Vision 2020 Strategic Framework – Caribbean 2010

Blindness and low vision are a public health problem throughout the world, this is why the World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB) together with NGOs have launched VISION 2020 – the global initiative for the elimination of avoidable blindness.  This initiative that brings together governments, WHO, international and national NGOs, as well as associations of professionals in eye care, aims to determine global, regional and national plans of action in prevention of avoidable blindness and inclusive services. In the Caribbean VISION 2020 was officially launched in Trinidad-Tobago in April 2000.

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STRATEGIC FRAMEWORK FOR VISION 2020: THE RIGHT TO SIGHT

CARIBBEAN REGION

PAN AMERICAN HEALTH ORGANIZATION
WORLD HEALTH ORGANIZATION
VISION 2020

Barbados
2010

CONTENTS

ACKNOWLEDGEMENT

ACRONYMS

INTRODUCTION

1. DISEASE CONTROL AND PREVENTION OF VISUAL IMPAIRMENT……………. 4

1.1 REDUCE BLINDNESS AND VISUAL IMPAIRMENT IN ADULTS
1.1.1 Reduce cataract blindness………………………………………………………. 4
1.1.2 Reduce blindness from diabetic retinopathy…………………………………………5
1.1.3 Reduce blindness due to open-angle glaucoma (OAG)……………………………7
1.1.4 Reduce visual disability due to uncorrected refractive errors in adults………. 7

1.2 REDUCE BLINDNESS AND VISUAL IMPAIRMENT IN CHILDREN
1.2.1 Reduction of the preventable & of treatable causes of childhood blindness…………………………….. 8
1.2.2 Reduce visual disability by detecting and treating uncorrected refractive errors in school children…9

1.3 REDUCE THE BURDEN OF BLINDNESS AND VISUAL IMPAIRMENT IN THE GENERAL POPULATION
1.3.1 Enhance vision related quality of life for people with functional low vision………………………………10
1.3.2. Inclusive services…………………………………………………………………………………………………..11

2. EYE CARE SYSTEMS
2.1 CENTRAL ORGANIZATION, LEADERSHIP AND GOVERNANCE…………………………………………………13
2.2 EYE CARE WORKFORCE………………………………………………………………………………………………13
2.3 MEDICAL PRODUCTS AND TECHNOLOGY………………………………………………………………………….14
2.4 EYE CARE INFORMATION SYSTEMS AND MONITORING ……………………………………………………….14

3. EYE CARE PROMOTION, PUBLIC EDUCATION & ADVOCACY
3.1. ADVOCACY …………………………………………………………………………………………………………… 15
3.2. PUBLIC AWARENESS AND EDUCA…………………………………………………………………………………15

BIBLIOGRAPHY

ANNEX 1

ACRONYMS

CBM Christoffel Blinden Mission
CCB Caribbean Council for the Blind
IAPB International Agency for the Prevention of Blindness
ICEE International Centre for Eye Care Education
ICEVI International Council for Education of People with Visual
INGO International Non Governmental Organizations
MoH Ministry of Health
MoE Ministry of Education
NGDO Non-governmental Development Organization
OAG Open Angle Glaucoma
OSWI Ophthalmological Society of the West Indies
PAAO Pan American Association of Ophthalmology
PAHO Pan American Health Organization
PBL Prevention of Blindness
PEC Primary Eye Care
PHC Primary Health Care
ROP Retinopathy of Prematurity
UNCRPD United Nations Convention on the Rights of Persons with Disabilities
WBU World Blind Union
WHO World Health Organization

ACKNOWLEDGEMENT

The valuable financial support provided by CCB, Sightsavers, CBM and the Pan American Health Organization, Regional Office of the World Health Organization, which made possible the services assessment, this meeting and document is gratefully acknowledged.

The organizations participating in the consultation consisted on the Ministry of Health of Dominica, Ministry of Health of Grenada, Ministry of Health Guyana, Ministry of Health of Jamaica, Ministry of Health of St Vincent, Eye Care Guyana, Caribbean Optometrists Association, Société Haïtienne D’Aide aux Aveugles (SHAA), National Prevention of Blindness Committee of Haiti, Jamaica Society for the Blind, St Lucia Blind Welfare Association, CCB-Eye Care Caribbean, Sightsavers, CBM, ORBIS International, Help Age International, International Agency for the Prevention of Blindness-IAPB, Operation Eyesight, International Center for Eye Care Education and the Pan American Health Organization-PAHO-WHO.

