Improving eye care in Rwanda

Abstract Problem Visual impairment affects nearly 285 million people worldwide. Although there has been much progress in combating the burden of visual impairment through initiatives such as VISION 2020, barriers to progress, especially in African countries, remain high. Approach The Rwandan Ministry of Health has formed partnerships with several nongovernmental organizations and has worked to integrate their efforts to prevent and treat visual impairment, including presbyopia. Local setting Rwanda, an eastern African country of approximately 11 million people. Relevant changes The Rwandan Ministry of Health developed a single national plan that allows key partners in vision care to coordinate more effectively in measuring eye disease, developing eye care infrastructure, building capacity, controlling disease, and delivering and evaluating services. Lessons learnt Collaboration between stakeholders under a single national plan has ensured that resources and efforts are complementary, optimizing the ability to provide eye care. Improved access to primary eye care and insurance coverage has increased demand for services at secondary and tertiary levels. A comprehensive strategy that includes prevention as well as a supply chain for glasses and lenses is needed.


Introduction
Visual impairment -both preventable and treatable -affects an estimated 285 million people globally. Most of the people affected (87%) live in low-and middle-income settings. 1,2 In Africa, an estimated 32 700 people per million are visually impaired. 3 A variety of eye disorders contribute to visual impairment, including cataract, glaucoma, trachoma and refractive error. 3 Nearly 80% of impairments are preventable or treatable. 4 Presbyopia -difficulty focusing on nearby objects -is a common feature of ageing, as the ocular lens loses elasticity. The ageing population and the lack of national plans to address the effect of visual impairment on people's productivity and quality of life, will likely increase the burden of eye disease in many African countries. 5 Providing eye care services to mitigate visual impairment is an important dimension of delivering comprehensive primary health care. It also contributes to economic growth and development by helping reduce injuries and by improving access to education and employment. 6 Investment in eye care services has a benefit-to-cost ratio of more than two to one. 4,7 While there is multilateral organizational support for integrating eye care services into health systems -including the launch of the VISION 2020 Right to Sight Initiative -there are barriers to progress, especially in low-income settings. 2 In many African countries, there is a shortage of eye care personnel, a lack of standardized training, inadequate coordination among eye care stakeholders and for those in need of eye care, the cost of equipment and treatment can be an obstacle. 4,8 Challenges with data collection and measurement of the burden of visual impairment complicate efforts to generate support for effective health policy development. 8 Here we summarize ongoing efforts to overcome barriers to addressing the burden of visual impairment in Rwanda.

Setting
Rwanda has 10.5 million inhabitants. Over the past two decades, mortality caused by infectious diseases has dropped, for instance, mortality related to acquired immunodeficiency syndrome fell by 82% between 2000 and 2012. Consequently, life expectancy has nearly doubled since the 1990s and is now at 63 years of age. 9 In the population older than 49 years, in 2006, the overall prevalence of visual impairment was 5.3% (not including presbyopia) and the prevalence of blindness was 1.8%. 10 In 2006, more than 80% of the eye conditions were considered preventable or treatable -including cataract, refractive error and trachoma. 10 Other estimates suggest that more than 65 000 people (0.6%) in Rwanda are blind in both eyes and 12% of the population -including those with presbyopia -have a correctable refractive error and are therefore in need of corrective lenses. 11 While Rwanda has experienced substantial economic growth, nearly 50% of the population still lives below the poverty line, especially in rural areas. This means that most people are not able to afford private eye care services. 12 More-Problem Visual impairment affects nearly 285 million people worldwide. Although there has been much progress in combating the burden of visual impairment through initiatives such as VISION 2020, barriers to progress, especially in African countries, remain high. Approach The Rwandan Ministry of Health has formed partnerships with several nongovernmental organizations and has worked to integrate their efforts to prevent and treat visual impairment, including presbyopia. Local setting Rwanda, an eastern African country of approximately 11 million people. Relevant changes The Rwandan Ministry of Health developed a single national plan that allows key partners in vision care to coordinate more effectively in measuring eye disease, developing eye care infrastructure, building capacity, controlling disease, and delivering and evaluating services. Lessons learnt Collaboration between stakeholders under a single national plan has ensured that resources and efforts are complementary, optimizing the ability to provide eye care. Improved access to primary eye care and insurance coverage has increased demand for services at secondary and tertiary levels. A comprehensive strategy that includes prevention as well as a supply chain for glasses and lenses is needed.

