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NHPP20 – National Programme for Control of Blindness

Quadrant – I

Personal details:

Role Name Affiliation

Principal Investigator Dr. C.P. Mishra Professor Department of Community Medicine Benaras Hindu University, Varanasi Uttar Pradesh, India

Paper Coordinator Dr. Davendra Kumar Taneja Director Professor Department of Community Medicine Maulana Azad Medical College New Delhi, India

Content Writer/Author Dr. Neeti Rustagi Assistant Professor Department of Community & Family Medicine All India Institute of Medical Sciences Jodhpur, India

Content Reviewer Dr. Bratati Banerjee Professor Department of Community Medicine Maulana Azad Medical College New Delhi, India

Description of Module:

Items Description of Module

Subject Name Community Medicine

Paper Name National Health Policies and Programmes Module Name/Title National Programme for Control of Blindness

Module Id NHPP20 Pre-requisites Knowledge on problems of women and requirements to realise their full potential

in the Indian context

Objectives To study about the National Programme for Control of Blindness Key words National Programme, Blindness

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Introduction:

National Programme for Control of Blindness was launched in the year 1976 as a 100% Centrally Sponsored scheme with the goal to reduce the prevalence of blindness from 1.4% to 0.3% by year 2020. During the 12

th five year plan (2012-2017), blindness has been categorised under programmes

for Disability Prevention and Rehabilitation1 and all 640 districts are targeted for coverage

nationwide.

Learning Outcomes At the end of this module the students should be able to:

State the burden of blindness in the country.

Describe the goals, objectives, strategies and organizational structure of the programme

Main Text

1.1 Burden of blindness Of the total estimated 37 million blind persons (VA< 3/60) globally, 7 million are in India. As per survey by NPCB- WHO and GOI, prevalence of blindness has reduced over time. (Table 1)

Table 1: Estimated burden of blindness1

Year Prevalence of Blindness (%) Survey

1976 1.49% NPCB- WHO survey 2002 1.10% Rapid Assessment (GOI)

2007 1.00% Rapid Assessment (GOI) 2020 0.30% Target to be achieved

With increasing life expectancy, the blindness due to senile disorders like Cataract, diabetic Retinopathy and Glaucoma is expected to increase. As per information available from various studies, there are estimated 12 million bilaterally blind persons in India with VA< 3/60. Main causes of blindness are discussed in Table 2.

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Table 2: Main causes of blindness in India Cataract 62.6% Refractive Error 19.70%

Corneal Blindness 0.90% Glaucoma 5.80%

Surgical Complication 1.20% Posterior Capsular Opacification 0.90%

Posterior Segment Disorders 4.70% Others 4.19%

Vision 2020 – The Right to Sight

A global initiative Right to Sight was launched by the World Health Organization and a Task Force of International Non-governmental Organizations in Geneva on February 18, 1999 to target global burden of blindness. Collaboration between governments, World Health Organization, International Agency for the Prevention of Blindness, funding agencies, international, nongovernmental and private organisations will be facilitated on five diseases globally.

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- Cataract

- Trachoma - Onchocerciasis - Childhood blindness

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- Refractive Errors and Low Vision

These conditions have been chosen on the basis of their contribution to the burden of blindness and the feasibility and affordability of interventions to control them.

Five basic strategies to combat the burden are:

1. Disease prevention and control 2. Training of personnel 3. Strengthening the existing eye care infrastructure 4. Use of appropriate and affordable technology 5. Mobilisation of resources

Implementation of all these initiatives to reduce burden of avoidable blindness by year 2020 necessitates developing and strengthening of the primary health/eye care approach.

1.3 Goal and objectives under NPCB

Goal: To reduce the prevalence of blindness to 0.3% by the year 2020. Objectives of NPCB in the XII Plan : India is committed to reduce the burden of avoidable blindness and proposes to develop infrastructure and Eye Care services delivery system during 12th Five Year Plan.

