Rapid action to avoid cataract blindness in South Sulawesi

Background: RAAB 2013 reported the prevalence of bilateral blindness in South Sulawesi was 2,6%, with cataract as the main causes of blindness (64.3%). This report described the ‘crash program’ for cataract blindness control in South Sulawesi within the last 3 years (2014 2016). Methods: This is a descriptive study of a ‘crash program’ in South Sulawesi which consist of data collection of cataract infrastructures, human resources, and cataract surgical rate (CSR) from each district in South Sulawesi. From these data, we conduct an analysis and ‘crash program’ planning, establish special and regional teams, and perform advocacy to stakeholders of each district to describe the condition of the eye health services and action plans for cataract blindness prevention in each district. Results: The number of cataract surgery in South Sulawesi was 13,988 with CSR of 1,753 in 2014. The number of cataract surgery in 2015 and 2016 was increased to 16,295 with CSR of 1,954 and 19,147 with CSR of 2,383 respectively. In August 2016, an advocacy workshop was held generating an agreement from all stakeholders from each district in South Sulawesi in the development of the cataract blindness control program. Conclusions: By implementing a sustained ‘crash program’ for cataract blindness control involving stakeholders from each district, the number of cataract-related blindness in South Sulawesi will be reduced and the CSR target of 3000 in 2018 can be reached.


INTRODUCTION
South Sulawesi is one of the Indonesian provinces in the southern peninsula of Sulawesi island.The 2010 census estimated the population as 8032551 people, which makes South Sulawesi the most populous province on the island (contributing 46% of the population of Sulawesi), and the sixth most populous province in Indonesia.South Sulawesi covers an area of 45764.53square kilometers.The province is bordered by Central Sulawesi and West Sulawesi to the north, the Gulf of Bone and Southeast Sulawesi to the east, Makassar Strait to the west, and Flores Sea to the south.Despite its massive natural resources and potential income, many people in South Sulawesi province still live in poverty. 1 According to national data in 2016, 9.24% people still live below the poverty line with per capita income ± 13 USD / month.Most of these unfortunate people live in rural area. 2 In 2013, studies in South Sulawesi, using Rapid Assessment of Avoidable Blindness (RAAB) method found that the prevalence of bilateral blindness was significantly higher than other countries (2.6%) in South-East Asia.The most common causes of blindness were cataract (64.3%), non trachomatous corneal opacity (10.8%), other posterior segment disease (7.1%), and diabetic retinopathy (2,2%).Untreated cataract is the major cause (54.5%) of severe visual impairment (people with visual acuity >3/60 -≤ 6/60).These problems need focused planning and implementation of eye programs.In this study, the implementation presented as 'crash program' (we use this name to indicate an extreme urgency of the intervention) to reduce cataract related blindness.The main goal is to increase the cataract surgical rate (CSR) from 1422 surgeries in 2013 to at least 3000 surgeries in 2018. 3

Data collection
The first step before launching or commencing a program was to collect necessary data.
To optimize the program, we collected data about potential health care facilities that have not performed cataract surgery at all or at full capacity, distribution of human resources (ophthalmologists) and coverage of the total area, numbers of population in each city and regency, and the distribution of CSR between the regions.The CSR distribution data are required since it is likely to be uneven.

Advocacy
The high prevalence of cataract-related blindness creates the need for a 'crash program' to address the issue as soon as

ORIGINAL ARTICLE
South Sulawesi.The goal of this advocacy workshop was to reduce the administrative problems.As explained above, South Sulawesi province is a large land area.With this in mind, South Sulawesi IOA realized it was important to establish a good referral system.South Sulawesi province would be divided into 4 principle zones, each with one referral    Training in case finding and workshops were performed in all 4 districts for general physicians (GP), nurses, and volunteers (cadres and school teachers).GP, nurses, and volunteers were taught about how to do proper cataract screening and when to refer.
Activity data suggest the 'crash program' for cataract blindness control, had been broadly successful in increasing the CSR.The total number of cataract surgeries in South Sulawesi was increased from 13,988 with CSR of 1,753 in 2014 to 16,295 with CSR of 1,954 in 2015.Data from 2016 shows an even bigger increase with 19,147 surgeries and CSR of 2,383.

DISCUSSION
The results of blindness survey using RAAB protocols performed in 3 provinces (West Nusa Tenggara, West Java and South Sulawesi) in 2013-2014 was the prevalence of blindness whose age was > 50 years old of 3.2% (average) and the main cause of this was cataract (71%). 4From a more optimistic perspective, blindness due to potentially reversible cause cataract was much higher than irreversible causes, such as glaucoma, corneal disease, and other posterior segment diseases combined.

