Meeting Report

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26–28 October 2015 Manila, Philippines

Meeting Report

Regional Meeting to Review and

Accelerate Country Progress in Prevention

of Avoidable Visual Impairment

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Regional Meeting to Review and Accelerate Country Progress in Prevention of Avoidable Visual Impairm 26–28 October 2015 Manila, Philippines

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WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

English only

MEETING REPORT

REGIONAL MEETING TO REVIEW AND ACCELERATE COUNTRY PROGRESS IN PREVENTION OF AVOIDABLE

VISUAL IMPAIRMENT

Convened by:

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

Manila, Philippines 26 to 28 October 2015

Not for sale Printed and distributed by:

World Health Organization Regional Office for the Western Pacific

Manila, Philippines 19 July 2016

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NOTE

The views expressed in this report are those of the participants of the Regional Meeting to Review and Accelerate Country Progress in Prevention of Avoidable Visual Impairment and do not necessarily reflect the policies of the conveners.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for Member States in the Region and for those who participated in the Regional Meeting to Review and Accelerate Country Progress in Prevention of Avoidable Visual Impairment in Manila, Philippines from 26 to 28 October 2015.

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In 2010, WHO estimated more than 90 million people in the Western Pacific Region have visual impairment. Of this number, around 10 million are blind and the remaining 80 million have low vision. With today's knowledge and technology, up to 80% of global visual impairment is preventable or treatable.

The Regional Meeting to Review and Accelerate Country Progress in Prevention of Avoidable Visual Impairment was held in Manila, Philippines in 2015 following the meeting on strengthening capacity to implement Universal Eye Health: A Global Action Plan 2014–2019.

The goals of the meeting were to strengthen the capacity of national eye-care coordinators in the use of new WHO tools for assessing evidence; to guide planning and setting of national targets; and to discuss strategic priorities of national eye-care programmes, including areas for WHO support. The meeting was attended by 12 country representatives, seven observers, two resource people and four WHO Secretariat.

The objectives of the meeting were: (1) to review the national indicator data submitted by countries for the first year of Towards Universal Eye Health: A Regional Action Plan for the Western Pacific (2014–2019); (2) to discuss lessons learnt on the use of new WHO tools to assess diabetes and diabetic retinopathy systems, eye care systems, and vision rehabilitation services; and (3) to support countries in developing national priorities for the implementation of the regional action plan.

The workshop was effective in enabling participating countries to jointly review their progress, share experience and insights on how best to accelerate country programming for eye care, guided by the WHO action plan at the global or regional level. Participants were briefed on the new WHO tools and also shared their tools and experiences in monitoring quality of care, especially for cataract surgery, as well as the barriers to monitoring and how they should be addressed. Resource persons from

nongovernmental organizations (NGOs) made the case for quality monitoring and ways to improve delivery systems that favour consumers.

Following the workshop, Member States were encouraged to carry out actions that will: (1) improve information and research, which is especially needed for advocacy, programming and improving quality; (2) augment limited human resources for eye care through training and institutional tie-ups, addressing urban-rural disparity, and better tasks and skills matching; (3)

improve service delivery through the establishment of referral pathways and institutionalizing audit or performance monitoring; (4) reduce the cost of consumables by making procurement processes more efficient; (5) facilitate partnership with the private sector, including private business foundations, to augment limited public sector resources; and (6) strengthen leadership and governance through stronger representation of the eye care sector in decision-making on budgets, assistive technologies and devices, NGO participation, and business process improvements in health care facilities.

WHO is requested to: (1) take the lead in generating the necessary findings using various WHO tools, especially the Eye Care Services Assessment Tool (ECSAT) disseminated among pertinent officials of relevant ministries to enable them to validate the accuracy of information and, at the same time, be informed; (2) establish a working group at the regional level to discuss how to upscale monitoring; and (3) continue fostering intercountry sharing of tools, expertise and experience. It was also recommended that WHO, in collaboration with the Secretariat of the Pacific Community (SPC), provide technical assistance in developing a more efficient procurement system for Pacific island countries to reduce the cost of consumables.

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Country specific recommendations and next steps:

Cambodia: Ministry of Health is implementing the strategy for eye health and a blindness prevention and control plan, which is aligned with the national strategic plan. From now to 2020, the number of ophthalmic nurses is expected to increase dramatically (increasing the training from 10 to 40

candidates per year), but distribution is problem which will be addressed. There is also a plan to improve primary eye care.

Fiji: The priorities of the action plan for 2016–2020: improved eye care service delivery by strengthening integration into the health care system; addressing gaps in refractive error and low vision services; and integrating the eye care indicators into the national health information system.

The immediate next steps are: 1) send data from various eye care studies to the WHO Regional Office; and 2) plan to carry out a prevalence of blindness survey for 2017.

The Lao People’s Democratic Republic: Drafted the national policy on eye care and adopted the national action plan which is aligned with the global and region action plan. For the action plan to gain traction, it is important to coordinate with NGOs and ASEAN countries. The country has 25 ophthalmologists. More nurses are now being trained to address service gaps.

Malaysia: The country is far ahead in the prevention of avoidable visual impairment and other countries will benefit from Malaysia’s experience. In terms of poor distribution of eye care personnel, the initial action taken was to increase enrolment of master’s level students from 30 per year to 50 per year since 2014. For primary health care, the public service department will be asked to deploy more optometrists in public service.

Mongolia: Ministry of Health signed into order The Strategy for the Prevention and Control of Blindness and Low Vision (2014 – 2019) and The Vision 2020: The Right to Sight campaign.

However implementation is very difficult due to frequent change in national leadership. A training series on a cataract surgery outcome monitoring system will start in December 2015. In the near future, the professional board will be working on policy guidelines and performance standards for eye care. Screening of schoolchildren will be promoted.

Papua New Guinea: Priority actions after the meeting are: 1) advocate to government the need for outreach for cataract surgery and diabetic retinopathy; 2) plan the collaboration and coordination needed to address low vision; 3) update the country's eye profile using the findings from ECSAT; 4) work on the eye care programme's representation in the Ministry of Health; and 5) plan for increased cataract surgical rate.

Philippines: National priority actions: 1) strengthen eye health system by increasing access of the poor to cataract surgery; 2) come up with the final version of the guidelines on cataract surgery and conduct the public hearing so that it can be approved by Q1 of 2016; 3) improve low vision screening;

4) learn from Malaysia in strengthening outcome monitoring; 5) upscale community eye health by training primary healthcare workers in eye health and collaboration with other partners; and 6) conclude the programme assessment that was funded by the WHO Regional Office for the Western Pacific and commence with the equipment on loan project.

Samoa: Action points to be pursued: 1) conduct the eye care assessment using the ECSAT and assess what epidemiological study would be appropriate; 2) advocate to NHS more budget; 3) endorse an eye care plan; 4) work with relevant organizations and development partners; and 5) generate

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resources to acquire the needed equipment to support and motivate eye care workers to perform their work.

Solomon Islands: Action points identified: 1) advocacy of the Regional Action Plan with other government agencies and other development partners, as they have only done it so far at the Ministry of Health; 2) revise the national action plan once the national health strategic plan is approved; and 3) share with Ministry of Health the concept of performance-based budgeting.