1. To reduce the backlog of blindness through identification and treatment of blind at primary, secondary and tertiary levels based on assessment of the overall burden of visual impairment in the country. 2. Develop and strengthen the strategy of NPCB for “Eye Health” and prevention of visual

impairment; through provision of comprehensive eye care services and quality service delivery. 3. Strengthening and up-gradation of RIOs to become centres of excellence in various sub-

specialities of ophthalmology 4. Strengthening the existing and developing additional human resources and infrastructure facilities for providing high quality comprehensive Eye Care in all Districts of the country; 5. To enhance community awareness on eye care and lay stress on preventive measures; 6. Increase and expand research for prevention of blindness and visual impairment 7.To secure participation of Voluntary Organisations/Private Practitioners in eye Care

1.4 Four pronged strategy of the program

• Strengthening service delivery, • Developing human resources for eye care, • Promoting outreach activities and public awareness • Developing institutional capacity

1.5 Definitions

Visual impairment is when a person has sight loss that cannot be fully corrected using glasses or contact lenses. There are two main categories of visual impairment:

Being partially sighted or sight impaired – where the level of sight loss is moderate

Severe sight impairment (blindness) – where the level of sight loss is so severe that activities that rely on eyesight become impossible.

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Blindness is defined by national programme for control of blindness (NPCB) under following headings:

Inability of a person to count fingers from a distance of 6 meters or 20 feet (technical definition)

Vision 6/60 or less with the best possible spectacle correction

Diminution of field vision to 20 feet or less in better eye

Types of blindness discussed in NPCB

Economic blindness: Inability of a person to count fingers from a distance of 6 meters or 20 feet (technical definition) Social blindness: Vision 3/60 or diminution of field of vision to 10

0

Manifest blindness: Vision 1/60 to just perception of light Absolute blindness: No perception of light Curable blindness: That stage of blindness where the damage is reversible by prompt management e.g. cataract Preventable blindness: The blindness that could have been completely prevented by institution of effective preventive or prophylactic measures e.g. xerophthalmia, trachoma, and glaucoma Avoidable blindness: The sum total of preventable or curable blindness is often referred to as avoidable blindness. 1.6 Organisational structure

NPCB being a centrally sponsored program, various activities are implemented at central, state and district level.

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Composition of State Health Society Secretary (Health) – Chairman Director of Health Services – Vice-chairman Representative of Finance Department – Member One reputed expert in Ophthalmology – Member One representative of NGO – Member Nominee/Representative of MOHFW – Member Joint Director (NPCB) – Member Secretary

NPCB

(centrally sponsored program )

Central Level : National Programme management Cell in DGHS/ MoHFW.

State Level :

- State Programme Cell

- State Health Society

District level :

District Health Societies

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Functions of State Health Society –

a. to monitor and supervise implementation of NPCB in the State b. release and monitor flow of funds, expenditure and functioning of District Health Society c. implement training and IEC activities in the State d. Recommend grant-in aid to NGO for non-recurring grants.

Funds for District Health Societies will be released through the State Health Societies, thus releasing pressure on the Central Government to focus more on programme monitoring and quality issues.

District Level: District Health Society is the programme implementation unit at the district level by coordinating different agencies and monitoring implementation by pooling in all the resources available.

1.7 Achievements during 11th Plan

SNo. Component Target Achievement (2007-11) 1 Cataract operations (lakh) 300 231.20

2 School Eye Screening (Spectacles to School Children) (lakh)

15 21

3 Collection of Donated Eyes (thousand) 265 170

4 Regional Institutes of Ophthalmology (new) 3 2 5 Medical Colleges supported 150 150

6 PHC/Vision Centres 3000 2725 7 Eye Surgeons trained 2000 1500

In order to bring out an improvement in the quality of services , following strategies have been worked upon so far:

a. Banning outdoor surgical camps

b. Emphasis on IOL implantation in cataract surgery at institutional level and greater coverage for women and underprivileged sections of the society etc.

c. High quality instruments and equipments provided for all eye care units under NPCB.

1.8 Constraints recognised to be addressed in 12th

plan

Some of the key constraints under NPCB recognised by the end of 11th

plan were:

1. Unequal distribution of Eye Surgeons: There are an estimated 12,000 Eye Surgeons in India for more than 1 billion population, with an average of ratio of 1 surgeon for about 1,00,000 population. However, there is wide disparity between urban and rural areas. Eye surgeon- population ratio varies from 1:20,000 in urban area to 1 in 2,50,000 in rural areas. This disparity has led to significant differences in services offered/sought by the public.

In 12th plan : Additional eye surgeons provided by continuing the 250 eye surgeons sanctioned in the 11

th plan and upscaling the number of surgeons to 650 in all District hospitals on contractual basis.

2. Insufficient number of paramedical eye care personnel- While desired eye surgeons- paramedic ratio should be 1:3 to 1:4 there are less number of qualified paramedics as compared to eye surgeons. The surgeons therefore have to sometimes perform jobs like refraction, pre-operative care and undertaking diagnostic tests, which can generally be carried out by paramedical personnel.

