Considering that 80 percent of what a child learns is visual, good vision is critical to a child’s ability to participate in and benefit from educational experiences. School-based eye health programs are a golden opportunity and we recognize that the timely provision of effective interventions can be an absolutely life-changing experience for a child in need.

Addressing this need across the country is a mammoth challenge but it is imperative that we REACH out to the millions of children across Nepal. Money raised through the See My Future appeal will help us expand our efforts in Nepal, giving more children the opportunity to attend school and have a brighter future. Often, the bigger picture of eye health and its connection to a child’s future is missed; however, access to quality eye care is one of the most cost-effective and efficient options for reversing the cycle of poverty and helping children achieve their full potential.

What do the projects Orbis runs mean to you personally?

What fills me with pride is the good work that continues at all the child-friendly facilities that Orbis has helped set up across the country. And the POLTCs continue to provide training and support to the eye care system in India, and many other countries. And because the model has been successfully replicated in Nepal and Bangladesh, it feels like our work can reach even more children across the world! Becoming a father of two small girls has brought a new-found relevance to our work for me. I can only imagine what the parents of children we help have gone through and hope that we have made a positive impact on their lives.

Can you give us some sense of scale when it comes to the challenges in India?

India is the second most populous country in the world – and home to over 20 percent of the world’s blind population. Even worse, India is home to the largest number of blind children in any one country. But that’s just half the picture; the situation becomes graver when you see the increasing divide between the rich and poor, which leaves a significant portion of the population – many of whom live in rural areas or urban slums – without access to basic healthcare services. To top it all, the majority of ophthalmologists in India live and practice in the cities. Millions of people go blind each year and millions more suffer from poor vision because they simply don’t have access to the care many of us take for granted. 

In 1976, India became the first country in the world to launch a 100 percent publicly-funded program to address these problems: the National Programme for Control of Blindness. Considering that our country is large and diverse, we are faced with many challenges. But I believe our strength lies in the fact that we work together and help each other to meet those challenges, which complements the efforts made by the government. And that’s where a vibrant not-for-profit eye care ecosystem comes into play, including local and international NGOs, academic institutions, social organizations, corporations and the public at large.

By definition, developing countries have fewer resources to tackle their public health problems compared with the developed world. But that drives us to constantly innovate our processes, systems and products to extract value from every dollar. It is imperative that we find ways to do more with what we have because that’s how big the problem is. There are many examples of innovations from the developing world that are now finding relevance in the developed world too – “reverse innovation.” And that’s how we all help each other.

Rahul Ali is Country Director for India at Orbis

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