The meeting participants consisted on Hazel Shillingford-Ricketts, Joan McLeod-Omawale, Dave Duncan, Julian McKoy-Davis, Lucine Edwards, Narine Singh, Charles Vandyke, Ava-Gay Timberlake, Peter Ackland, Pat Ferguson, Nelson Rivera, Jillia Bird, Nigel St Rose, Conrad Harris, Anthony Avril, Philip Hand, Arvel Grant, Frank Bowen, Keva Richards, Kathy Barrett, Gavin Henry, Rachelle Noelsaint, Reginald Paul, Martin Ruppenthal, Juan Carlos Silva.

INTRODUCTION

Blindness and low vision are a public health problem throughout the world, this is why the World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB) together with NGOs have launched VISION 2020 – the global initiative for the elimination of avoidable blindness. This initiative that brings together governments, WHO, international and national NGOs, as well as associations of professionals in eye care, aims to determine global, regional and national plans of action in prevention of avoidable blindness and inclusive services. In the Caribbean VISION 2020 was officially launched in Trinidad-Tobago in April 2000.

The World Health Organization’s Fifty-Sixth World Health Assembly approved Resolution WHA56.26, which requested the Director to strengthen WHO’s collaboration with Member States on the Global Initiative for the Elimination of Avoidable Blindness. In Resolution WHA59.25, the Fifty-Ninth World Health Assembly reaffirmed its commitment to give priority to the prevention of blindness. The 144th Session of the Pan American Health Organization – PAHO Executive Committee recommended that the Directing Council adopt a resolution as a way to bolster regional and national efforts to reach the objectives of the Plan of Action for the Prevention of Avoidable Blindness and Visual Impairment. In September 2009 the 49th PAHO Directing Council – WHO 61st Session of the Regional Committee approved the prevention of blindness plan of action and passed the resolution (Annex 1).

In the year 2002 a VISION 2020 strategic plan was developed for the Caribbean region through a series of in-house discussions in PAHO, as well as through meetings with member states, the IAPB, national and international non-governmental organizations and scientific societies. In the Caribbean, PAHO, implement the VISION 2020 initiative in alliance with the IAPB, Sightsavers, Caribbean Council for the Blind-CCB, CBM, ORBIS and the ICEE. Significant progress has been achieved in the Caribbean in the prevention of avoidable blindness, and access to eye care services has been increasing in most countries working in this initiative.

On December 1st 2009 PAHO, CCB, Sightsavers, CBM, ORBIS and all Caribbean Vision 2020 partners organized a meeting in Barbados to review and update the Vision 2020 Caribbean Plan that was produced in the year 2002. This new strategic framework for VISION 2020 in the Caribbean Region was prepared utilizing a very participatory methodology that included consultation with several Ministries of Health of the English speaking countries, national and international partners and incorporated the strategies of the Plan of Action on the Prevention of Avoidable Blindness and Visual Impairment approved by the PAHO 49th DIRECTING COUNCIL in 2009. This strategic framework serves as a guideline to support countries and stakeholders in priority setting and objectives development, it does not pretend to be a norm and each country may adapt it to its own realities, priorities and resources. Each priority established by a country should utilize a primary health care approach and have a referral system available for quality care for every condition.

1. DISEASE CONTROL AND PREVENTION OF VISUAL IMPAIRMENT

The most prevalent causes of blindness in the Caribbean are non-operated cataract and glaucoma, followed by diabetic retinopathy and uncorrected refractive errors. Childhood blindness is not as prevalent, but is a main cause of blinding years in the population. An important percentage of blindness in the Caribbean region is avoidable (preventable or curable). Cataract and diabetic retinopathy can be cured with relatively inexpensive surgical treatments; refractive errors are correctable with simple optical devices; and preventive strategies and effective referral systems can reduce the burden of childhood blindness. The application of new technology can be used in future to improve the detection and treatment of glaucoma.

1.1 REDUCE BLINDNESS AND VISUAL IMPAIRMENT IN ADULTS

1.1.1 Reduce Cataract blindness
In Latin America and the Caribbean, cataract (opacification of the lens) is the most prevalent cause of blindness; cataract surgery has been shown to be one of the most cost effective of all health care interventions. Most cataracts are age-related and cannot be prevented, but cataract surgery with insertion of an intraocular lens (IOL) is highly effective, providing almost immediate visual rehabilitation.

Magnitude of Problem
The results of the Barbados Eye Study show that 12% of people 40-84 years old have visual impairment or visual acuity worse than 6/12 (normal value 6/6). Three percent (3%) have severe visual impairment worse than 6/60 and most have cataract or lens opacities, thus demonstrating that most visual impairment in this population is associated with lens opacities.