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In 12th

plan : To meet the deficiency of ophthalmic assistants, it is proposed to appoint 425 additional ophthalmic assistants in District Hospitals and PHCs/Vision Centres

Appointment of the following personnel (Contractual):

- Ophthalmic Surgeons: in all District Hospitals.

- Ophthalmic Assistants: in all District Hospitals and in PHCs/Vision Centers, where they are not available.

- Eye Donation Counsellors: in Eye Banks under Government Sector and NGO Sector

- Data Entry Operators: for all the districts

- Driver cum Assistant: one for each district

3. Sub Optimal Coverage by Govt. Institutions - Government facilities, NGO and private sector are usually located in urban/ semi-urban areas. Geo-physically remote and socio-economically backward population remains underserved. NGO sector has been contributing effectively to reduce backlog of cataract from the country including NE Region.

As per 12th plan the strategies are:

3.1 Multi-Purpose mobile ophthalmic units to be introduced at all the district levels to reach the remote areas for following activities

a. Screening Eye Camp b. School Eye Screening c. Transporting Patients for treatment d. On the spot refraction and provision of glasses e. Diagnosis of diseases like diabetic retinopathy, glaucoma etc. f. Display of IEC NPCB messages on its outer panels g. Monitoring of NPCB activities by DPMs

3.2 Construction of dedicated Eye units in District Hospitals in North-Eastern States, Bihar, Jharkhand, J&K, Himachal Pradesh, Uttarakhand and few other States where dedicated Operation theatres are not available.

4. Inadequate service provision for Eye Diseases other than cataract: Cataract intervention has been given the highest priority attention under the National Programme for Control of Blindness and the problem of Corneal Blindness, Glaucoma and Diabetic Retinopathy have not been adequately addressed. Similarly Pediatric Ophthalmology and low vision have also received a lower priority.

As per 12th

plan: To make NPCB more comprehensive, assistance for eye diseases other than cataract was initiated during the 11

th Plan. It is proposed to continue the same initiative during the 12

th

plan.

5. Lack of Public Awareness: Rural, illiterate and under privileged population are not fully aware about various interventions that are available to restore vision of the blind. Integration with primary health care is also limited and therefore rural health workers are not motivating potential beneficiaries.

As per 12th

plan: For more public awareness about eye care and utilisation of eye care services, IEC activities will be intensified through print, audio-visual media as well as mid-media and interpersonal counselling to make people from all walks of life aware of various activities like free cataract surgery with Intra Ocular Lens (IOL), free spectacles for school children and old persons, diagnosis and treatment of corneal opacities, diabetic retinopathy, glaucoma, squint etc.

1.9 (1) Focus Areas in 12th

year pan for NPCB:

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In line with Vision 2020, the causes of avoidable blindness to be concerted upon :

- Cataract - Refractive Error - Low Vision - Corneal Blindness - Other emerging diseases like Glaucoma, Diabetic Retinopathy, and causes of Childhood Blindness like Congenital Cataract, Squint, Amblyopia etc

1.9 (2) Strategies and Initiatives under NPCB (12th plan)

New Strategic Initiatives for improved implementation and expansion of existing services during the 12

th Plan are as follows:

1. Development of Mobile Ophthalmic Units in NE States, Hilly States and difficult terrains for diagnosis and medical management of eye diseases especially in remote and underserved areas. Development of about 400 Multipurpose District Mobile Ophthalmic Units in District Hospitals has been approved in a phased manner.

2. Distribution of free spectacles for near work to old persons suffering from presbyopia4

3. Involvement of Private Practitioners in Sub District, Blocks and Village Level. 4. All diabetics should be referred for regular fundus examination from all Medicine

departments across the country and necessary IEC material to be developed. 5. Delink all Central government hospitals and Medical colleges of Delhi from Delhi State

Health Society and be funded @ Rs 80 lac directly from centre. 6. In order to procure uniform and high quality cost effective equipment a Rate Contract is to be

established in the Central Cell in NPCB. A technical committee to be set up at central level for specifications. Efforts will be made for the maintenance of Ophthalmic Equipments supplied to Regional Institutes of Ophthalmology, Medical Colleges, District/Sub-District Hospitals, PHC/Vision Centres.

