Journey of the systems change through Inclusive Eye Health approaches in Pakistan

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What are the most pressing concerns on eye health in your country? What were you trying to achieve?

In Pakistan, 26 million people live with vision impairment, including 1.5 million who are blind, and over 3 million children face preventable sight loss. Most (90%) reside in low- to middle-income regions with limited access to eye care, often compounded by barriers faced by persons with disabilities. Punjab, a densely populated province with 110 million residents, experiences severe poverty, leaving 12.1 million with vision impairments, including 1.2 million who are blind. In Rahimyar Khan, a district in Punjab, affordable eye care services are scarce.

About the project

The Layton Rahmatulla Benevolent Trust (LRBT), in strategic collaboration with Christian Blind Mission (CBM) and the Federal Ministry of Economic Cooperation and Development (Germany), is implementing an inclusive eye health project in Rahimyar Khan, South Punjab, Pakistan. This project focuses on equitable and inclusive eye care, prioritizing underserved communities. By integrating disability-inclusive practices, the initiative aims to enhance the quality of life for those affected by visual impairments and blindness in Punjab. Initiated in December 2020, this four-year program aims to address the barriers marginalized groups, face in accessing equitable and quality eye health services.

The project introduces a systems-strengthening approach to expand access to inclusive eye care services. It focuses on improving ophthalmic care at primary and secondary health levels, capacity-building of health staff, advocacy for inclusive health policies, and empowering communities through Self-Help Groups and Organizations of Persons with Disabilities (OPDs).

Over 315,000 people have been screened for eye diseases and visual impairments. More than 2,600 eye surgeries have been performed, and 101,500 pairs of eyeglasses have been prescribed. Additionally, over 200 low-vision services has been provided, and more than 480 assistive devices have been distributed to individuals with disabilities enhancing their quality of life and fostering greater independence.

What was done? The course of action

Systems Strengthening

The program upgraded 30 health facilities, including 24 Basic Health Units, five Rural Health Centers (primary level), and one Tehsil Headquarters Hospital (secondary level). These upgrades included provision of state of the art ophthalmic equipment and the establishment of a low-vision clinic at the secondary center, which also offered cataract surgeries, comprehensive post-operative care, and rehabilitative services.

Capacity Building

Training programs were conducted for over 385 outreach staff, including Lady Health Workers, and 55 health personnel, such as Medical Officers and optometrists, in primary eye care and disability inclusion. School Health and Nutrition Supervisors were trained to use Peek technology for early identification of eye issues among schoolchildren. These efforts extended to special education schools, screening 876 children with disabilities and providing eyeglasses, surgeries, and low-vision aids.

Community-Based Inclusive Development

A community-based approach tackled financial and logistical barriers to eye care. Awareness campaigns emphasized eye health and disability rights, reducing stigma and discrimination. Collaboration with the Social Welfare Department and NADRA facilitated over 410 CNICs for persons with disabilities, enabling access to government benefits.

Locally, 12 organizations for persons with disabilities and 24 self-help groups were established to support access to inclusive eye health services. Over 470 assistive devices were provided, and 28 health facilities were made accessible to persons with disabilities.

Advocacy

The project established the District Inclusive Eye Health Committee, comprising technical experts and officials, under the District Health Authority’s leadership. The committee developed the first District-Level Inclusive Eye Health Plan for 2024-2026, aligned with national and provincial integrated people-centered eye care plans. This advocacy effort highlights the importance of collaboration in achieving systemic change in eye health delivery.

Through this multifaceted approach, the program addresses critical gaps in eye care services, ensuring inclusivity and equity in health services for marginalized and underserved populations in Rahimyar Khan.

Key Stakeholders

The project began with a comprehensive systems mapping exercise and a baseline survey to identify gaps in eye care service delivery across Rahimyar Khan. These insights shaped a tailored approach to integrate eye health services into 30 existing health facilities. The program fostered collaboration across district, provincial, and national levels, engaging key stakeholders such as:

National Committee for Eye Health
Punjab Provincial Cell
District Health and Education Department
District Health Development Center
Punjab Health Facility Management Company (PHFMC)
District Health Information System
Integrated Reproductive Maternal Newborn & Child Health (IRMNCH)
Social Welfare Department
National Database and Registration Authority (NADRA)
Other Non-Government Organizations in the district

These partnerships were instrumental in translating national and provincial plans into actionable district-level strategies. Stakeholders like the district education department, PHFMC, social welfare departments, NADRA, and IRMNCH played pivotal roles in extending the program’s reach to underserved and marginalized groups, including children, women, and persons with disabilities.