Tonga: Currently implementing the national strategic plan for eye health but currently does not have an eye doctor. One doctor is being trained in Fiji and two nurses are expected to join the team in 2016.

The eye clinic in Nukualofa has three staff. Philippines could deploy ophthalmologists in Tonga.

Partners were encouraged to support the deployment of one ophthalmologist in Tonga for a year until the one being trained in Fiji comes home.

Viet Nam: Next step for the country is to have the action plan submitted to the Prime Minister and have it endorsed within the year. For 2016, the actions points include: 1) conduct of meetings to detail the action plan; 2) activity planning and implementation for increase CSR, reduce cost, improve quality of CS guided by the learning from Malaysia; 3) develop guidelines for eye care at the district level; and 4) increase eye care screening at the community level.

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1. INTRODUCTION

1.1 Meeting organization

The Regional Meeting to Review and Accelerate Country Progress in Prevention of Avoidable Visual Impairment was held in Manila, Philippines from 26 to 28 October 2015. The goals of the meeting were to strengthen the capacity of national eye care coordinators to translate the new tools that have been developed by WHO to assess the various facets of eye care into evidences that will guide planning and setting of national targets, and to discuss strategic priorities of national eye care programmes, including required WHO support. The meeting was attended by 12 country representatives, seven observers, two resource persons and four Secretariat staff. A total of 19

Member States and 10 agencies were invited to send a representative. An internal preparatory meeting was held on 2 July 2015.

1.2 Meeting objectives

The objectives of the meeting were:

(1) to review the national indicator data submitted by countries for the first year of Towards Universal Eye Health: A Regional Action Plan for the Western Pacific (2014-2019);

(2) to discuss lessons learnt on the use of new WHO tools to assess diabetes and diabetic retinopathy systems, eye care systems, and vision rehabilitation services; and

(3) to support countries in developing national priorities for the implementation of the regional action plan.

2. PROCEEDINGS

2.1 Opening session

Dr Andreas Mueller welcomed the participants to the meeting and introduced Ms Pauline Kleinitz who delivered the opening remarks on behalf of Dr Shin Young-soo, WHO Regional Director for the Western Pacific. With an estimated 90 million people with visual impairment living in the Region, many challenges remain, despite Member States making good progress in building stronger eye-health systems. Too many people are unnecessarily visually impaired because they lack access to services and affordable spectacles. Diabetic eye care is often unavailable, with the gap most prevalent in the Pacific where diabetes is often a national crisis. Half of the world’s blindness is due to un-operated cataracts, even though cataract surgery is just as highly cost-effective as vaccinations for other diseases. While the Region has made tremendous progress in eliminating trachoma, many Pacific island countries remain trachoma-endemic.

In a motion by Dr Mueller, duly seconded by the participants, the following people were designated as meeting officers: Dr Vuong Anh Duong of Viet Nam as meeting Chairperson, Dr Luisa

Cikamatana Rauto of Fiji as Deputy Chairperson and Mr Pedrito dela Cruz as rapporteur.

2.2 Introducing new WHO tools

(a) Eye Care Services Assessment Tool (ECSAT)

Dr Ivo Kocur presented the ECSAT in relation to the Global Action Plan (GAP), as the ECSAT is an offshoot of the latter and both embody the health systems approach. After three World Health

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Assembly (WHA) resolutions issued over the last 10 years, the last one being the Global Action Plan endorsed by the WHA in 2013, there have been major accomplishments at the country level. The GAP established a target of 25% reduction in avoidable visual impairment by 2019 (from the 2010 baseline). Member States should translate this to national targets and monitor how they are progressing. Convincing Member States to agree in 2013 to monitor accomplishments and what exactly should be monitored (i.e., through a list of core indicators) is an important accomplishment, and the momentum for this should be sustained. Dr Kocur acknowledged the extensive work in pilot- testing the tool in the Region (Australia, Fiji, Malaysia and Papua New Guinea) which led to its refinement.

The ECSAT follows the three objectives of the Action Plan. Departing from a one-size-fits-all approach, the tool has a modular structure whereby it is divided into sections, giving latitude to the user to jump from one section to another and not be bogged down by sections or items for which there is no easily obtainable information.

(b) Tools for the Assessment of Diabetic Retinopathy and Diabetes Services (TADDS) and Tool for the Assessment of Rehabilitation Services (TARS)

TADDS

On behalf of Dr Silvio Mariotti of WHO headquarters, Dr Mueller gave an overview of the TADDS, which was developed to assess both management of diabetes and diabetic retinopathy in countries and to estimate the level of cooperation and synergy between these two branches of health care. Diabetic retinopathy (DR) is the fifth leading cause of visual impairment and the fourth leading cause of blindness in the world. DR control cannot be achieved without good diabetes control. TADDS, which has been piloted in the Western Pacific Region, conveys the level of interaction that should exist between eye care and other branches of health care. The tool builds on the health systems framework and should be discussed and shared with the NCD or eye health programme coordinators in the ministry of health.

It is a rapid method to determine what services exist, who has access to which services, where they are provided and how they are financed. The aim is to assess not to measure, and to identify gaps and weaknesses and strengths of the system. The intent is to guide the planning, implementation and monitoring of national programmes. Informants to TADDS include the ministry of health, the WHO country office, national programme committees, professional associations, local and international NGOs, consumer/patient representative organizations and the diabetes association. Just like ECSAT, this should be done periodically (i.e. annually or every other year) to assess progress or changes.

Based on experience, the tool can be accomplished in four weeks, on average.

Dr Mueller walked the participants through the various sections of the tool and afterwards encouraged them to communicate directly with Dr Mariotti should they have questions.

WHO Tool for Assessment of Rehabilitation Services and System (TARSS)

Dr Mueller gave an overview of TARSS, which has been designed to obtain baseline data on eye care services available for people with low vision and blindness.

Findings from TARSS are for Member States to use in analysing and responding to a situation where low vision rehabilitation services – especially in low and middle-income countries – are ignored or given low priority in terms of financing, human resources and provision of services. The tool is linked

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to the WHO Global Disability Plan 2014-2021 and exhorts programme managers to think broadly from a health systems standpoint. The tool is now being applied in the Philippines and Viet Nam, and will be launched in final format.

Applying the WHO Tool for Assessment of Rehabilitation Services and System (TARSS) in the Philippines

Dr Eusebio shared the initial findings from the application of the WHO-TARSS in the Philippines, following the five components, namely: (a) demand; (b) leadership; (c) service delivery; (d)

awareness; and (e) funding. Dr Eusebio presented the prevalence of low vision and blindness among Filipino children (at 0.4 and 0.2 per thousand population, respectively) and among adults (at 1.97%

and 0.0558%, respectively). On leadership, she cited enabling plans and policies, such as the National Plan for Blindness and Prevention; the Magna Carta for Disabled Persons (Republic Act 7277 and 9442) which gives a 20% discount on services and medicines for people with disability; and Department of Education policies on inclusive education that covers children with low vision, and laws providing employment and social insurance benefits for persons with disabilities. The absence of a national plan for low vision is a limiting factor, and so is the maldistribution of low vision clinics and special education centres in favour of urban areas. Low vision specialists see an average of 70 clients per month, despite the huge number of people with low vision, and optometrists can play a major role as most cases only need spectacles. Information on low vision rehabilitation services are provided mainly by ophthalmologists, followed by optometrists and institutional websites, teachers, elderly caregivers and through notices. The NGO Resources for the Blind (RBI) has been providing low vision services to poor communities for the last 20 years. In the Department of Health, low vision is part of the programme for persons with disabilities and there is now a plan to develop low vision into a full programme.

