According to the World Health Organization (WHO), every five seconds one person in the world goes blind, while every minute a child loses his sight. On a global scale, the number of blind people is alarming, considering the fact that 80 percent of blindness is avoidable.
Transposed to the sub-region, a mid-term 2000’s study conducted in Botswana revealed 3.7 percent or more than 74 000 blindness incidence and prevalence rates among the adult population 50 years and beyond, due to cataract, diabetic retinopathy (DR), corneal scars, trachoma and glaucoma. Another study conducted in 2009 identified uncorrected refractive errors as the leading cause of blindness on children in Botswana. The results pose daunting challenges for the health sector to strengthen local efforts for the implementation of Vision 2020 strategies to improve the delivery of ophthalmic services in the country.
Total blindness is described as the complete lack of or no visual light perception (NVLP) due to physiological or neurological factors. Among the sighted the experience of being lost, isolated, oblivion or vulnerability can be animated by closing one’s eyes for a while.
Although blindness frequently describes severe visual impairment with residual vision, those having only light perception have no more sight than the ability to tell light from dark and the general direction of a light source.
Ministry of Health (MoH) National Prevention of Blindness Coordinator One of the greatest challenges in Preventive Ophthalmology Alice Lehasa says glaucoma is an aathyn optic neuropathy characterised by pathological cupping and optic atrophy leading to visual field loss. Being a global public health challenge in eye care delivery and blindness prevention glaucoma constitutes the 2nd cause of blindness in the world and 1st cause of irreversible blindness. At least half of all cases still go undetected, even in the most developed European and North American countries. However, the acute prototype is not chronic but common in Africa.
Major challenges to the management of glaucoma in the developing world involve early screening and diagnosis as a silent disease with very few symptoms, until in advanced stages. Loss of vision is slowly progressive, one eye is usually more affected, (sometimes blind) than the other as a result most patients present late to the clinic. The high cost of anti- glaucoma medical treatment and pharmaceutical drugs is a nightmare to most patients and therefore hardly sustainable.
According to Vision 2020 recommendations for glaucoma programmes in Africa, people aged 40 years and above should have their visual acuity screened once every 2 years and should be referred to an eye nurse when less than the required minimum of 6/18 in one or both eyes. A register of diagnosed cases should be kept, so that persons who default on follow up can be traced.
Strategies for developing countries should include setting up coherent and functional national policies for early screening and management of glaucoma, cost and availability of anti-glaucomatous medicines, and monitoring of efficiency of current treatment and follow up of most patients.
Lehasa says that Diabetic Retinopathy which is increasing world wide in proportion to people living with the malady is the 5th cause of global blindness affecting 1.8 million, especially in economically active age group, in middle and low income countries. There is also an alarming increasing of blindness due to an increase in global incidence and prevalence of type 2 diabetes, due to ageing plus change in lifestyles leading to obesity. Screening for type 1 Diabetes should be done at puberty and then annually, while for those with type 2 at diagnosis and then annually.
Early diagnosis of DR for treatment and early laser for maculopathy or proliferative retinopathy and fundal photography results only those patients with positive findings are referred to the ophthalmologist.
Molepolole Institute of Health Sciences (IHS) Head of Ophthalmic Nursing Training (ONT) Chatawana Molao says MOH’s strategy of the Prevention of Blindness programme (PBP) is focused on achieving the Vision 2020: “Right to Sight Goal” of eradicating avoidable blindness by 2020. Since WHO estimates 80% of blindness worldwide as avoidable, developing services preventing, detecting and treating sight threatening conditions can eradicate avoidable blindness in Botswana.
Molao says MoH has come up with policy guidelines and scoping of practice for ophthalmic nurses (ON) to strengthen primary eye care and improve access to eye care for rural communities. Part of the implementation strategies include developing transfer and deployment guidelines for ON along with supportive management regulations. The procurement, maintenance and replacement of basic standard ophthalmic equipment and essential drugs in all facilities as well as the formulation of continuing professional development (CPD) and mentoring programme for ON, should become a best medical practice
Addressing the Ophthalmic Personnel Workshop held in Gaborone from March 4 to 8, 2013 with the Theme: “The Integrated Eye Care Team- Working to Eliminate Avoidable Blindness” Molao also it was designed to enhance the spirit of team work and shared vision of eliminating avoidable blindness and the availability of eye care delivery services in the country.