7. Strengthening of existing Regional Institutes of Ophthalmology (RIOs) on priority and link the medical colleges for training and development and setting up of more RIOs in different parts of the Country. The number of such RIOs was increased to 16 during 10

th Plan. The

number of these RIOs has now been raised to 20 with inclusion of RIO Srinagar during 12th

Five Year Plan. These Regional Institutes of Ophthalmology are considered to be the Centres of Excellence and play an important role in strengthening of eye care services delivery by bringing in latest technology and contributing in developing the human resources. The assistance sanctioned from MoHFW has been raised from Rs. 60 lakh provided during 11

th

Plan to Rs. 1.00 crore for 15 RIOs and Rs. 3.00 crore for 5 best performing RIOs during the 12

th Plan.

8. Eye banks should be established in all existing RIOs

1.10 Expected Outcomes : It is proposed to perform 350 lakh Cataract operations during the period 2012-17 of which minimum of about 60 lakh school children with refractive error and presbyopic middle aged poor persons will be provided free spectacles. Presbyopic glasses to be provided as a new initiative to all BPL persons requiring corrective glasses for sharp near vision.

Network of eye care infrastructure and commodity assistance in the form of equipments, consumables and drugs will be established to increase capacity of the state in providing comprehensive eye care services to the community. Increase in eye donations by strengthening eye banks and eye donation centres, training of adequate number of eye care personnel, reduction in disability years and increasing productivity will be other focus areas.

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Physical targets 11th

plan 12th

plan

Cataract surgery 300 lakh 350 lakh (90% operation will be by Intra Ocular Lens implantation )

Spectacles to school children 15 lakh 50 lakh

Collection of donated eyes 2,65,000 3,00,000 Spectacles for near work to old persons (Once in every five years)

Nil 10 lakh

1.11 Monitoring and Accountability framework:

- The State Programme Officer/District Health Society shall inspect the work done as and when required and shall also obtain monthly report from the NGO of the work done. The grantee NGO shall be duty bound to submit such reports on a timely basis.

- Random checks will be carried out to assess the validity of reported data, status of follow-up, provision of glasses and patient satisfaction.

- Standard Cataract Surgery Records for operation performed will help in providing relevant information about visual outcome and other quality parameters.

- Periodic review should be undertaken by the District Health Society to assess the progress in each block and by each provider unit.

1.12 Involvement of voluntary organisations

National Program for control of Blindness aims to address issues leading to blindness in a comprehensive manner through Public Private Partnership (PPP) i.e. management of Diabetic Retinopathy (DR), Glaucoma, Squint, Kerato Plasty, Retinopathy of Prematurity, (ROP), low vision etc. in addition to cataract, refractive errors and other ongoing schemes of previous five year plan.

The focus is specifically targeted towards providing services in rural/tribal and other difficult areas by developing eye care infrastructure to provide appropriate eye care services to reduce the prevalence of blindness.

A provision of Rs.2506.90 crore has been approved by the Government for implementation of the NPCB during the 12

th Five Year Plan for activities upto the district and below hospitals.

Following schemes are presently available for the voluntary sector:

Non-recurring Grant-in-aid Recurring Grant-in-aid

1. To District Health Societies (NPCB) for release to NGOs for strengthening/expansion of Eye Care Units in rural and tribal areas (upto maximum Rs. 30.00 lakhs)

1. Recurring Grant-in-aid for free cataract operations and other eye diseases by voluntary organisations/PRI etc. in camps/fixed facilities

2. To Eye Banks in Government/Voluntary Sector (upto maximum Rs. 15.00 lakhs)

2. Recurring Grant-in-aid for Eye Banks in Government/Voluntary Sector.

3. For Eye Donation Centres in Government/Voluntary Sector (upto maximum Rs. 1.00 lakhs).

3. Recurring Grant-in-aid for Eye Donation Centres in Government/Voluntary Sector

4. For Development of Mobile Ophthalmic Units with Tele-Ophthalmic Network and few fixed Tele-Models (upto maximum Rs.

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60.00 lakhs).

5. For PHC/Vision Centres in Government and Voluntary Sector (upto maximum Rs. 50 Thousand)

Summary

Globally, Right to Sight envisaged under Vision 2020 targets many prevalent causes of avoidable blindness. India, under NPCB, has reduced the burden of blindness from 1.4% to 1% and strives to achieve its target of 0.3% by year 2020. Various strategies to address constraints of program so far are envisaged under 12

th five year plan and proportionate budget is allocated both for public and private

institutional mechanisms to achieve it. Strengthening of existing Regional Institutes of Ophthalmology to provide state of art care in eye and expansion of services to rural and remote areas along with extensive IEC activities need to be worked upon.

