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Nepal REACH Program
Refractive Error Among Children (REACH) Project, Nepal
Globally refractive errors are the single largest cause of visual impairment for both adults and children and the most common reason for patients to consult an ophthalmologist. The problem becomes more complex in children as they do not complain of defective vision and may not even be aware of their problem. In the global initiative “VISION 2020 The Right to Sight,” childhood visual impairment and refractive error are highlighted as a priority area. Without appropriate optical correction, millions of children are losing educational opportunities and adults are excluded from productive working lives, with severe economic and social consequences. Individuals and families are frequently pushed into a cycle of deepening poverty because of their inability to see well. Almost 13 million children (age 5 to 15) and 45 million working-age adults (age 16 to 49) are affected globally. Fully 90% of all people with uncorrected refractive errors live in low and middle-income countries.
In the Nepali context, lack of authentic prevalence data specifically for children means that the extent of Childhood Visual Impairment is not known. Consequently, it is not prioritized in eye care services and it also requires additional resources and expertise which are not readily available. IAPB data (2010) for Nepal estimate that 4.9% of the population (30 million) have visual impairment and 0.8% are blind. Studies also show that the rate of myopia particularly in urban areas is increasing.
To address the problem of uncorrected refractive error in children, Orbis India is working closely with Nepal Netra Jyoti Sangh (NNJS), the central coordinating body for eye care in Nepal, and four associate hospitals (Mechi Eye Hospital, Birtamod and Biratnagar Eye Hospital, Biratnagar, Sagarmatha Choudhary Eye Hospital, Lahan and RM Kedia Eye Hospital, Birganj) to roll out the REACH a bespoke IT solution paperless program in Nepal. Through the implementation of the REACH model, partners will be able to screen and treat children and gather much-needed data on the levels of refractive error on school going children which can then be channeled into advocacy initiatives.
Feasibility Study/Base line Survey
The project has been commenced in 2018 as a pilot study in Jhapa by Mechi Eye Hospital and in Sunsari and Biratnagar Metropolitan City of Morang by Biratnagar Eye Hospital. Project, and then scaled up to Sagarmatha Choudhary Eye Hospital for Siraha district and RM Kedia Eye Hospital for Parsa district in 2019 as it was felt strong need during this pilot phase. These two districts i.e. Jhapa and Sunsari from Eastern Nepal were selected in order to pilot the project based on the findings revealed by the numerous surveys conducted in the respective region.
To reduce visual impairment due to uncorrected refractive error as a barrier to education for children by undertaking 8,08,292 pediatric screenings among school-going children between 6-18 years children in Province 1 and 2 of Nepal.
- To increase access to child eye health by providing comprehensive refractive error services to school-going children.
- To improve the quality of child eye health through high-quality refractive error services for school-going children.
- To develop an enabling environment to ensure the delivery and sustainability of quality refractive error services for school-going children.
In addition, a standardized IT-enabled data management system, REACHSoft, will be deployed across all project sites (base hospital and all outreach events) to manage data and facilitate smooth project operations.This unique software was designed as part of the Qatar Creating Vision programme in India (see section on Orbis capacity).
The project will work collaboratively with Government Health and Education departments to seek permission to do the screenings.They will also receive regular reports on project progress and be invited to observe project activities.It will increase their involvement and ownership in eye care programs. The data generated will form a good evidence base for research which can be used in advocacy initiatives to lobby for improved school eye care services in Nepal.
- Approximately 8,08,292 screenings will be performed on school going children, ages 6-18yrs.
- For the children who requires further sophisticated examination and suspected for the surgical services will be referred to the base hospital without charging any cost to them.
- Those children who were found to be suffered from refractive error will be provided a pair of glasses free of cost.
- Each of the eligible child in the school will be monitored during compliance visit after the three months of the spectacle delivery.
- Annul follow up to the same school will be made for those students who were left at the previousexamination and new enrollment in the school.