Box 1. Summary of main lessons learnt
• Collaboration between stakeholders under a single national plan has ensured that resources and efforts are complementary, optimizing the ability to provide eye care. • Improved access to primary eye care and provision of insurance has increased demand for eye care services at secondary and tertiary levels. • A comprehensive strategy is needed; one that includes prevention of eye disease and a supply chain for glasses and lenses.
over, most eye care resources are located in the capital of Kigali, a situation which has resulted in public-private partnerships aiming to ensure equity in access to eye care services.

Forming partnerships
In 2002, Rwanda signed the VISION 2020 initiative and created a national vision plan to end needless blindness. The plan has been updated regularly in collaboration with stakeholders. 11 As part of the plan, the Ministry of Health partners with various nongovernmental organizations (NGOs) and private providers to address the preventable and treatable burden of visual impairment, especially at the primary care level. Here we describe partnerships between the Ministry of Health and three international non-profit partners: Vision for a Nation, the Christoffel Blinden Mission and the Fred Hollows Foundation. We categorize these partnerships in four pillars: (i) measurement of disease prevalence and evaluation of services (e.g. funding disease burden studies); (ii) infrastructure development (e.g. building of eye care clinics); (iii) human resources development (e.g. standardizing the eye care curriculum for nurses); and (iv) disease control and service delivery (e.g. providing low-cost or free eye glasses to those in need; Table 1).

Guiding principles
Three principles have guided these changes in the way eye care services are delivered in Rwanda: prioritizing geographic equity of service delivery, reducing the cost of access to services, and coordinating all partners under a single national plan. The Rwanda health system aims to provide eye care services at primary, secondary and tertiary levels (Fig. 1) in a decentralized and evenly distributed manner. Primary health care is delivered through a network of 45 000 community health workers and 502 health centres. In 2010 the Rwandan government launched a comprehensive primary eye care programme with the support of the organization Vision for a Nation. This programme includes creating a permanent primary eye care curriculum at all eight nursing schools in Rwanda, educating 1250 existing health centre nurses in primary eye care services and improving referral guidance. To date, the programme has administered approximately 200 000 vision assessments nationally and created a sustainable nationwide supply chain for eye glasses. National campaigns are run to inform people that they can access these services.
To ensure that services are affordable, the Rwandan community-based health insurance scheme, which enrols most of the population, 9 now includes vision care services, including reimbursement for consumables.
The Ministry of Health coordinates partners by ensuring that their activities align with the national vision plan. A technical working group -consisting of partners and Ministry of Health representatives -advises on implementation. The working group provides planning and ensures that each partner is providing the most appropriate services, given their available resources and expertise. For example, through the primary eye care programme, efforts to increase awareness and attention to vision care at the primary level have increased demand for more advanced vision care at the secondary and tertiary care levels, including cataract surgery. Therefore, other partners -such as the Fred Hollows Foundation and the Christoffel Blinden Mission -have provided their expertise to create curricula, support scholarship programmes to train eyecare specialists, deliver specialty care and develop critical health-care infrastructure at these more resource-intensive levels. These efforts complement private eye care clinics and hospitals that also provide more advanced eye care services in Rwanda.

Next steps
Although these non-profit collaborations have helped to orchestrate the development of eye care delivery infrastructure, human resource capacity and quantity of services, formal assessments will be necessary to document improvements in population health. Evaluation of the primary eye care programme is ongoing and the next population survey to assess the burden of avoidable blindness will be done this year. However, evidence from the Rwandan electronic health management information system suggests that demand for eye care services may be increasing: eye disease was the second leading reason for seeking care in 2014. In 2009, eye diseases were not among the 10 leading reasons for seeking care. Additional indicators -such as the number of cataract operations done and the number of people presenting with glaucoma -recently added to the electronic information system will help to monitor progress and identify remaining gaps, especially for more advanced eye care. The World Health Organization has set a target of 2000 operations per million population per year for cataract surgery in Africa. The cataract surgery rate in Rwanda was estimated at 300 operations per million population per year in 2007. 14 Also, despite the gradual increase in human capacity, there continues to be a shortage of trained eye care specialists across sub-Saharan Africa. 8 In 2014, there were only 18 ophthalmologists in Rwanda, most of whom resided in the capital, leaving rural areas underserved. 10 Policies to promote task shifting, such as through the Rwandan three-year ophthalmic technician train-ing course, has helped to address this gap, yet more trained professionals will be needed. Other east African countries, such as Uganda, are also investigating task shifting to bolster workforce capacity through its ophthalmic clinical officers' programme. 15 Collaborations between the Ministry of Health and key partners have improved the capacity to manage visual impairment in Rwanda (Box 1). Though advanced eye care services need more development, we are optimistic that continued collaboration will provide opportunities to overcome the remaining challenges. ■

Competing interests: None declared.
Lessons from the field Improving eye care in Rwanda Agnes Binagwaho et al.