Issues
• Inadequate public awareness of cataract and how it can be rectified with a straightforward surgical procedure, leading to low demand for services.
• Numerous barriers between needs and services, including poor availability and accessibility and high costs.
• Evidence of good vision outcomes lacking after surgery.
• Insufficient information on outputs and outcomes in public sector, private sector and bilateral cooperation initiatives.

Expected Outcome
• Provide cataract surgical services at a rate adequate to eliminate the backlog of cataract, at a price that is affordable for all people, both rural and urban and with high success rate in terms of visual outcome.

Proposed actions for Member States
• Make national assessments of cataract surgical services, including availability, access, affordability and quality, as well as collection and management of information and data.
• Measure prevalence of cataract blindness, determine services coverage level and identify barriers to access in selected countries.
• Develop country and district-specific cataract service plans with measurable targets that address equity (availability, accessibility, affordability) and quality of services.
• Ensure eye health services are integrated into a primary health care system to detect and refer people with eye diseases.
• Develop a human resources development plan for cataract surgical services.
• Promote high-quality surgery and ensure satisfactory visual outcomes and patient satisfaction.
• Develop appropriate communication strategies for the target population- viz. adults 50 years and older.

Proposed actions for organizations supporting VISION 2020 activities
• Provide technical cooperation for the design of Rapid Assessment of Avoidable Blindness (RAAB) and similar studies.
• Develop a situation analysis of cataract surgical services at regional and national levels.
• Advocate and provide technical cooperation for development and implementation of national cataract plans.
• Mobilize resources with regional and international partners.

Indicators
• Reach a cataract surgical rate (CSR) of 2,000 per 1 million population per year in the majority of countries by the year 2014. (See Table 2 below)

• 4 countries utilizing a cataract outcomes monitoring tool/system in 2014.

Table 2. Caribbean Cataract Surgical Rate, Year 2009
Country Population CSR year 2010 Target 2014
Thousands
Antigua 88 1345 1800
Bahamas 342 2500 3000
Barbados 256 2001 2500
Belize 307 1648 2000
Dominica 67 1746 2000
Grenada 104 1062 1500
Guyana 762 1700 2000
Haiti 10,033 440 1000
Jamaica 2719 1000 1500
St Lucia 172 843 1500
St Vincent 109 1066 1500
Trinidad 1339 2600 3000

1.1.2 Reduce the prevalence of blindness from diabetic retinopathy
Diabetes causes weakening of the blood vessels in the body. Retinal blood vessels are particularly susceptible and weakening of these blood vessels, accompanied by structural changes in the retina, is termed as diabetic retinopathy. Diabetic retinopathy is symptomless in its early stage and eye examinations/screening is the only way to identify affected people to prevent them from going blind. Evidence-based treatment is available to significantly reduce the risks of blindness and of moderate vision loss. Clinical studies spanning more than 30 years have shown that appropriate treatment with laser can reduce the risks by more than 90%.

Magnitude of the problem
The prevalence of diabetes among adults in Latin America and the Caribbean varies from country to country. More than 75% of patients who have had diabetes mellitus for more than 20 years will have some form of diabetic retinopathy. After 15 years of diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment. In Barbados, 18% of persons of African descent between the ages of 40 and 84, report having a history of diabetes mellitus; among people with diabetes 30% has diabetic retinopathy 8.6% of diabetics have clinically significant macular edema and 1% has proliferative diabetic retinopathy needing laser treatment.

Issues
• Inadequate medical management and control of diabetes.
• Inadequate development of detection and referral systems.
• Insufficient public awareness relating to cause and prevention of blindness due to diabetes.
• Insufficient awareness and knowledge of PHC practitioners, general physicians and internists regarding their role in the prevention of blindness due to diabetes.
• Limited number of ophthalmologists with training in diagnosis and treatment of diabetic retinopathy.
• Inadequate technological infrastructure in the health services.
• Poor resourcing and low capacity of national diabetes associations.

Expected Outcome
• Countries implementing early detection, referral and treatment for diabetic retinopathy

Proposed actions for Member States
• Integrate blindness prevention strategies into national diabetes programs and ensure their incorporation into non communicable chronic diseases programs of the Ministries of Health.
• Encourage strategies for prevention, early detection and effective treatment of diabetes and hypertension, which will prevent complications that lead to blindness.
• Develop public awareness programs to target groups that are at high risk.
• Establish referral systems from services for diabetics to the ophthalmologic services.
• Establish screening services using digital photography to detect and refer treatable diabetic retinopathy.
• Ensure laser treatment services for diabetic retinopathy are available, accessible and affordable.

