Accessibility, Affordability and Sustainability of glaucoma treatment in Nepal

Tik Bahadur Gharti (63) from Rauswa makes regular visits to Kathmandu at least twice a year, to see a doctor. For him the ability to feed his family depends on keeping his eyesight protected.

With every bitter dose of eye drop he instils; he prays that his disease will be cured. Although the doctor tells him, he needs to do so for the rest of his life, but he still hopes. Following this path, he walks from his home for three hours to get a bus to Kathmandu. He has no other way. Sometimes he gets free eyedrops, but often, he is prescribed a cheaper drug.

Glaucoma is a common cause of irreversible blindness. Although medications and surgical treatments are promising to control the intraocular pressure and maintain the optic nerve; the disease is harder on the patients living in rural Nepal.

Every district of Nepal has primary eye care centers (PECC) with ophthalmic assistants and occasional visits of eye surgeons. Moreover, fourteen districts along the longest India-Nepal border are well equipped with modern technology for glaucoma treatment. Twenty-two tertiary eye hospitals out of thirty-five, are in this region. The PECCs of large hospitals have penetrated all parts of the Terai districts. However, the situation isn’t the same in districts in the hilly and mountain regions. Due to geographical constraints, the PECCs are hard to reach and glaucoma medications difficult to access.

“People are more conscious of their health than in the past, so they reach district eye centers or eye hospitals. Glaucoma patients are told to follow up as per the doctor’s suggestion. But we are still unsure about the compliance once they leave the hospital.” —   Glaucoma Specialist                                      

Most of the glaucoma medications prescribed in Nepal are available under the benefit scheme of Social health insurance. 66 out of 77 districts have already rolled out this programme since 2016. Glaucoma medications are the most expensive among ocular drugs ranging from 1 to 20 dollars in Nepal. The surgical treatment of glaucoma is cost-effective in comparison to life-long medications; however, the outcomes are not convincing. The failure rate is high, and the patient needs to follow up regularly for 5-6 months.

“The first line of drug- alpha-agonist are expensive so sometimes, we have to choose based on the patient’s economic status. It’s better their eyes are protected with cheaper beta-blockers than no medication because of unaffordability of the first line of the drug.”    —  District eye care center ophthalmic assistant

Barriers for access

Availability of anti-glaucoma medication is a major issue: followed by financial accessibility. Pharmacies tend to stock medicines that are frequently prescribed to an optimal number of health service receivers.  Anti-glaucoma drugs are not available in local pharmacies in urban as well as rural areas. They are available only in pharmacies at the eye hospital premises. Because of lack of data on disease surveillance of glaucoma, the demand for anti-glaucoma drugs in a particular district or region is not predictable. Besides that, there are very few glaucoma surgeons (approximately 30) for the population. The catchment of glaucoma patients is also uncommon, as most of the eye camps are focused on cataract screening. Patients with primary open-angle glaucoma are diagnosed during opportunistic evaluation in such community eye camps. There are very few to almost non-existent dedicated glaucoma screening community eye camps and similarly health education and awareness programmes. Lack of awareness is also a barrier to accessing the service.

Innovation

However, some innovative ways of screening unaware glaucoma patients have raised hope. Some of the inventive campaigns are community household eye screening by EREC-P in eastern Terai, refractive error among child (REACH) project in different districts, outreach camps by hospitals and INGOs, Vision Screening March Months campaign by Nepalese Association of Optometrist (NAO).

Marginally extending the general eye camps for evaluating the posterior segment of the eye can have a greater return in terms of finding opportunistic glaucoma cases. Maintaining a patient database through community surveillance for glaucoma and connecting this with the national health service delivery chain can be rewarding for accessibility of anti-glaucoma drugs for all insured and uninsured patients. Skill transfer to optometrists and ophthalmic assistants on the early-stage evaluation of glaucoma and referral to specialists, at the primary level can have promising outcomes in the context of Nepal.

Nevertheless, had the drugs been available at his PHC, Tik Bahadur Gharti wouldn’t need to travel every 6 months despite the financial burden to protect his sight.

Increasing financing and maintaining sustainability in glaucoma treatment is the need. It can only be achieved by greater political commitment and a policy departure in the eye health sector of Nepal. The government needs to fully integrate basic eye services in the health service package at all levels. The social health insurance (SHI) needs to cover all seventy-seven districts, with financial support to conduct outreach activities with detailed ophthalmoscopy and availability of glaucoma medications at all local health posts and hospitals available free of cost to the needy.

Image: Performing perimetry by Brahamdev Mandal