2.3 Update on the collection of WHO Action Plan Indicator Data in the Region (a) Summary of 2014 data

Dr Mueller provided background information and presented the partial results of the RAP Indicator Survey (Regional Survey on the Prevention of Avoidable Visual Impairment) to which 11 Member States have responded, namely: Brunei Darussalam, Cambodia, China, Cook Islands, Kiribati, the Lao People’s Democratic Republic, Malaysia, Mongolia, the Philippines, Singapore and Viet Nam. The scope of data collected covers national indicators (e.g. existing human resources, cataract surgeries performed) and data on how countries are generating evidence for advocacy, developing policies, plans and programmes and forging multisectoral engagements and effective partnerships. Dr Mueller highlighted the gaps in human resources, quality assurance, and generating information, with the scarcity in human resources most severe in Pacific island countries.

Dr Mueller asked the participants from countries that have not yet submitted the accomplished questionnaire to share the accomplished tool with the WHO Regional Office for the Western Pacific.

(b) Implementing the WHO Action Plan in Mongolia

Ms Davaatseren presented on the WHO action plan progress in Mongolia.

The Vision 2020: The Right to Sight campaign was launched in 2003 in Mongolia. However, a frequent change in national leadership has made implementation very difficult. In 2014, the Minister of Health signed the order for The Strategy for the Prevention and Control of Blindness and Low Vision, 2014-2019. A National Prevention of Blindness Committee was created, with the Deputy

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Minister of the Ministry of Health designated as the coordinator and another officer of the Ministry of Health as secretary. Committee members include: the Secretary of Professional Board of

Ophthalmology at the Ministry of Health: the Chief Ophthalmologist of the Ministry of Health: Head of the Department of Mongolia National University of Medical Sciences (MNUMS); Head of the Departments of Tertiary level Hospitals; ophthalmologists from District Health Centers;

ophthalmologists from three Regional Health Centers (province); the President of the Optical Association, the President of the Association of Blind, and a representative from the WHO Country Office.

(c) Implementing the WHO Action Plan in Papua New Guinea

Dr Jambi Garap shared some of the action plan indicator data on Papua New Guinea, with a

population of between 7.2 to 7.5 million people and a highly diverse culture and difficult geography.

Based on a 2006 study, 29.2% of the population have visual impairment, of which 8.9% are functionally blind.

There are 15 ophthalmologists, but four are also doing administrative work. There are seven

ophthalmic registrars and seven optometrists, with one optometrist working with an NGO. Compared to earlier years, there was a significant improvement starting in 2008 as there are now 100 allied ophthalmic workers people can consult at mid-level. About 7000 cataract surgeries were done in 2014. A lack of human resources and motivation and interest to do outreach cataract surgeries are major constraints. Equipment and consumables are also a problem.

(d) Roundtable discussion on implementing the WHO Action Plan The following are the highlights of the discussion.

Mongolia aggregates the data collected at the provincial level. There are only two public hospitals and four private hospitals in Ulaanbaatar performing cataract surgery. Thus, it is very easy to call on the department heads to get statistics.

Papua New Guinea, which has 15 ophthalmologists when 72 are needed, underscored the challenge of motivating eye care professionals to do more to improve coverage of services. The distance and difficult terrains and lack of equipment and supplies, which are commonly cited reasons for the less- than-desired coverage of cataract surgeries, should also be addressed. Provincial hospitals should be equipped. An incentive system for eye care doctors to work in underserved areas should be explored.

There is also a need to gather all ophthalmologists and discuss with them how to address issues.

Ophthalmology as a specialization should also be marketed in the residency programme.

Kiribati, represented by the country's first ophthalmologist, shared that it has formulated a National Eye Care Plan in 2014, but the budget for this has yet to be endorsed.

Tonga has no eye doctor, but three ophthalmic nurses trained in Fiji can correct refractive errors, treat inflammations and external eye concerns. Surgeries are performed by visiting ophthalmologists (e.g.

from Chinese ships) 3-4 times a year and their arrival is announced a week in advance to prepare patients. Acute cases are brought to another country that can provide needed services. Tonga has developed a national plan which seeks to raise eye care standards through free services, including cataract surgery and spectacles.

Solomon Islands has trained eye care workers stationed in the provinces. Annual outreach missions are also conducted in the provinces, with trained eye care workers facilitating the missions. Solomon

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Islands has yet to finalize a new 5-year eye care plan for 2015–2019, which was drafted after the regional meeting in 2014 and sent to Ministry of Health in June 2015. The plan is aligned with the GAP/RAP. However, since the Ministry of Health is now developing a new National Health Strategic Plan, the eye care plan may have to be aligned with this plan once it is approved. It is not yet clear if the new eye care centre in Honiara will support other countries in the Pacific.

Fiji is incorporating the RAP in the Ministry of Health’s national health strategic plan, acknowledging that the GAP/RAP helped position eye health in the plan.

Samoa has two ophthalmologists augmented by visiting ophthalmologists from Fred Hollows Foundation (FHF) who conduct cataract surgeries in island hospitals. It is now in the process of drafting the first national eye plan. The importance of conducting a prevalence survey on visual impairment was emphasized, although it was also suggested by Dr Mueller and Dr Kocur that while there is a critical need for evidence to support priority setting, it is understandable that this be done in practical ways, especially in cases where there are severe resource constraints. One way is to use data from a prevalence survey done five years ago and triangulate this data with information at the facility and area level.

Malaysia has no difficulty tracking the number and quality of cataract surgeries done in the public sector, as compared with the private sector and NGOs doing outreach. Big private hospitals

commonly refuse to share information, as they are concerned that their finances may be scrutinized.

Advocating through medical societies can be very tedious as there are a number of societies for each specialty. Educating medical students in universities about the importance of data is one way this problem can be addressed. Malaysia also shared what seems to be an emerging good practice, though it is still at pilot scale. The cataract-free zone initiative anchored on local ownership mobilizes village volunteers to conduct exhaustive cataract case-finding, followed by referral to the eye care services delivery system. To augment government funds, the project is partnering with NGOs, family clinicians and private foundations, such as the Standard Chartered Bank, which established an intra- ocular bank. Under the initiative, a cataract surgery will cost a client some US$ 20 in a government facility, compared to US$ 690–1150 in a private hospital. This initiative is part of the Malaysian action plan for eye health which was developed after a Rapid Assessment of Avoidable Blindness (RAAB) survey covering 15 000 people over the age of 50 revealed that 58% of preventable blindness was due to cataract.