References

1. Report of the Working Group on Disease Burden for 12th

Five Year Plan. WG­3 (2): Non Communicable Diseases.

2. Vision 2020: The Right To Sight. Plan of Action. National Programme for Control of Blindness, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India.

3. Guidelines for State Health Society and District Health Society. 11th

five year plan 2009. NPCB. http://npcb.nic.in/writereaddata/mainlinkfile/File106.pdf

4. Guidelines for distribution of free spectacles for near work to old persons suffering from presbyopia under the National Programme for Control of Blindness during the 12

th Five Year

Plan. http://npcb.nic.in/writereaddata/mainlinkfile/File306.pdf

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Quadrant III. Self-Assessment exercises

1. What are the goal and objectives as per 12th

five year plan for National Program for Control of Blindness?

Goal: To reduce the prevalence of blindness to 0.3% by the year 2020. Objectives of NPCB in the XII Plan: India is committed to reduce the burden of avoidable blindness and proposes to develop infrastructure and Eye Care services delivery system during 12th Five Year Plan.

1. To reduce the backlog of blindness through identification and treatment of blind at primary, secondary and tertiary levels based on assessment of the overall burden of visual impairment in the country. 2. Develop and strengthen the strategy of NPCB for “Eye Health” and prevention of visual impairment; through provision of comprehensive eye care services and quality service delivery. 3. Strengthening and up-gradation of RIOs to become centres of excellence in various sub-specialities of ophthalmology 4. Strengthening the existing and developing additional human resources and infrastructure facilities for providing high quality comprehensive Eye Care in all Districts of the country; 5. To enhance community awareness on eye care and lay stress on preventive measures; 6. Increase and expand research for prevention of blindness and visual impairment; 7. To secure participation of Voluntary Organisations/Private Practitioners in eye Care

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2. Describe the Institutional structure for implementation and monitoring of NPCB.

Various records included for monitoring purpose :

- Inspection by State Programme Officer/district Health Society - Monthly report from the NGO - Random checks to assess the validity of reported data, status of follow-up, provision of glasses and patient satisfaction. - Standard Cataract Surgery Records for operation performed - Periodic review by the District Health Society

3. What are the constraints recognized so far under NPCB and how does the 12th five

year plan envisage to overcome them?

NPCB Constraints Aim under 12th

plan 1. Unequal distribution of Eye Surgeons Additional eye surgeons (250) eye surgeons

previously sanctioned to continue and upscaling the number of surgeons to 650 in all District hospitals on contractual basis.

2.Insufficient number of paramedical eye care personnel

Appoint 425 additional ophthalmic assistants in District Hospitals and PHCs/Vision Centres

3.Sub Optimal Coverage by Govt. Institutions

- Multi-Purpose mobile ophthalmic units - Construction of dedicated Eye units in District Hospitals especially where dedicated Operation theatres are not available.

4.Inadequate service provision for Eye Diseases other than cataract:

- Assistance for eye diseases other than cataract to continue

5. Lack of Public Awareness - Intensified IEC activities through print, audio-visual media as well as mid-media and interpersonal counselling

NPCB

(centrally sponsored program )

Central Level : National Programme management Cell in DGHS/ MoHFW.

State Level :

- State Programme Cell

- State Health Society

District level :

District Health Societies

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4. MCQ

1. Following diseases will be targeted under NPCB, except

a. Trachoma

b. Onchocerciasis

c. Childhood blindness

d. Refractive Errors

2. New initiatives under 12th

five year plan in NPCB are all, except

a. Free spectacles for presbyopic adults

b. Regular fundus examination of diabetics

c. Strengthening and increasing number of Regional Institute of Ophthalmology

d. Changing Mobile Ophthalmic Unit to fixed centres

Key to answers

1. b

2. d

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Quadrant-IV: Learn more/Web Resources/Supporting Materials/Interesting Facts:

npcb.nic.in/

npcb.nic.in/writereaddata/mainlinkfile/file108.pdf

npcb.nic.in/index1.asp?linkid=80&langid=1

npcb.nic.in/index1.asp?linkid=86&langid=1

https://www.ncbi.nlm.nih.gov › NCBI › Literature › PubMed Central (PMC)

www.nhp.gov.in/national-programme-for-control-of-blindness_pg

www.mohfw.nic.in/index1.php?lang=1&level=7&sublinkid=4607&lid=391