Proposed actions for organizations supporting VISION 2020 activities
• Perform a situation analysis of the management of diabetic retinopathy in the Region as a baseline for planning and advocacy.
• Conduct national assessments of services for diabetic retinopathy in selected countries.
• Develop education packages and training programs for the general public and health care providers.
• Develop continuing medical education programs for ophthalmologists and optometrists.
• Support countries in the development of screening programs and laser services for Diabetic Retinopathy.
• Establish regional protocols and management guidelines
• Establish an inter-country referral system for treatment according to an established protocol.
• Diabetes Associations playing a lead role in awareness raising and prevention of blindness due to diabetes.

Indicators
• Situation analysis conducted in five selected countries by the year 2014.
• At least three of the selected countries integrate early detection and treatment programs for diabetic retinopathy into non-communicable chronic diseases programs by the year 2014.
• Increase the number of countries with digital photograph screening and laser treatment programs from 1 to 4 by the year 2014.

1.1.3 Reduce the incidence of blindness due to open-angle glaucoma (OAG) in high-risk groups
OAG is a major public health problem in the Afro-Caribbean population, where it is a major cause of visual loss and the leading cause of irreversible blindness. Vision 2020 programs need to include mechanisms for glaucoma detection and treatment for high-risk segments of the population, including persons of African descent in the Caribbean population, persons over 40 years of age, and individuals with a family history of glaucoma.

Magnitude of the problem
Open Angle Glaucoma prevalence in Afro-Caribbean people over 40 years of age is over 7% and increases with age. In the Barbados Eye Study, OAG affected 1 in 11 Afro-Caribbeans older than 50 years of age, reaching a prevalence of 1 in 6 in those over 70 years. About 2% of individuals over 40 years are blind and, of that percentage, one-third are blind due to OAG.

Issues
• High disease frequency.
• Very limited availability of sensitive and specific screening methods at reasonable cost.
• Silent nature of the disease.
• Late detection and poor compliance.
• High cost of medication.
• Lack of public awareness about need for people over 40 years of age to get eyes checked for glaucoma.

Expected Outcome
• Strengthen national programs for detection and treatment of glaucoma in segments of the population with risk factors as outlined in national eye care plans.

Proposed actions for Member States
• Include glaucoma detection as an integral part of comprehensive eye examinations for persons over 40 years of age.
• Ensure that eye care units are have the capacity (equipment & HR) to provide glaucoma diagnosis and treatment.
• Increase awareness among the general population of the importance of regular eye examinations and glaucoma screening for those over age 40, as well of other risk factors for glaucoma.
• Provide affordable treatments and medications.

Proposed actions for organizations supporting VISION 2020 activities
• Utilize available epidemiologic information to promote early detection and treatment in countries in high-risk groups.
• Utilize best practices to promote and design public awareness programs and interventions.
• Mobilize technical and financial resources to strengthen national eye care services in glaucoma detection and treatment
• Train professionals to implement existing evidence-based protocols.

Indicators
• Increasing from 3 to 6 the number of countries carrying out glaucoma community awareness programs by the year 2014.
• A regional procurement and distribution system for affordable glaucoma medications
• Number of countries including glaucoma eye medications in subsidized drug list and encouraging practitioners to use it

1.1.4. Reduce visual disability by detecting and treating uncorrected refractive errors in adults
The Barbados Eye Studies found high prevalence of myopia and hyperopia in adults. Most adults over 50 years of age suffer presbyopia.

Proposed actions for Member States
• Include refraction in a comprehensive eye examination to identify spectacles requirements in adults.
• Increase public awareness through information, education, and communication strategies.

Proposed actions for organizations supporting VISION 2020 activities
• Promote and support screening and refractive errors correction in adults, including presbyopia.

1.2. REDUCE BLINDNESS AND VISUAL IMPAIRMENT IN CHILDREN

1.2.1 Reduction of the preventable causes and of treatable causes of childhood blindness.

Magnitude of the problem
As the causes of Blindness in children differ from those in adults, different control measures are needed; childrens’ eye problems need timely attention or they may become irreversibly blind; specific expertise and equipment are required. While data is limited, the following causes of childhood blindness has being reported in the Caribbean Region: Retinopathy of Prematurity (ROP) , cataract and glaucoma in children have been reported in some countries, corneal scarring (the drying out and scarring of the outer eye because of vitamin A deficiency) is not common and has been reported in a few countries. However, visual impairment from trauma is commonly reported in Jamaica, especially among boys.