The Philippines has a prevention of blindness plan in the Department of Health's NCD strategic plan.

Low vision is part of the programme for people with disability and cataract services are embedded in the senior citizens programme. The NCD strategic plan preceded the action plan by one year. A Department of Health administrative order was passed to release $40 000 to $50 000 for the blindness prevention plan. As to data collection, there is a policy requiring all hospitals to submit statistics but only a few private hospitals comply. With the devolution, getting data from the provincial level and below has become a challenge. As proxy, data on benefit utilization of covered eye care services may be obtained from the Philippine Health Insurance Corporation (PhilHealth).

Viet Nam shared that a many major issues need to be addressed in their action plan which prioritizes cataract, refractive error and the need for epidemiological data. Cataract surgical rate needs to be improved, with some provinces having a rate of 60% and some only 40%. In the public sector, cataract surgeries are done only in hospitals. Each province has a hospital, though there are provinces that cannot provide functional surgery. For refractive errors, only 50% of spectacles distributed are of the best quality. There are public and private low vision clinics. In terms of data, there have been

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various surveys in the last two years (e.g. on refractive error and trachoma). There is a national committee led by the Vice Minister of the Ministry of Health. There is also a standing committee in the central hospital. Political participation is also a consideration in promoting greater buy-ins and political support for national eye care plans. What would be more politically palatable? A Ministry of Health driven or approved national eye care plan, or one that is approved by the Prime Minister?

Cambodia has a new strategic plan for blindness prevention and control (2016–2020), the development of which was informed by an assessment of the current plan (2008–2015).

The Lao People’s Democratic Republic shared the adoption of a National Action Plan consisting of six key objectives that are aligned with the GAP/RAP.

Towards the end of the roundtable discussion, the following points were emphasized by WHO and other participating organizations:

• In situations where it is difficult to obtain the specific information on indicators, Member States can make do with what they can presently generate. There are many equally

compelling issues with underserved populations that need to be prioritized, and a point will be reached beyond which it will not be worth the time and money required to get the data.

• Eye care data from health insurance systems should be utilized to the fullest, given the current weakness in collecting information from private hospitals and, in some countries, also from public hospitals.

• Collaborating towards building referral pathways is important, given the inadequacy of human resources especially at the primary level. Strengthening service delivery by integrating eye care and disability programmes is likewise important. Mobilizing the private business sector for innovative undertakings, such as the Standard Charter's intra-ocular lens bank in Malaysia, can also be explored to augment limited public sector spending on eye care.

• More efficient procurement of assistive devices like spectacles and intra-ocular lens should be explored by Member States. Linkages between country programme managers and social enterprises, including the Hong Kong Society for Low Vision Resource Centre, could be established.

• That countries like Cambodia, the Lao People’s Democratic Republic and Fiji are developing their national eye care plans based on new health strategic plans is no coincidence, as Universal Health Coverage is driving universal eye health, with the GAP and RAP as very important catalysts. The other goals of the Sustainable Development Goals around disability, inclusion and gender equality are also helping.

Day 2

2.4 Improving the effectiveness and quality of eye care programmes

Dr Mueller provided a summary of the first day, after which he introduced Mr David Green whose wealth of knowledge and experience in working with NGOs in making health care delivery efficient and affordable can be applied to the eye care sector.

Mr Green gave the overall context for his presentation. He cited the challenges of income inequality and ageing population and their implications to eye care. Many health care systems, especially in emerging economies, have demand versus capacity issues, as manifested by extended waiting period for services. Nine in every 10 people cannot access basic surgical care in lower middle income

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countries. Poor people in in low income countries are not only largely excluded from services, but care, when received, is likely to be of lower quality.

The following are the highlights of his presentation.

• In countries with government-led health insurance, the trend is towards private hospitals increasingly getting a greater share in service provision, thus begging the question of what these health insurance systems can do to change the situation in favour of the consumer. The question becomes crucial when one considers the high cost of consumables, consisting about one-half to two-thirds of the total amount reimbursed by government for cataract surgery.

Without lowering the cost of consumables, it will be difficult to introduce other types of interventions, such as improving surgical outcomes, having the right ophthalmologist-para- medical ratio, doing effective outreach, and introducing different incentive mechanisms.

• It is equally important to know how insurance money flows through the system and whether it promotes excellence (i.e. if it contributes to greater access by a marginalized population, improved quality of care and improved cost-effectiveness) or inhibits it. The incentives created by insurance reimbursements for cataract surgeries do not always lead to excellence.

For example, there are a lot of margin-eaters in supply chains, making insurance system- dominated eye care very expensive.

• The best business models are those that use technology, price and quality to change the competitive landscape in favour of the consumer. The corporate culture or value systems of organizations espousing these models enable them to use profit to serve more people rather than just improving bottom lines.

• Most money in health care is spent on chronic diseases. How do you wrap a model around clinical medicine in such a way that it serves the growing needs of the population? There is a middle way for capitalism, which was perverted by the overriding quest for return of investment (ROI). There are also ways to avoid dispensing grants that do not reach the intended beneficiaries. Maximizing margins may be appropriate, but how do we use this to serve others? This is where the government and private sector still have work to do.

• There are key variables that should be scrutinized and adjusted to improve outcomes, such as (i) ratio of surgeons to technicians; (ii) surgical volume per surgeon/day; (iii) outreach; (iv) cost based accounting/per unit cost of surgery; (v) cost of consumables; (vi) doctors' salaries;

(vii) surgical technique (Phacoemulsification (phaco) vs. Manual Small Incision Cataract Surgery (MSICS); (viii) cross subsidization; (ix) quality outcomes in surgery; (x) optical business; (xi) start-up costs (how to reduce); and (xii) effects of health insurance. For example, the minimum ratio of surgeons to technicians should be 1:5. Surgeons can perform up to 10 or 12 surgeries per hour. The cost of consumables is a key variable. In Mexico, a focus on reducing just this cost resulted in the programme reducing the per-unit cost by 50%. They are now earning $50 000 per month, and the money allows them to fuel their own transformation.

This shows that there is more money in the marketplace in countries without national health insurance than from any top-down largesse. In many countries like China and Viet Nam, there is high demand for phaco surgery. A number of companies promote this to make money on their consumables. Yet the results are the same or better with small-incision surgery which is much cheaper.

• Demographic variables (geography, paying capacity, population density and transportation infrastructure) are key to effective intervention. As reprogrammed money starts flowing through the system, the question arises as to how maximizing distribution over the long-term can be sustained. Understanding the local capacity to pay, basically using government data on income quintiles, is important.

• There are over 300 eye care programmes that are self-financing and serving low income segments. Eye care, more than any other medical specialty, has proven that primary, secondary and tertiary care can be self-financing and serving the poor. Lessons learnt in eye care need to be applied to other medical arenas

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• In India, the Aravind Eye Hospital started in the late 70s with 3000 surgeries. In 2012, it performed 401 000 surgeries and served a client base of 3.1 million. Even though a quarter of the surgeries are done for free, Aravind still makes a large profit. In 2014, Aravind made a 31%

profit, while also helping 300 hospitals with capacity-building. Its facility is a living laboratory for on-the-job training. One lesson learnt from Aravind is that as one reaches the lower strata, the increased visibility also attracts higher-margin patients. Eye care is probably the most self-sustaining area of health care, and other subspecialties have a lot to learn. In Bangladesh, Grameen has two profitable eye hospitals. In Egypt, the Magrabe Eye Hospital provides affordable eye care services to a high volume of clients, and it became more profitable even as 40% of surgeries were done free. The focus is on “getting it right” in areas such as surgery and bookkeeping.