Molao gave details of a Situational Analysis of Ophthalmic Nursing Services in Botswana from study conducted in 2010 as a fulfillment of a Masters of Science in Community Eye Health at the London School of Hygiene and Tropical Medicine.
“Since the early 1970s, the World Health Organization has been collaborating with concerned governments and non-governmental organizations to come up with strategies to prevent blindness among world populations. Through this effort a global initiative for the elimination of avoidable blindness by the year 2020 has been launched by the attainment of the three core Vision 2020 strategies by National Programmes; Human Resource Development, Disease Control, Infrastructure and Appropriate Technology Development to make eye care services more available and accessible to the communities.
She said Sub-Saharan Africa faces the highest regional burden of blindness and has vast communities with limited or no access to eye services attributable to inadequate human resources. Health systems rely on competent and motivated workforce for effective, efficient and quality service delivery. Ophthalmic nurses (ON) are the front liners of eye care delivery at primary and secondary care settings in Botswana. There is anecdotal data relating to ophthalmic nursing practice in Botswana hence the need for situational analysis to identify the gaps and challenges that may hamper service delivery.
The aim of the study was to explore on challenges, assess core competencies of ON and map out their distribution and deployment at all levels of health systems in Botswana.
The other objective was too identify available infrastructure for ON at all health facilities in Botswana as well as explain their key core competencies and identify areas for continuous professional development.
Out of the total 70 contingent of ON in Botswana, based on age distribution although 1/3 in their 50’s are in their early retirement, the 30 – 39 age category are being deployed predominantly in rural settings where they function independently without support.
Rural clinics have limited essential equipment for ophthalmic services and only 50% of required drugs. The primary and district level, which serves a large proportion of semi urban populations, has less than 70% of equipment or essential drugs.
“Although ON’s are better remunerated, monetary incentives and professional development were regarded as the least essential motivator. Ophthalmic service delivery lack of defined policy guidelines was cited as a challenge hampering the delivery of ophthalmic nursing services in Botswana.
“There are no ophthalmic or prevention of blindness policies at all, generally we practice what we have been taught during training, and this brings confusion in practice of ophthalmic nursing. The challenge is that our health system is skewed towards providing curative services as opposed to public preventive service. As a result, OPN need to be allowed to interact with communities, where services are most needed”, Molao stated.
Furthermore, the deployment and distribution of ophthalmic nurses in the country lies with the Clinical Services Department, but their services are coordinated through the Public Health Department. The catch 22 is that there is no clearly defined structure harmonising activities of the two departments; clinical services transfer nurses any how to different facilities without taking our recommendations into consideration, while communication and feedbacks very poor in MOH. The ophthalmic nurses are not given support to practise their speciality and mostly engage in general nursing duties
The ON work at the clinic level as general nurses and are not allowed to concentrate on ophthalmic care because of the lack of equipment.
“In my facility management does not know what is happening in eye clinic; most of the times when they take hospital ward rounds, they never come to eye clinic. In most facilities our speciality is not recognised and we end up being used as floating nurses to relieve in other units.”
Be that as it may ON are the key human resources for eye health in Botswana but there is an imbalance in their distribution of between the rural and semi-urban and urban settings in Botswana.
Another drawback is that 1/3 of the entire population in rural areas are unable to access eye care services which are more skewed towards the urbanised settings and major villages.
As a way forward, the study came out with recommendations to MoH, especially strengthening of ON training programme to increase the output of 12 to 15 nurses every two years, while developing a CPD and mentoring programme.
Some of the proposals for implementation include the development of policy guidelines and scope of practice for ON; strengthening of primary eye care to improve access to eye care for rural communities; developing a transfer and deployment guideline along with supportive management regulations.
The procurement of basic equipment and essential drugs in all facilities, its maintenance and replacement is an essential component of the policy guidelines.