Issues
• Insufficient data about the causes or magnitude of childhood blindness and visual impairment in the Caribbean.
• Lack of policies that support inclusion of an eye care component in Maternal & Child Health programs.
• Insufficient awareness and knowledge among pediatricians, obstetricians, general physicians and health personnel about their role in prevention of children’s visual impairment and blindness.
• Insufficient involvement of general ophthalmologists in prevention of childhood blindness programs.

Expected Outcome
Provide services to detect and treat children with Retinopathy of Prematurity, congenital cataract, congenital glaucoma and corneal ulcer or scarring, and other non-blinding eye problems, such as strabismus, trauma,

Proposed actions for Member States
• Integrate childhood blindness prevention with early diagnosis, evaluation and treatment into all national maternal and child health plans and policies.
• Assess the main causes of blindness and visual impairment in children in the Caribbean as a base for future planning.
• Promote detection of eye diseases and eye problems as part of the national policies in maternal and child health.
• Provide ocular prophylaxis of newborns to prevent neonatal conjunctivitis through utilization of Povidone Iodine.
• Reduce blindness in premature babies due to retinopathy of prematurity
Prevention of blindness due to ROP is planned on three levels:
a) Primary prevention: reduce the incidence of ROP through improved prenatal and neonatal care.
b) Secondary prevention: early identification of severe cases of ROP in premature babies in neonatal care through regular examination of those deemed to be high-risk by skilled ophthalmologists and timely treatment with laser or cryotherapy of severe ROP
c) Tertiary prevention: restore useful vision in children with retinal complications through vitreoretinal surgery and/or offer rehabilitation.
• Promote systems, networks and protocols for safe neonatal care, adequate referral, and follow-up.
• Elaborate and promote national guidelines and minimum acceptable standards.
• Ensure the availability of the necessary equipment for primary prevention, examination and treatment.
• Improve the quality of available information on neonatal care.

Proposed actions for organizations supporting VISION 2020 activities
• Collect and analyze information on causes of childhood blindness in school children who are blind utilizing the appropriate documentation.
• Conduct national assessments of needs and resources for ROP programs.
• Organize regional and national workshops to increase awareness.
• Organize regional and national training programs for professionals (obstetricians, pediatricians, nurses, and ophthalmologists).
• Promote the utilization of regional guidelines on neonatal care and ROP programs.
• Support countries in the development of ROP services
• Organize a referral pediatric ophthalmology center

Indicators
• Documentation on causes of childhood blindness in school children who are blind in the Caribbean.
• Increase the number of countries that have a national ROP prevention policy from 1 to 4 by the year 2014.
• Number of countries that are implementing an eye care component in maternal and child care programs.
• Number of countries with capacity (pediatric oriented ophthalmologists and equipment) in tertiary facility to perform pediatric cataract, ROP examinations and treatment, and other blinding and non-blinding children’s eye conditions.

1.2.2 Reduce visual disability by detecting and treating uncorrected refractive errors in school children

Magnitude of the problem
According to epidemiologic studies in Latin America PAHO-WHO estimates that about 7% of school children may require spectacles for correction of refractive errors.
The steps in the provision of refraction services are as follows:
(a) Screening: identification of individuals with poor vision which can be improved by correction.
(b) Eye examination: to evaluate the condition of the eye and identify coexisting pathologies requiring care.
(c) Refraction: determine what correction is required.
(d) Dispensing: provide and supply appropriate corrective eyeglasses.
(e) Follow-up: ensure compliance with prescription, care of the eyeglasses, repair or substitution of spectacles, if needed.

Issues
• No data available on need for spectacles in school children.
• No data available on best practices on refractive errors programs in schools children.
• Different priorities and criteria in eye care programs for school children in the different countries.
• Lack of policies that include an eye care component in school health programs.
• Small number of ophthalmologic and optometry services that diagnose refractive errors in school children of low socio-economic status.
• Spectacles often too expensive for the majority of patients.
• Inadequate collaboration between health and education stakeholders.
• Lack of parent’s awareness and commitment to comply.

Expected Outcome
• Prevention of visual impairment and blindness due to uncorrected refractive errors in school children by integrating eye health into policies and practice in health and education sectors.