• In the United States, where it is harder to introduce change, given its legal system and provider mindsets, the Pacific Vision Foundation (PVF) Eye Institute in San Francisco provides services to the uninsured. The health care dysfunction stems from lack of transparency and price competition. It is very expensive and very difficult for people to navigate. With intelligent purchasing, fixed hourly cost per surgeon (rather than unit price), high volumes and low unit price can be achieved, from $2500 to $490. As a result of improved cataract performance, Medicare reimbursement for cataract surgery dropped from

$1800 to $300.

• Tiered pricing and intelligent purchasing is very useful. In Egypt, for example, the cost of a consumables was reduced from $90 to just $20. With a spreadsheet tool, one can adjust variables like volume and price of consumables to model the future or set goals.

• In surgery, much time is wasted between cases. In a truly optimized system, one keeps the surgeon busy by preparing six surgical tables instead of just one, and increasing the number of assistants. Aravind has less than half of the percentage of complications than in the UK.

One can afford state-of-the-art equipment in a high-volume setting.

• Removing time from the equation is critical. In the Philippines, a lot of cases are lost because of the time spent to access surgery. Counselling and education are keys to acceptance of surgery. One can aim for 60%, and Aravind's aim is 92%, necessitating the setting up of camps for next-day free surgery for counselled clients. This lowers per unit cost dramatically.

• Change does not happen through grand proclamations. The power of persuasion should be employed to change the system quietly and slowly.

Group work and discussion: problems, barriers and solutions in improving the effectiveness of eye care programmes.

The participants formed two groups. One group consisted of Pacific island countries (Fiji, Kiribati, Papua New Guinea, Samoa, Solomon Islands and Tonga) with representatives from the International Agency for the Prevention of Blindness (IAPB) and the other consisted of participants from the ASEAN region (Cambodia, the Lao People’s Democratic Republic, Malaysia, Philippines and Viet Nam) with representatives from CBM, IAPB, and FHF. Both groups were asked to identify and discuss problems or barriers to improving the effectiveness of eye care programmes and what they believe are the best solutions.

Plenary presentations:

For the Pacific group, the main problems or barriers are: (i) lack of human resources resulting in dependence on foreign visiting teams; and (ii) lack of funds because of the lump sum, top-bottom approach to health sector budgeting and the absence of health insurance. The proposed solutions are:

(i) reducing the cost of commodities and equipment through bulk procurement (i.e. from a common provider) among Pacific island countries eye care programmes; and (ii) stronger advocacy for eye care within the Ministry of Health. It was further suggested that dialogues with government about

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procurement costs, the need for transparency, and the ways to lower costs should be initiated. The support of WHO and the Secretariat for Pacific Communities (SPC) for the conduct of the procurement policy dialogue and more responsive budgeting for health care should be explored.

The ASEAN group identified the following as the main problems or barriers in improving eye care: (i) limited access to affordable intraocular lens (IOLs); (ii) resistance of ophthalmologists to small incision cataract surgery (SICS) as almost all of them subscribe to phaco; (iii) government hospitals cannot order directly from social enterprises like Auralab. There has to be a middle person which makes it complicated for government hospitals to order affordable IOLs from India. The proposed solutions are: (i) adopt a three-tiered pricing system for IOLs (the Lao People’s Democratic Republic);

(ii) perform SICS in remote areas, thus reducing the cost (Cambodia); (iii) organize training workshops on SICS; (iv) advocate to government (Mongolia) and conduct awareness raising for patients (Malaysia); and (iv) register Auralab locally to dispense with the need for a middle person.

Ms Beatrice Varga cautioned the participants that changing mindsets and conduct in favour of SICS over phaco, which will effectively bring down costs, will likely be an uphill battle.

2.5 Quality assurance for cataract surgery – an update on strategies and experiences (a) The Philippine experience

Dr Uy spoke about the process leading to the development of a cataract surgical outcome monitoring tool in the Philippines, which has a decentralized health care delivery system and with around 30 poor provinces. In 2014, around 140 000 cataract surgeries were performed but whose outcomes were not monitored systematically. The Prevention of Blindness Program of the Department of Health puts a premium on regular monitoring and evaluation. For one, there is sound evidence that monitoring surgical outcome contributes to improved quality of cataract surgery especially in low-and-middle income countries. It is important that programmes for monitoring cataract surgical outcomes work in the local context. As such, the Department of Health and various programme partners developed and implemented the Cataract Surgical Outcome Monitoring Project which covers: (i) the development of the Cataract Surgical Outcome Monitoring (CSOM) Tool; (ii) development of the Cataract Surgical Outcome Monitoring System (CSOMS); (iii) piloting of CSOMs; and (iv) full implementation of CSOMS.

Discussion

Ms Davaatseren shared that MNUMS is organizing training on surgical outcome monitoring, to which all cataract surgeons in Mongolia will be invited. Following the presentation of Dr Uy, they will now include WHO and other partners.

Responding to Dr Vuong's question on how data on cataract surgeries in the Philippines are collected, Dr Uy explained that the programme cannot rely yet on the existing online registry as it is not yet fully operational, with less than 50% of government hospitals reporting.

(b) The Malaysia experience

Dr Ngah presented on cataract surgical competency outcomes monitoring in Malaysia, where two techniques are used by Ministry of Health surgeons and trainees, namely: (i) Cumulative Summation (CUSUM); and (ii) Key Performance Indicator (KPI).

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Discussion

Ms Beatrice Varga commended the Malaysian cataract monitoring system. She pointed out that it required substantial resources and massive buy-ins to put in place, and not all countries may have that level of support.

Dr Mueller commented that Malaysia is very far ahead and other countries have a lot to learn. This is an example of where the system is functioning quite well.

(c) Technology to support cataract surgical monitoring

Ms Varga presented BOOST (Better Operative Outcomes Software Tool) which may be considered as an alternative solution to some of the challenges in monitoring surgical outcomes.

BOOST was conceived to unite stakeholders behind a single cataract outcomes monitoring system (Aravind, International Centre for Eye Health (ICEH), NGOs, IAPB, International Council of Ophthalmology (ICO), WHO, end-users, etc.) and to exploit the fact that assessment of outcomes is now practical due to widespread use of small incisions (SICS, phaco).

The system will be based on a stable, centralized platform for long-term use. It features a cloud-based central database, password-protected user accounts (i.e. user decides who sees their data) and will exist as a cross-platform application, with wide pilot testing with country partners.

Ms Varga ended her presentation by stressing that the road to improving cataract surgical quality is a long one and many institutions have not even started the journey due to lack of a "car". Thus, FHF proposes to provide a robust, simple, high-quality "bicycle".