ORIGINAL ARTICLE
In South Sulawesi itself, the RAAB conducted in 2013 found that the prevalence of bilateral blindness (2.6%), again with cataract as the most common cause (64.3%). 3Compare to other provinces in Indonesia, the prevalence of bilateral blindness in South Sulawesi was lower than West Java (2.8%) and West Nusa Tenggara (4%).However, it is still high compared to avoidable blindness in another country, such as Maldives (2.0%).Based on these data, the decline in the prevalence of blindness due to cataracts in South Sulawesi was urgent.
In order to reduce the number of cataracts, it is necessary to match the cataract surgical rate with the incidence of 'operable' cataract.In India and other countries in South East Asia, to deal with cataract causing visual acuity of less than 6/60, they need to perform at least 3000 cataract surgeries per one million populations per year. 12he 2013 CSR in South Sulawesi was 1422.This is a commendable number, considering the wide geographical area and the level of poverty.This number was higher than average CSR in Indonesia (800 in 2012) and many African countries, such as Ethiopia and Kenya (lower than 500), 9 but lower than in some countries in Asia, such as India (5054 in 2013) 10 and China (3073 in 2013). 11In comparison, CSR in developed countries was about 4000-7000.According to this data, the CSR number in South Sulawesi in 2013 was still too low to overcome the cataract blindness.
Several conditions limit the eradication of cataract blindness in South Sulawesi, including resistance from local ophthalmologists, lack of attention and participation from local government, and lack of screening.The local ophthalmologists refuse free mass cataract surgery program from South Sulawesi IOA.They believed this program would reduce their income.Screening problem was caused by inadequate knowledge among GPs, nurses, and cadres to detect the patients with cataract.Therefore, many patients with operable cataract were not referred or treated adequately.
Based on this evaluation of the challenges and scale of the problem, we conducted a 'crash program' from 2013 to 2016.This program started with established trust through advocacy to the governor and local ophthalmologists.The next step was to achieve the recommendations from all ophthalmologists and stakeholders in each district in need of the cataract blindness control program.We also held training for case finders, from GPs, nurses, and cadres.We established and developed regional teams that serve as referral centers for cataract treatment.In order to execute this 'crash program' , we received financial support, equipment, and resource development from several NGOs, such as Lions Club International, ORBIS, HKI, Mata Hati, and CBM.
During the course of the 'crash program' , resistance from local ophthalmology appeared to diminish with the mutual agreement that had been made in the advocacy workshop.With this agreement, South Sulawesi IOA was able to develop cataract blindness control programs in each district in collaboration with local ophthalmologists and stakeholders.With the cooperation of our two active regional teams; southern and northern teams; and one growing team in the central area of South Sulawesi, we believe that we will be able to establish adequate coordination and transportation system to improve eye health services and raise the CSR rate in South Sulawesi.
The main challenge to the 'crash program' is the national health insurance policy that does not offer reimbursement to cover the social services part of the program.In this program, the funding came from NGOs only.This creates dependence on donations which means the program may not be sustained on government budget alone.
The program has resulted in an increase of CSR is possible even in a few short years.Based on these numbers in South Sulawesi in the last three years, we believe that it is possible to reach CSR of 3000 in 2018.

CONCLUSION
By implementing a sustained 'crash program' for cataract blindness control and involving all stakeholders from each city and district, the number of cataract-related blindness in South Sulawesi appears to be reduced and the CSR target of 3000 in 2018 can be reached.

Figure 2
Figure 2 The 4 referral areas in South Sulawesi Province

Figure 4
Figure 4 Training and workshop for Nurses and General Practitioners

Figure 3
Figure 3 Equipment donation by LCIF as part of Sight First Grant

Table 1 Recommendation that has been signed by stakeholders and local ophthalmologists in each district in South Sulawesi Province No Districts CSR 2015 Target of total operation to achieve CSR 2500 (2017) Target of total operation to achieve CSR 3000 (2018) Advice on the number Cataract Mass Operation/Year
South Sulawesi's capital).National Eye Health Committee, governor, regent, city mayor, all of the ophthalmologists and all of the directors of the district hospitals in South Sulawesi attended this workshop.This workshop generated commitment and recommendations related to the blindness control program from all stakeholders and ophthalmologists from each district in

Table 4 Total of cataract surgery and CSR in South Sulawesi Province (2013-2016)
Figure 1 Advocacy workshop attended by all stakeholders in South Sulawesi Province