Proposed actions for Member States
• Develop national guidelines for the detection and treatment of refractive errors, taking into account national realities.
• Establish screening during the first school level and during the sixth grade.
• Develop and follow pilot refractive error programs to identify and disseminate best practices.
• Promote refractive error services and provision of spectacles in the public sector for school children, adults and any person in need
• Increase availability and affordability of eyeglasses and facilitate their production through the establishment of low-cost laboratories.
• Increase public awareness through information, education, and communication strategies.

Proposed actions for organizations supporting VISION 2020 activities
• Promote the utilization of the regional guide in refractive errors programs.
• Standardize technology: screening kit and affordable instruments.
• Develop advocacy plan for health and educational authorities.
• Promote a study in refractive error correction needs for school children.
• Support development of low cost spectacle production and distribution systems.

Indicators
• Increase the number of countries implementing a national standard refractive errors program as part of national eye care policies and plans from 2 to 7 by the year 2014.
• Increase in the spectacle labs producing affordable, quality spectacles

1.3. REDUCE THE IMPACT OF BLINDNESS AND VISUAL IMPAIRMENT IN THE GENERAL POPULATION

1.3.1 Enhance vision related quality of life for people with functional low vision.
Low-vision services are aimed at people who have residual vision that can be used and enhanced by specific aids. Low vision is currently defined as ‘visual acuity of < 6/18 down to and including 3/60 in the better eye’, from all causes.

Magnitude of the problem
It is estimated that for every thousand people, 17 has low vision, of those about 6 could benefit from low vision interventions.

Expected outcome
Provide comprehensive low-vision services for persons who are blind or severely visually impaired integrating clinical eye care, rehabilitation and educational services in each country.

Issues
• Inadequate government policy for visual rehabilitation.
• Limited public and eye care professionals’ awareness of low vision.
• Insufficient professional services and technical expertise in this specialty.
• Insufficient affordable optical devices for assessment and prescription.
• Insufficient rehabilitation and educational services for people with low vision.
• Insufficient adapted teaching materials and technologies for students with low vision.

Proposed actions for Member States
• Develop national policies on comprehensive low-vision care.
• Establish low-vision services at the national level in public facilities.
• Promote early identification of all children and adults who are irrevocably blind severely visually impaired and ensure that an effective referral system is in place.
• Establish units that can provide comprehensive low vision services, utilizing technicians in optometry to perform low vision examinations, assess and counsel patients, prescribe optical devices and provide instruction in device use.
• Promote low vision services for children as early as possible through an integrated system of clinical and pedagogic services.

Proposed actions for organizations supporting VISION 2020 activities
• Organize low-vision courses at regional and national congresses of ophthalmology.
• Promote the establishment of resource centers for the training of trainers, curricula standardization, and technology development.
• Support the organization of low-vision centers in underserved countries currently without such services.
• Develop a system to make low-vision aids affordable.
• Advocate for national inter-sectoral policies and plans for inclusive education and for rehabilitation programs for persons who are blind
• Train low-vision teams (eye care, low-vision therapy, rehabilitation, education, and social services).
• Create regional or national funding bases for the purchase of devices
• Develop specific continuing education programs in low vision care for existing/available personnel.

Indicator
• Increase the number of countries with low-vision services from 3 to 6 by the year 2014.

1.3.2. Inclusive services
Children who are blind should have access to inclusive education and supportive services; adults who are blind require rehabilitation (adjustment to blindness) programs to strengthen their emotional and social capabilities; as well as training in daily living skills, orientation mobility skills, and vocational training. Insofar as it is feasible, inclusive education and adjustment to blindness services should be supported by access to adaptive aids, including devices for reading and writing; white canes; adapted domestic aids; and low-vision appliances and technologies.

Issues
• Inadequate government policy for visual rehabilitation.
• Insufficient rehabilitation and educational services for people with low vision and blindness.
• Insufficient adapted teaching materials and technologies.

Expected outcome
Education and Rehabilitation services available for persons with blindness or visual disability.

Proposed actions for Member States
• Legislation and policies approved/enacted that support implementation of the UN Convention on the Rights of Persons with Disabilities UNCRPD (Signed in 2009)
• National Disability Plan is approved and implemented by the Government (MoE and MoH)
• Ensuring availability and accessibility of inclusive services (Rehabilitation, education and social services)
• Education and social services department is strengthened to provide expanded service delivery for children and adults who are blind.
• MoE provides sufficient support to meet the educational needs of blind and VI students.