(d) Challenges in monitoring outcomes

Dr Moerchen presented on the challenges in outcome monitoring in eye care, as well as medical care in general, elaborating first on its history when Florence Nightingale introduced handwashing in hospitals during the Crimean War and how it reduced deaths from nosocomial infections, followed by Ernest Codman's admonition that every hospital establish a follow-up system to make the result of each case available at all times for investigation.

Citing published sources, Dr Moerchen raised the following points that proponents of outcome monitoring could consider:

• Audit should be integrated into local and national service priorities and needs. Audit will continue to be regarded as a burden additional to normal clinical work if it is introduced to clinicians only after they have qualified. Medical undergraduates should be introduced early to the concepts and methods of audit.

• Quality in cataract surgery is multifactorial, and can be taken from the perspective of the surgeon and service provider, or the patient and community perspective. Evaluation of the quality of a surgical service is a complex process.

• Different benchmarks and processes will be needed for trainees and consultants.

• Most doctors are resistant to outcome monitoring, thus inhibiting them from being open about the real issues or problems.

• Doctors cite lack of time as a reason for not conducting an audit, although this is not seen as a barrier to another, similar activity – namely, research. Monitoring and auditing papers are also very difficult to get published, especially from civil institutions.

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Group work and discussion: challenges in monitoring outcomes

The same groups in the first breakout session were given the following guide questions for their group work:

(i) How do you measure quality of cataract surgeries in your country? Consider such issues as national and local tools, different stakeholders and regional differences.

(ii) What kind of feedback do you get from eye health staff about their experiences?

(iii) What are your plans to upscale monitoring?

Plenary presentations

Pacific Group

Some countries do not have an ophthalmologist to perform cataract surgery, so they depend on visiting teams, while some have only one or very few ophthalmologists. Most Pacific island countries do not have a cataract monitoring system. In 2006, when the Pacific Island Eye Institute was

established, a cataract monitoring software was introduced for trained doctors to use. However, some doctors said the tool is not user-friendly and time consuming. Only Solomon Islands continued entering data in their registry.

To scale up monitoring, the group suggested that a user-friendly outcome monitoring tool, such as BOOST, be adopted. This can be used with smartphones, since hospitals in most Pacific island countries and areas lacking computers. It is important to encourage doctors to use the tool and to stress the point that is for the improvement of their performance, as well as for patient safety.

Avoiding the possibility of litigation through service improvement is another message that can be used to promote outcome monitoring.

ASEAN Group

For Malaysia, the Cumulative Sum Control Chart (eCUSUM) system is installed and running with the cooperation of 90% of eye doctors. It captures data on surgical details that can also be accessed through the web. Results of the monitoring had been used to ensure the availability of resources, as budget from government is based on performance recorded in the system. There are plans to compare results across hospitals. If this system is introduced in other countries, it should be promoted first among junior doctors as they are more receptive.

Viet Nam, has localized outcome monitoring in selected hospitals. Outside these hospitals, outcomes are measured through periodic surveys, as the Cataract Surgery Surveillance System (CSSS) is not compulsory. Health insurance payment for cataract surgery (CS) is not tied to outcome monitoring.

There is good compliance with guidelines on data capture pre-operatively and during operations, but not post-operatively or once the patient has left the hospital.

For the Philippines, the reported controversy on reimbursements for cataract surgery cases in certain private hospitals has spawned interest in outcome monitoring. There is now a plan to combine the CSOM tool with health insurance outcome monitoring. A suggestion was made to reduce the amount of information capture and to shorten the period for post-operative monitoring. In the case of outreach, one to three days would be sufficient, but for hospitals, it could be one day to one week. There is a need to work or coordinate with specialty groups as standards are set by the academy of

ophthalmologists and not the Department of Health.

For Mongolia, monitoring check is done one day post-surgery and one week after. Geographic distance makes it physically difficult to conduct monitoring. There is a plan to develop a tool and a system. Training on CS outcome monitoring is planned in December 2015.

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For Cambodia, outcome monitoring is done only in one eye hospital, even after a 2012 workshop attended by focal points from a number of hospitals. Outreach monitoring is done for one week, but only for visual acuity, without capturing complications. Outcome monitoring in residency training is logbook-based, but when there are complications no actions are taken.

For the Lao People’s Democratic Republic, hospital-based outcome monitoring is done one day, one week, and three months post-operative based on government guidelines. Outcome monitoring for outreach is done after one day. Follow-up home visits are made. Findings from outcome monitoring are encouraging more and more SICS because there is less complication, compared with Extra Capsular Cataract Extraction (ECCE) with sutures.

The group gave two overall recommendations: (i) establish a working group at the regional and country level to discuss how to upscale monitoring; and (ii) initiate intercountry sharing of tools, expertise and experience.

Day 3

2.6 Setting programme priorities and national targets in line with the WHO Action Plan (a) The global target

Dr Kocur asked participants who will present to give critical perspectives on how they determined the objectives and set targets for their countries. He explained that the whole rationale behind the

calculation of the global target, which is 25% reduction in the prevalence of avoidable visual

impairment, was based on population growth trends, on expected trends in the prevalence of blindness and visual impairment, and on the realistic chance to influence the trend. It entailed building four scenarios: doing nothing, doing just a little, doing more, and aiming for a revolution. In the end, countries agreed on the target of 25% reduction globally.

(b) Target setting in Viet Nam

Dr Vuong presented on the eye care challenges and targets in Viet Nam, which has 63 provinces, with 426 provincial hospitals, in addition to district hospitals and central hospitals. On the whole, there are 2.15 million Vietnamese with eye conditions. By 2020, this is expected to increase to 3 million.

Among Viet Nam's achievements in eye care are: (i) establishment of eye care networks from local to central level; (ii) increased human resources; (iii) significant contribution from the private health sector; (iv) transfer of new technologies in eye care to lower level hospitals by the national

programme; (v) models of community-based comprehensive eye care and district level eye care being piloted; (vi) development and adoption by the Ministry of Health of re-training programmes for doctors and nurses specializing in ophthalmology; (vii) introduction of an early screening programme in communities and schools to detect causes of blindness; (viii) controlling trachoma; and (ix)

improved cataract surgery services, resulting in an increasing number of cataract surgeries, and setting up outcome monitoring in select provinces.

Some of the challenges include limited multisectoral involvement, insufficient health education and promotion programme, low capacity at the lower levels of health care, and weak quality assurance of services, especially by the private sector (e.g. in four provinces, less than 50% of the glasses

dispensed from private optical shops were provided at best correction). Also, at the provincial level, it is difficult to define where responsibility for eye care rests.

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(c) Target setting in Fiji

Dr Rauto started by going through the various National Eye Care Strategic Plans and Ministry of Health National Strategic Plans in Fiji. The national eye care strategic plans were not really synchronized with the Ministry of Health strategic plan, as the years that they cover do not match.

This year, the eye care priorities will have to be aligned with the Ministry of Health National Strategic Plan. With the help of WHO tools, the eye care strategic plan was developed and will be finalized.

