Background to planning at the district level
There is an African saying. The question is: “How do you eat an elephant?” The answer is: “One mouthful at a time, slowly, with a lot of help from your friends”. There is much that we can learn from this wisdom and apply to a district-level plan. The question is: “How do you overcome the seemingly insurmountable problem of global blindness?” The answer is: “Piece by piece, in digestible portions, step by step, and working together as a team”.
It is recommended that each of our district levels should be for service units of about 1 million population (0.5-2 million). As indicated previously, this administrative unit of about 1 million may be called by different names in different countries, e.g. sub-district, district, region, province, etc. These are the ‘pieces of the elephant’. If we have a country of 40 million population, we should not plan just a single national programme, but 40 separate district-level programmes that together make up the national programme (Figure 1).
What is involved at the district level?
District level programmes are developed as one-year operational plans, prepared as integral components of the district general health operational plan and guided by the five-year national strategic eye health plans. A comprehensive approach (preventive, curative, and rehabilitation) is built on equity, community involvement, focus on prevention, appropriate technology, and a multi-sectoral approach. In the past, these four elements have been working separately and without focus. All district programmes will have the same elements, but no two programmes will be the same because no two districts are the same.
Challenges and lessons learnt from experience: The Asian context
In 1996 the district programme concept was piloted in Bannu, located in the North-West Frontier province of Pakistan. The district hospital had limited ophthalmic infrastructure, human resources, equipment and management.
There were two ophthalmologists, no paramedic staff, no separate operating theatre (it was shared with other specialities), no separate eye ward, and minimal equipment. The output was 150 cataract operations per year.
A collaborating partnership between the Pakistan Institute of Community Ophthalmology, the Government of North-West Frontier Province, and an international non-governmental organisation (NGO) was established. The collaboration initially strengthened the district by providing equipment, as per the IAPB Standard List. The government posted two new ophthalmologists trained in ECCE and IOL implantation, and five paramedics were trained, with one of the paramedics trained in management. The infrastructure was upgraded with a separate eye theatre, a separate eye ward, and an outpatient complex. Primary eye care
workers were trained in the detection and treatment of minor disorders and referral of major ones.
The eye unit was evaluated after two years, and the cataract output had increased sevenfold to 1,050 operations. The programme now includes successful refractive and low vision services, and a trachoma control programme. Eye care services for children will soon be added.
It was agreed by the national committee that this model should be replicated in other districts in the country, with the support of NGOs. Thus far, 53 district programmes have been established out of a total of 119 districts in Pakistan resulting in a 375% increase in cataract surgical rate.
What have been the challenges?
One of the challenges was to build a stable and committed team. It was important to engage the government so that frequent transfers of staff would not take place. The motivation of the eye team to maintain high volume surgery was addressed by giving a forum to display surgical
results every year and establishing a system of peer review. Monitoring of outcomes needs to be introduced so that the eye teams can maintain high standards of visual outcome.
What have been the key learning points?
Challenges and lessons learnt from experience: The African context
The main challenge to the successful implementation of district programmes in Africa has been the lack of human resources, both clinical and managerial (Figure 3). In Kilimanjaro district, there was one cataract surgeon for every 1 million population. The cataract surgeons were doing less than 500 cataract surgeries per year, and this needed to double.
Effective management was required at the district level. Human resource development was a priority. We needed to train more cataract surgeons and effective managers.
An effective district VISION 2020 programme: Kilimanjaro region, Tanzania
What management changes were made?