Proposed actions for organizations supporting VISION 2020 activities
• Advocate for inclusive services in every country.
• Coordinate efforts among NGOs to resource social and education services.
• Make available affordable technical equipment and special supplies for blind and visually impaired.
• Conduct a region wide situation assessment on rehabilitation and education services for persons who are blind.

Indicator
• Number of countries that are implementing national plans for inclusive education and adjustment to blindness by 2014.

2. EYE CARE SYSTEMS

2.1 Central Organization, Leadership and Governance

Expected outcome: Provide leadership and governance that ensures an effective and equitable eye care system.
Involves ensuring strategic policy combined with coalition building, the provision of appropriate regulations, incentives and accountability.

Regional and National Strategy
• Ensure national strategic policy framework.
• Encourage National Committee and a Focal Person for the Prevention of Blindness that will assist the ministry of health, education and other national authorities and organizations in the development of regulations and plans and the implementation and monitoring of programs.
• Support the implementation of the plan.
• Keep updated information on VISION 2020 implementation at all levels.
• Promote networking and capacity building.

2.2 Eye Care Workforce

Issues
• Insufficient ophthalmology and optometry training programs in the region, resulting in an inadequate number of qualified professionals in ophthalmology, optometry and allied health personnel.
• In the Caribbean the surgical productivity per ophthalmologist is low, in part because several clinical ophthalmologists do not perform surgery. Others work in private practice and limit their services to patients who can afford their fees.
• In many countries primary eye care is not yet implemented.

Expected outcome: Have a well-performing health workforce fair and efficient to achieve the best eye care outcomes possible given available resources and circumstances. There are sufficient numbers and mix of staff, fairly distributed; they are competent and productive.

Regional and National Strategy
• Organize new ophthalmology and optometry training programs in the Region and strengthen those that exist.
• Expand numbers of mid level personnel such as refractionists, ophthalmic assistants and low vision technicians in the delivery of eye care in the Caribbean.
• Identify and or train sub-specialists in pediatric ophthalmology and retinal services including the necessary referral system for the established referral services.
• Train primary health care (PHC) workers in primary eye care at the national level.
• Establish the productivity norms for key resources (for example cataract surgeries per ophthalmologist per year).
• Develop continuing educational programs.
• Develop manpower for equipment maintenance repair, low cost spectacle production and eye drops preparation.

Indicators
• Number of countries reaching the minimum ratio set of one active ophthalmic surgeon per 50,000 populations.
• Number of countries reaching the minimum ratio set of one active optometrist per 50,000 populations.
• Number of countries reaching the minimum ratio set of one active ophthalmic nurse per 50,000 populations
• Number of countries having an active PEC service integrated to the PHC service.
• Number of countries with network of maintenance technicians available covering all hospitals in country by 2014.
• Increase the number of countries having spectacles lab technicians from 3 to 6.

2.3. Medical Products and Technologies

Issues
• Limited availability of affordable consumables.
• Limited production of spectacles and medications.
• Underutilization of equipment due to lack of skills.
• Limited government understanding of eye care equipment management.

Expected outcome:
To ensure an optimal supply of appropriate, high-quality, affordable equipment, instruments, consumables essential for the delivery of eye care services.

Regional and national Strategy
• Promote the utilization of small incision cataract surgery.
• Produce and/or distribute affordable consumables.
• Provide practitioners, ministries of health, hospitals and clinics with information on good quality and affordable appropriate technology.
• Ensure availability of spectacles, ophthalmic supplies and equipment at costs appropriate to local economies.
• Provide training to support staff in maintaining and repairing ophthalmic equipment.

2.4. Eye Care Information Systems and Monitoring

Issues
• Insufficient data on outputs and outcomes of services to support planning, monitoring, advocacy and reporting.

Expected outcomes:
Include eye care in the national planning, health and education information system.
Periodic information available on the situation and trends on eye care delivery in the Caribbean.

Regional and national Strategy
• Identify mechanisms to include eye care in the present Health Management Information system.
• Develop data management systems for eye care: data collection, compilation, reporting and analysis
• Define how analysis and distribution of information will be carried out.
• Define procedures for annual, mid-term and final review of the strategy implementation.
• Identify feedback mechanisms for various levels of staff.

3. EYE CARE PROMOTION, PUBLIC EDUCATION & ADVOCACY
About 80% of blindness is avoidable: it either results from conditions that could have been prevented or conditions that may have being successfully treated to restore sight. It is necessary that high risks groups have adequate information to ensure they look for services to detect and treat eye problems and that they increase compliance on follow-up and treatments. The aim of eye care promotion and public education is to improve knowledge, attitudes, motivation and action for high risk groups and health authorities.