The NSP will be for 2016–2020 and it needs to be endorsed by Cabinet in the coming months.

Setting national targets continues to be a challenge due to information gaps and weak research.

Monitoring and evaluation are also vital. The national targets are: (i) reduced prevalence of VI + blindness from 13.6% to below 10% by 2019; (ii) by 2020 increase the doctor to population ratio to1/1000 and fill seven out of 19 nurse vacancy posts. There are also yearly targets for rehabilitating low vision, dispensing glasses, diabetes screening, cataract surgeries and examining refractive errors.

(d) Target setting in the Philippines

Dr Noel Chua then presented on targets in the Philippines.

The National Prevention of Blindness Plan (2013–2017) have the general objective of reducing the current prevalence of bilateral blindness due to all causes to less than 0.5%, as well as the specific objectives of: (i) reducing the prevalence of cataract blindness by 50% by 2016; (ii) reducing blindness and visual impairment due to refractive errors by 10% per year by 2016; and (iii) reducing the prevalence of blindness and visual impairment in children by 50% by 2016. The targets and priorities were determined based on analysis of the current situation and guided by the Global Plan of Action, the Strategic Direction and Thrust of the National and Local Government (i.e. universal health coverage).

Roundtable sharing

Dr Mueller called for any remaining questions and issues that should be discussed. He then suggested that each participant identify a few action points from their reports that they can pursue upon

returning to their country. It is important for countries to demonstrate what they have accomplished or plan to accomplish.

For Mongolia, Ms Davaatseren said that action plan implementation started in 2014. A workshop involving ophthalmologists and policy-makers from the Ministry of Health and other ministries will be held November 6 to 7, 2015 to implement the action plan. The action plan will be published in Mongolian and English and disseminated afterwards. In the near future, the professional board will be working on policy guidelines and performance standards for eye care. Screening of schoolchildren will be promoted. A training series on a cataract surgery outcome monitoring system will start in December.

For Malaysia, Dr Ngah said there had been a national blindness survey, with six RAABs conducted in two months. In terms of poor distribution of eye care personnel, the initial action taken was to

increase enrolment of master’s level students from 30 per year to 50 per year since 2014. Starting in 2016, a parallel programme will be implemented where they will complete their final year training at a ministry of health hospital. For primary health care (PHC), the public service department will be asked to deploy more optometrists in public service. Malaysia will have its first national public health

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committee meeting, followed by a public health subcommittee meeting which will cover public health and hospital care.

For the Lao People’s Democratic Republic, there is a national policy on eye care which has just been drafted. An eye health assessment has been conducted in the north as well as a glaucoma survey. The country has 25 ophthalmologists and is sending a good number for residency in Thailand for three years. More nurses are now being trained. There is DR screening in big hospitals in the cities, and this is expanding to the provinces. For the Lao People’s Democratic Republic action plan to gain traction, it is important to coordinate with NGOs and ASEAN countries (i.e. to work together on priority setting, such as manpower and disease control).

For Kiribati, Dr Tekeraoi said the plan which was drafted in 2014 is not yet approved. The equipment for starting off an eye care programme is being provided by WHO and the Pacific Islands Project.

This regional meeting is very important because the tools shared now enable countries to determine gaps and needs. The next priority is to secure the required consumables, which is a problem as the ministry does not allocate a budget for these. Dr Rauto added that the ministry gets a lump sum budget (i.e. no separate budget for eye care) and there are competing health priorities.

For Cambodia, Dr Sok first spoke from the perspective of the six building blocks. On policy and leadership, there is now a strategy for eye health and a blindness prevention and control (BPC) plan, aligned with the national strategic plan of the Ministry of Health. There is also an eye health coordinator in every province. In terms of human resources, there are 33 ophthalmologists but the problem is distribution, as most are in Phnom Penh. In Cambodia, only three to four candidates can enrol in ophthalmology, which means the country will not reach the target of 150 ophthalmologists by 2020. However, the country is increasing the training of ophthalmic nurses, from 10 to 40 candidates per year. The training centre was previously under the Ministry of Health, but is now with the

University of Eye Health. From now to 2020, the number of ophthalmic nurses is expected to increase dramatically. The distribution of ophthalmic nurses throughout the country is an issue. There is no special training for optometrists, though international lecturers come to train optometrists every two months. A few are sent to train overseas. Some working in the health centre are trained to do eye care, and village volunteers are also trained to do promotion. There is a plan to improve primary eye care.

Cambodia has established six to seven vision centres for primary eye care with ophthalmic nurses conducting basic examination, prescribing eye glasses, and making referrals to base hospitals. There are 25 provincial hospitals, but four of them do not have eye units. There are also no eye units in district hospitals. On service delivery, the programme tries to increase the cataract surgical rate (CSR) from 400 in 2004 to 1800 in 2014. There is a national essential medicine list which includes

consumables, which means they are available from the Ministry of Health. The information system is a problem. Monitoring quality is very weak, as there is only one eye hospital that collects information.

The 20 eye units do not collect quality information. This is now a priority, as we have learnt from Malaysia and Thailand.

For Tonga, there is a national strategic plan for eye health. There are three workers running the eye clinic in Nukualofa. There is an eye clinic on another island but the ophthalmologist just migrated to New Zealand. A doctor, now being trained in Fiji, and two nurses are expected to join the team next year, and will help improve the standards and capacity for service provision. For severe cases like perforated eye injury, the decision point is either to refer to New Zealand or Fiji. Surgical visits of foreign doctors (3 to 4 times a year) are very helpful. Dr Mueller suggested that the Philippines could deploy ophthalmologists in Tonga. Dr Chua explained that there is always that possibility. He cited though that they recently posted information for a posting in another Pacific island country but no one

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has yet expressed interest. When there is a request for Filipino ophthalmologists the information is shared with the academy and the new graduates through the schools and new diplomates. Dr Mueller said that interest comes with some financial remuneration, and this is a real opportunity to make a difference, that is, if partners would be willing to support the deployment of one ophthalmologist in Tonga for a year until the one being trained in Fiji comes home.

For Solomon Islands, the action point identified by Mr Jack included (i) advocacy of the RAP with other government agencies and other development partners, as they have only done it so far at the Ministry of Health; (ii) revise the national action plan once the national health strategic plan is approved; and (iii) share with Ministry of Health the concept of performance-based budgeting.

For Samoa, Dr Takazawa shared the immediate action points she will pursue after the meeting, which are: (i) conduct the eye care assessment using the ECSAT and assess what epidemiological study would be appropriate (is a RAAB survey necessary given the small population?); (ii) advocate to NHS more budget; (iii) endorse an eye care plan; (iv) work with relevant organizations and development partners; (v) generate resources to acquire the needed equipment to support and motivate eye care workers to perform their work.

For Papua New Guinea, Dr Garap's priority actions after the meeting are: (i) advocate to government the need for outreach for cataract surgery and diabetic retinopathy; (ii) plan the collaboration and coordination needed to address low vision; (iii) update the country's eye profile using the findings from ECSAT and use it as basis for planning and policy development for improved eye care; (iv) work on the eye care programme's representation in the Ministry of Health; (v) plan for increased cataract surgical rate and improved coverage of services for DR and refractive errors; and (vi) in reference to the example from Viet Nam, make sure that the plan is accepted by government.

