Outreach: linking people with eye care
Several years ago, I had the opportunity to accompany a team from an eye hospital as they went to several locations on what they called ‘outreach’. The primary purpose of these trips was to identify operable cataract patients. Many people attended these outreach clinics, but they identified very few cataracts. The second day, I made friends with a couple of primary school children and explained to them that I wanted to find some people who were blind. I asked them to take me through the village to find these people. With the help of these children, I found five blind people, three with operable cataracts. None of these ever came to the ‘outreach clinic’. From that day on, I was convinced that we needed a new paradigm, new ideas in order to connect these people with services. Some of the major barriers for blind people are actually within the first 100 metres of their front door.
Service delivery in prevention of blindness is usually based on two different models. The first model focuses mainly on making eye care accessible to as many people as possible. This model is best employed in the urban areas of a country, where there are sufficient eye care professionals, but many of the poor cannot afford eye care from their small household budgets due to the high cost of services.
Establishing high-volume reputable eye hospitals in these areas can reduce the cost of eye services to a level that is affordable for most of the population and leads to a sustainable service. There should be no need for outreach in these areas if this works well. In fact ‘outreach surgical camps’ in these areas undermine the viability of these sustainable services.
The second model focuses on making eye care available to people in need who live far from eye care professionals. These communities are isolated, suffer frompoor infrastructure, and a low-density population, which prohibits the establishment of a highvolume surgical unit. However, there are many people in need of eye surgery in these areas and we need to plan how to reach them. It is in this setting that outreach can be used most effectively.
In my experience, the most effective way to reach these communities has been to train and integrate primary eye care workers into the existing primary health care systems. Ideally, a resident of these communities is identified and trained for this work – what most projects call a community-based rehabilitation (CBR) worker. These primary eye care workers are best placed to penetrate the 100-metre barrier that exists around a blind person’s home.
Many rural-based projects conduct what they call ‘mobile clinics’ in order to bring primary eye care to scattered, isolated communities. One should be careful not to confuse the terms ‘mobile clinics’ with ‘outreach’. Mobile clinics should be a permanent strategy used by rural projects to make eye care available on a well-known and regular schedule to remote communities. It is part of their day-to-day activities for their catchment area. Once they have identified a sufficient number of patients who need specialised services, the decision can be made whether to transfer these clients to a surgical facility or to organise for a surgical team to come to them ‘on outreach’.
In many countries, there are no tertiary eye care professionals in rural areas. Most of these professionals (usually surgeons) are based in the urban hospitals for a variety of reasons. We depend heavily on them to provide accessible services to the population. They can also be used in outreach eye care projects that are making services available. ‘Outreach’ should be defined as the provision of a specialised service to a location outside the normal service catchment area of the clinic. In order to utilise the services of these professionals in an efficient manner, clients should already have been identified and collected at a central location. It is not an efficient use of scarce human resources to use ophthalmologists to conduct screening clinics on outreach. Screening should be built into a permanent primary health care delivery system and only specialised services, like surgery, should be catered for through outreach.
Many of us have seen the popular book Where There Is No Doctor. The author describes ways to identify and treat ailments in a very practical manner, especially in cases where there is no doctor to give advice. At the end of each section, the author lists those diagnoses that require a visit to the doctor. Where there is no eye doctor, outreach projects can link people with eye care services. The primary health care worker can identify the clients needing to see a doctor. This helps to reinforce the work of the primary eye care worker and also improves the efficiency of the tertiary service providers.
There are too many examples of outreach being driven by the needs of the service providers (remuneration, statistics, exotic locations, charitable works etc.) instead of the genuine service needs within the catchment areas. Out-of-station allowances are paid for this work and many eye care workers depend on this to supplement their income. This should not be a factor in determining when or where to do outreach. Salaries should be set at equitable levels and outreach should only be undertaken when there are justifiable numbers of clients to be seen who require the expertise of eye care professionals that cannot be found in the host project. The first priority is to establish a permanent primary eye care service wherever possible, and then specialised outreach can be conducted to support this service. Outreach should be carefully planned so as not to jeopardise the normal services of the tertiary centre. It does not make a lot of sense to travel for three days to perform 10 operations when one could be doing over 30 per day at one’s normal place of work.
There is a popular song that refers to the need to “reach out and touch somebody.” Outreach should be planned so that you can count on touching that ‘somebody’. Clients in need of the specialised expertise brought by the outreach team should have already been identified, mobilised, and be willing to receive the services offered. A strategy of outreach is justified provided we efficiently combine those projects seeking to provide accessible services with those projects making services available.