The promotion of eye health as part of the national health policy is, invariably, a necessary prerequisite for a National Program for the Prevention of Blindness. This fosters public awareness, leads to societal responsiveness and participation and facilitates co-ordination of activities carried out by various partners, such as non-governmental organizations, the private sector and the government itself.

3.1. Advocacy
Expected Outcomes
• Increased political commitment in all countries to include eye health in the national health plans.
• Increased commitment of professional societies to regional and national eye care programs.

Regional and National Strategy
• Ministries of Health are acquainted with the PAHO and WHO resolutions in prevention of blindness.
• Strengthen national data-gathering capabilities, to facilitate regional collection of epidemiological and service delivery information and allow disaggregation of data by gender and age.
• Establish and keep current a register of all known persons with visual disability.
• Promote epidemiological and service delivery assessments.
• Participate in ophthalmic regional professional societies’ meeting.
• Promote eye care professionals gathering regionally and sub-regionally for continuing medical education and eye care planning.
• Promote V2020 / Prevention of Blindness Committees gathering regionally for cross learning, skill sharing and collaboration.
• Publish papers in regional scientific journals.
• Advocate for the inclusion of critical eye care in the national health information systems.
• Observe the second Thursday of October every year as World Sight Day.
• Celebrate any day to promote specific topics.

Indicators
• Number of countries celebrating the World Sight Day and related days each year.
• Increase the number of countries implementing a national vision 2020 plan from 6 to 10 by 2014.
• Number of countries including eye health services in the national health plan from 4 to 8 by 2014.

3.2 Public awareness and education

Expected outcome: Increased public knowledge and utilization of eye care services.

Regional and National Strategy
• Assess the baseline data in knowledge, beliefs, attitudes and actions of the population in regard to eye care.
• Develop a communication program including printed and audio-visual materials.
• Utilise general health and eye health professionals to create public awareness.

Indicators
• Increase the number of countries implementing an eye care public awareness program.
• Increase the number of people using eye care services by 30% over 5 years

BIBLIOGRAPHY

3. Pan American Health Organization. Health in the Americas. Health conditions and Trends. Ocular Health. Regional Volume. PAHO: Washington DC;2007:141-142. Available at: http://www.paho.org/HIA/homeing.html. Accessed: February 17, 2010.

Annex 1

PAN AMERICAN HEALTH ORGANIZATION
WORLD HEALTH ORGANIZATION

49th DIRECTING COUNCIL
61st SESSION OF THE REGIONAL COMMITTEE

Washington, D.C., USA, 28 September-2 October 2009

CD49/19 (Eng.)
Annex B
ORIGINAL: ENGLISH

PROPOSED RESOLUTION

PLAN OF ACTION ON THE PREVENTION OF AVOIDABLE BLINDNESS
AND VISUAL IMPAIRMENT

THE 49th DIRECTING COUNCIL,

Having reviewed Document CD49/19 Plan of Action on the Prevention of Avoidable Blindness and Visual Impairment;

Recalling Resolution WHA56.26 of the World Health Assembly on the elimination of avoidable blindness;

Noting that visual disability is a prevalent problem in the Region and is related to poverty and social marginalization;

Aware that most of the causes of blindness are avoidable and that treatments available are among the most successful and cost-effective of all health interventions;

Acknowledging that preventing blindness and visual impairment relieves poverty and improves opportunities for education and employment; and

Appreciating the efforts made by Member States in recent years to prevent avoidable blindness, but mindful of the need for further action,

RESOLVES:

1. To approve the Plan of Action on the Prevention of Avoidable Blindness and Visual Impairment.

2. To urge Member States to:

(a) establish national coordinating committees to help develop and implement national blindness prevention plans;

(b) include prevention of avoidable blindness and visual impairment in national development plans and goals;

(c) advance the integration of prevention of blindness and visual impairment in existing plans and programs for primary health care at the national level, ensuring their sensitivity to gender and ethnicity;

(d) support the mobilization of resources for eliminating avoidable blindness;

(e) encourage partnerships between the public sector, nongovernmental organizations, private sector, civil society, and communities in programs and activities that promote the prevention of blindness; and

(f) encourage intercountry cooperation in the areas of blindness and visual impairment prevention and care.

3. To request the Director to:

(a) support the implementation of the Plan of Action on the Prevention of Avoidable Blindness and Visual Impairment;

(b) maintain and strengthen PAHO Secretariat’s collaboration with Member States on the prevention of blindness; and