For the Philippines, Dr Uy enumerated the following priority actions: (i) strengthen eye health system by increasing access of the poor to CS; (ii) come up with the final version of the guidelines on CS and conduct the public hearing so that it can be approved by Q1 of 2016; (iii) improve low vision

screening; (iv) learn from Malaysia in strengthening outcome monitoring; (v) upscale community eye health by training PHC workers in eye health and collaboration with other partners; (vi) and conclude the programme assessment that was funded by the WHO Regional Office for the Western Pacific and commence with the equipment on loan project.

For Viet Nam, Dr Vuong mentioned that the most important next step is to have the action plan submitted to the Prime Minister and have it endorsed within the year. For next year, the actions points include: (i) conduct of meetings to detail the action plan; (ii) activity planning and implementation for increase CSR, reduce cost, improve quality of CS guided by the learning from Malaysia; (iii) develop guidelines for eye care at the district level; and (iv) increase eye care screening at the community level.

For Fiji, Dr Rauto listed the priorities of the action plan for 2016–2020 which will hopefully be approved by December 2015 by the Cabinet: (i) improved eye care service delivery by strengthening integration into the health care system; (ii) addressing gaps in refractive error and low vision services;

(iii) integrating the eye care indicators into the national health information system. The immediate next steps are (i) send data from various eye care studies to the WHO Regional Office; and (ii) plan to carry out a prevalence of blindness survey for 2017, for which technical assistance or guidance is requested regarding the best method to apply.

In relation to human resources for eye care, Dr Chua mentioned that with the ASEAN integration, Philippine schools can train students from countries in the Region and can also offer residency

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training programmes. He also shared that National Committee for Sight Preservation (NCSP) can help connect Pacific island countries to suppliers of ophthalmic equipment, as it is less expensive if purchased in the Philippines, as was done for the Federated States of Micronesia.

2.7 Closing

Dr Mueller thanked all the participants for a successful workshop. He said that very important information had been shared and concrete actions were thought out after the input sessions. He then mentioned changes in the organization of the disability and blindness programme in the WHO Regional Office, and part of this is the end of his tour of duty after a short extension. A new

individual will be heading up the disability programme, in which blindness will be a part. He advised participants to feel free to consult Dr Kocur, who will continue to work with WHO on eye care matters. He thanked the Chair and Vice-Chair for their able facilitation of the meeting.

Dr Kocur thanked everyone for their active participation in the meeting which strengthened partnerships and sharing of experience, information and tools. He acknowledged that the WHO blindness programme faces challenges. He thanked Dr Mueller for all his efforts and dedication which attained so much for the programme. He asked participants to remain optimistic since Dr Mueller will continue to work in the eye care sector.

3. CONCLUSIONS AND RECOMMENDATIONS

3.2.1 Recommendations for Member States Member States are encouraged:

1. to improve information and research which is especially needed for advocacy, programming and improving quality;

2. to augment limited human resources for eye care through training and institutional tie-ups, address urban-rural disparity, and better tasks and skills matching;

3. to improve service delivery by establishing referral pathways and institutionalizing audit or performance monitoring;

4. to reduce the cost of consumables by making procurement processes more efficient;

5. to facilitate partnership with the private sector, including private foundations, to augment limited public sector resources; and

6. to strengthen leadership and governance through stronger representation of the eye-care sector in decision-making on budgets, assistive technologies and devices, NGO participation, and business process improvements in health-care facilities.

3.2.2 Recommendations for WHO WHO is requested:

7. to be instrumental disseminating findings (generated using WHO tools, especially the ECSAT) among relevant ministries so that they can be informed of the results and validate the accuracy of information;

8. to establish a regional working group to discuss how to up-scale monitoring; and

9. to continue fostering intercountry sharing of tools, expertise and experience. It was also recommended that WHO, in collaboration with the Secretariat of the Pacific Community, provide technical assistance in developing a more efficient procurement system for Pacific island countries to reduce the cost of consumables.

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ANNEX 1 PROVISIONAL LIST OF PARTICIPANTS, RESOURCE PERSONS,

REPRESENTATIVES/ OBSERVERS AND SECRETARIAT

1. PARTICIPANTS

Dr SOK Kheng, Officer, Ophthalmologist, Khmer Soviet Friendship Hospital

149 St Phlov Lum, Samarky Village, Sangkat Russeykeo, Khan Russeykeo, Phnom Penh Cambodia, Tel. No.: (855) 12456747; E-mail: [email protected]

Dr Luisa Cikamatana RAUTO, Consultant/Ophthalmologist, Acting Deputy Secretary Hospital Services, Lautoka Hospital, P.O. Box 5734, Lautoka, Suva, Fiji

Tel. No.: (679) 6626474, Fax No.: 8610) 6665423, E-mail: [email protected] Dr Rabebe TEKERAOI, Ophthalmologist, c/o Ministry of Health and Medical Services Nawerewere, Tarawa, Kiribati, Tel. No.: (686) 28100 or (686) 68612

E-mail: [email protected]

Dr Khamkhoune HOLANOUPHAP, Ophthalmologist, National Ophthalmology Center Ministry of Health, Vientiane Capital, Vientiane, Lao People's Democratic Republic Tel. No.: (020) 55601854, E-mail: [email protected]

Dr Nor Fariza NGAH, National Head of Ophthalmology Services, Consultant/

Ophthalmologist, Department of Ophthalmology, Hospital Selayang, Selangor 68100 Malaysia, Tel. No.: (603) 61203233 ext 4133 or (6012) 3181292

E-mail: [email protected]

Ms Uranchimeg DAVAATSEREN, Head, Department of Ophthalmology, Mongolian National University of Medical Sciences, Zorig Street-3, Sukhbaatar District, Ulaanbaatar Mongolia, Tel. No.: (976) 199992174, E-mail: [email protected];

[email protected]

Dr Jambi GARAP, Deputy Chief Ophthalmology (Southern Region), National Department of Health, P.O. Box 6686, National Capital District, Boroko, Papua New Guinea

Tel. No.: (675) 3248222/72248204, Fax No.: (675) 3013604, E-mail: [email protected] Dr Maria Rosario Sylvia Z. UY, Medical Officer IV, Disease Prevention and Control Bureau Essential Non-Communicable Disease Division & Lifestyle Related Disease Division

Department of Health, 3rd floor, Building 14, DOH Central Office, San Lazaro Compound Sta Cruz , Manila, Philippines, Tel. No.: (632) 651-7800 local 1751-1752/(632) 732-2493 Email: [email protected]

Dr Aana Erna TAKAZAWA, National Eye Coordinator, National Health Services P.O. Box 604, Apia, Samoa, Tel. No.: 66542/7603101, E-mail: [email protected] or [email protected]

Meeting Report

26–28 October 2015 Manila, Philippines

Meeting Report

Regional Meeting to Review and

Accelerate Country Progress in Prevention

of Avoidable Visual Impairment

WORLD HEALTH ORGANIZATION

CONTENTS