By leveraging resources, expertise, and networks, these collaborations significantly enhanced the project’s impact and sustainability, ensuring inclusive and equitable access to quality eye care services.

Lessons Learnt

Before the program’s initiation, access to primary-level eye health services in Rahim Yar Khan district was not available, posing substantial challenges for individuals, especially those living in remotest communities and with disabilities. The exclusive provider of eye health services, the Tehsil Head Quarter hospital in Sadiqabad, lacked the necessary facilities, equipment, and staff, resulting in a significant backlog in treating blindness and other eye conditions. Furthermore, there was a lack of coordination among stakeholders in the ophthalmic sector in Rahim Yar Khan.

In light of these challenges, the inclusive eye health project adopted a comprehensive approach to enhance access to eye care, focusing on the promotion, prevention, treatment, and rehabilitation of eye conditions. Here are some key lessons learned from the project:

Comprehensive Situational Analysis and intervention feasibility: The project conducted district-level ECSAT (Eye Care Situational Analysis Tool) and feasibility assessments as preliminary steps before designing the project. The assessments effectively identified existing gaps, highlighted key stakeholders and power dynamics, and ensured that people with disabilities were given a voice from the very beginning of the design process.

Multi-Sectoral Participatory Planning and Multi-Sector Collaboration: The project achieved success through high-level endorsement by the National Committee for Eye Health and participation, buy-in, and collaboration across local-level stakeholders, delivering high-quality and inclusive eye care services. it overcame challenges such as government transition delays through strategic leadership and advocacy.

Alignment with WHO and National Health Plans: The project design was in alignment with the WHO Report on Vision and national eye health strategies, advocating for systems strengthening and increased commitment to eye health at the national level.
Integration into Primary Health Care: The initiative successfully integrated eye care services into primary health care centers, improving access to services by training existing health workers and deploying optometrists to rural areas.
Support for Vulnerable Groups: By fostering Self-Help Groups (SHGs) and Organizations of Persons with Disabilities (OPDs), the project facilitated access to inclusive eye care services. The program initially sought support from the Social Welfare Department for individuals with disabilities, but due to financial constraints, it shifted focus to the Industries, Commerce, Investment, and Skills Development Department Govt. of Punjab, receiving encouraging responses.
School Eye Screening: Although School Health and Nutrition Supervisors were initially tasked with eye screenings for children, their many responsibilities hindered effectiveness. To improve this, optometrists and social organizers were enlisted for support.
Gender Equity: The project took a gender-sensitive approach, which led to an increased number of women accessing eye care services, promoting equity in healthcare delivery.
Sustainability: The project’s systems-strengthening approach ensured its long-term viability. Local health authorities, the Layton Rahmatulla Benevolent Trust (LRBT), and the corporate sector expressed interest in sustaining the optometric workforce and continuing support for the program.

Tips & Tricks

Foster goodwill through proactive local engagement: Collaboration with local stakeholders especially the local health, education, and social welfare administration, and local health personnel ensured successful and timely project execution.
Leverage systems strengthening: Appointing a dedicated District Health Officer to streamline administrative arrangements helped to drive effective program implementation.
Empower communities: Mobilizing communities to form Self-Help Groups (SHGs) and Organizations of Persons with Disabilities (OPDs) for collective action.
Track progress systematically: The program established a robust monitoring, and evaluation system and ensured improved and effective reporting
Creative awareness raising: Organizing impactful World Sight Day campaigns, and other International events with the involvement of the CEO Health Office, district officials, and local communities, contributed significantly to raising awareness.
Build Cross-sector partnerships: The program united diverse stakeholders, including health, development, education, social welfare department, groups representing persons with disabilities, and communities, fostering a culture of collaborative planning and shared learning.
Showcase impact consistently: Continuous sharing of progress with the CEO Health Office, provincial and national forums, and key stakeholders highlighted the project’s needs and demonstrated its impact on individuals.