Indonesia (Helen Keller International)

Lead Agency
Helen Keller International (HKI)

Name of Project
Strengthening Cataract Interventions Toward Vision 2020 Goals

Name of Partner/ Implementing Organisation
Implementing organisation: Helen Keller International
Implementing partners:
· Ministry of Health, Government of Indonesia
· Lombok Community Eye Care Institution

Location
Island of Lombok, West Nusa Tenggara Province

BRIEF DESCRIPTION

Helen Keller International Blindness is the greatest single cause of disability in Indonesia. A 1993-96 survey identified 1.5 percent of the population as blind, 52 percent (1.6 million people) of which was due to cataracts. The gap between needs and services remains today, with an incidence of more than 200,000 against only 50,000 surgeries a year. This indicates an annual cataract surgical rate of only 250 surgeries per 1 million persons – well below the Vision 2020 target of 3,000 surgeries per 1 million persons.

HKI is currently piloting a cataract intervention model that integrates the state of the art in
surgical service delivery with the most advanced program models from HKI’s health and
nutrition, and social marketing programmes. This approach seeks to optimize outcomes for each of the four components of cataract intervention: patient mobilization, patient selection, surgery, and aftercare.

Indonesia Map

With the overall goal of developing a sustainable model for enhanced cataract service delivery to meet the goals of Vision 2020 for the effective control of cataract, this pilot project seeks to:

Enhance patient identification and mobilization through the development of an Eye Health Information System and an appropriate social marketing strategy,
Strengthen the eye health infrastructure to meet service delivery needs based on Vision 2020 targets for cataract control, and
Enhance post-surgery follow up and aftercare services through patient tracking facilitated by the Eye Health Information System.

Funding from Standard Chartered Bank (SCB) would be most optimally used by the project to support the service delivery and infrastructure-building objectives, through the delivery of 1,000 cataract operations per project year for three years; and training of 6 new ophthalmologists, and 20 community eye health facilitators.

While the proposed HKI activities primarily target the long neglected and substantial issue of cataract, the core of HKI’s health programming aims to integrate a more general community-based preventive approach with facility-based treatment. Thus, the training of the Community Eye Facilitators (CEHF) and establishment of the Eye Health Information System (EHIS) will enable the program to address a wide range of ophthalmologic problems. For example, it is anticipated that the CEHF’s will detect and refer over 50 cases/year of trachoma for lid surgery or treatment. Moreover, integrations with the community based vitamin A program will result in a reduction of approximately 8000 cases of night blindness per year. Additional benefits with respect to referrals for refractive error, eye injury, and other issues would exceed 1,000 cases per year. Perhaps most importantly, the establishment of these systems as simple and locally sustainable means to improve eye health will enable the benefits to continue beyond the life of the project.

BACKGROUND

Lombok has a total population of 2.7 million, with 24,000 people blind due to cataract, and an annual incidence of 2,700. 800 surgeries were completed in 2003 of which approximately 70% were with Intra Ocular Lens (IOL). There are four ophthalmologists, four ophthalmic nurses, one general hospital in Mataram (provincial capital), one general hospital in Selong (both having eye departments), and one BKMM based in Mataram. The latter has support from CBM and previously had support from local Lions organisations.

PROGRESS

The structure of this project, and the method which aims to achieve the much needed advancement in eye service take-up, is based on a familiar two pronged approach to community ophthalmology, leading to reduced prevalence.

Firstly; an enhancement of community mobilisation, resulting in much increased demand, through provision of the following factors:

Information and education through Community Eye Health Assistants (or HKI staff) and local NGOs.
Education regarding cataract and treatment options.
Provision of information on how to seek help.
Reminders for follow up.
Transportation to service providers.
Social marketing.
Information by radio messages.
Community events.
Financial assistance in the form of reduced surgical costs, provision of consumables, assistance with transport and reduced service fees at the RSU (provincial hospital).

Secondly, infrastructure development to increase capacity, through the following means:

Development of two Puskesmases to serve as BKMM satellite surgical service centres.
Provision of equipment and consumables to the two Puskesmases and the Provincial Hospital (RSU) in Mataram.
Placement of two Senior Resident Ophthalmologists at the Puskesmases.
Training of two ophthalmic nurses at Cicendo University.
Surgeons incentive scheme to promote quality & quantity surgery.

These activities are being implemented through links with the Mataram BKMM, four currently practicing ophthalmologists, local NGOs, the provincial and district level health departments, the Indonesian Ophthalmologists Association (PERDAMI), the Sub-Directorate for Eye Health of the MOH and the Department of Ophthalmology at the University of Indonesia. The main partner at the BKMM, Dr Farida, is also the main partner of CBM, so there is much scope to co-ordinate international non-government organisation (INGO) services in Lombok, for maximum benefit and coverage.

In addition to these high level links, a new and very necessary staffing group is being introduced to work at community level between the cadres and the mid level ophthalmic personnel. These are Community Eye Health Assistants, or HKI staff, who will provide information, conduct household screening and identify individuals with cataract. They will monitor take-up of follow up services as well as recovery status.

The work accomplished so far is mainly since October 2004 when direction of the programme was taken over by Marcella Pierce. She has established collaboration between her team, local experts and local non-government organisations (NGOs). Some surgical equipment has already been supplied to the RSU. One BKMM satellite, at the Puskesmas in Tanjung (N Lombok), has been identified and one other in the central / southern area is under investigation. They have held the workshop for the rapid assessment survey, some of the senior resident ophthalmologists have been identified many patients have been identified in the first month.

SITUATION

This section is a general comment on the situation in Indonesia, which is not supplied by HKI. It is based on a short meeting with the Director General of Community Ophthalmology at Dep Kes (the Ministry of Health) in Jakarta in January 2005.

A meeting with the Director General highlighted these key areas;

50% of blindness in Indonesia is due to cataract. There is a 1.5% prevalence of blindness.
60% of school children have refractive problems but the Government budget only allocates 12.5% of spectacles free of charge.
Less than 50% (nationally) of District Hospitals have an eye department. More in Java; less elsewhere.
All provincial hospitals have eye department and ophthalmologists.
BKMMs act like a health centre but some are staffed and equipped as a small hospital.
The schools of medicine need to teach community ophthalmology or the response to need will not be very fast
Health is supposedly a free system, but in reality costs are negotiated. Cataract surgery costs a maximum of 250,000 Rupiah (£16) in BKMMs. Rupiah 10M (£625) is normal in the private sector and might go as high as Rupiah 15M (£937). To put this in context, the daily rate for a labourer / agricultural worker is Rupiah 80,000 (£5)