- In addition, approximately 8000 Teachers, 500 FCHVs and 2200 Vision Ambassadors will be oriented on eye health during the Nepal REACH Project.
Orbis Nepal partners have deployed these projects in three phases: Prepare, Deliver and Consolidate. These three phases are chronologically implemented at any one school such that over time within the overall project there will be some schools in the ‘Prepare’ phase, while others will be in the ‘Deliver’ phase and yet others will be in the ‘Consolidate’ phase. The ‘Prepare’ phase includes the formation and training of an eye care team at the hospital, putting the required equipment in place, networking with stakeholders, preparation of a master database of identified schools and enrolled students and developing the plan for conducting activities in schools. The ‘Deliver’ phase is when screening and refraction services for students in schools will be conducted following a standardized protocol. Glasses will be prescribed/ dispensed to all children diagnosed with refractive errors and those from weaker socio-economic sections will be given spectacles free of cost or at a subsidized price. Children identified with other eye conditions will be referred to the base hospital for further diagnosis and treatment to provide comprehensive services to all children who need them. The ‘Consolidate’ phase comprises compliance checks and follow-up visits. Female Community Health Volunteers (FCHV), School teachers and senior students (Vision Guardians/Ambassadors) will be trained in each of the schools to support in regular screening, follow-up and ensuring compliance to spectacle wear.
A standardized IT-enabled data management system, REACHSoft, is being used across all project sites (base hospital and all school-based outreach events) to manage data and to facilitate smooth implementation of the project activities. The partners will liaise with government agencies, including the health and education departments, and by sharing project data will create a case for further Government intervention.
Expected Project Outcome/Result
- Approximately 8,08,292 screenings will be performed on school going children, ages 6-18yrs, through the Nepal REACH Project.
- In addition, it has been expected that more than 8000 Teachers, 500 FCHVs and 2200 Vision Ambassadors will be oriented on eye health.
- It has been expected that refractive error services at the base hospital will be strengthened.
- Refractive Error and surgical coverage will be improved.
- Quality Management System will be strengthened at each service delivery point to ensure quality outcomes.
- Awareness on Refractive Error will be imparted to support referral of children.
- Program/hospital/donor visibility will be improved through targeted communication initiatives.
- Refractive error services will be ensured with active engagement of stakeholders.
Project Achievement So far
Project Implemented sites
As indicated in the below map, the Orbis-NNJS REACH Project is being implemented in the Eastern region of Nepal.
- Biratnagar Eye Hospital, a tertiary level eye care facility, is located in Biratnagar in the Eastern Region of Nepal.
- Mechi Eye Hospital is in Birtamod, a township in the Eastern Region of Nepal.
- Sagarmatha Choudhary Eye Hospital, Lahan
- RM Kedia Eye Hsopital, Birganj
These districts were selected keeping the following points in mind:
- This is a pilot implementation of REACH in Nepal, and hence only one region has been selected.
- Since this is a pilot, one larger facility (Biratnagar: 56,000 surgeries annually) and one smaller facility (Mechi: 25,000 surgeries annually) have been chosen.
- As with REACH in India, partners, where there are established pediatric eye care services, have been chosen to ensure that quality services are available to those children referred from REACH field activities.
- Core project activities are hold for the time being due to COVID-19. All the REACH teams in all the hospitals are being mobilized in COVID responses activities within the hospitals.
- Delay in funds transfers due to this pandemic.
- Underutilization of all the REACH teams.
- Poor referral compliance- To be strategic from the beginning
- Average rate of spectacles compliance rate- To be strategic from the beginning
- Delay in spectacles delivery- Process to be expedite
- No dedicated counselor-Should be appointed dedicated one in BEH
- Lack of effective counsellor training
- No support for teacher spectacles
- Hard to track the referred cases reported to other institutes
- Poor quality assurance visit
- No accuracy in the data provided by schools