A MODEL OF EYE CARE SERVICE IN THE EASTERN REGION OF NEPAL

1. Mechi Eye Care Centre, Birtamod, Jhapa, Nepal. 2. World Health Organization, Geneva 27, Switzerland. Address for correspondence : Dr. S. K. Singh, MD, Ophthalmologist Incharge Mechi Eye Care Centre, Birtamod Jhapa, Nepal. Phone No.: 023-40153, 023-41093. Email: mecc@fech.wlink.com.np Mechi Eye Care Center was established in a rented building in Nov. 1996 with the help of Eye Care Himalaya, The Netherlands. In the last four and half years patient flow has increased gradually and the present facility is stretched to the limit. Provision of efficient and good quality treatment, close monitoring on attainment of good surgical quality and visual outcome are the main aims of this eye centre. Community involvement (such as active participation in screening camp and land donation for new proposed eye hospital) has been exemplary. Trained Ophthalmic assistants are fully utilized thus enabling Ophthalmologists to devote their time in surgery and examination of referred patients. Preventive maintenance of instruments & equipment is a routine practice in this eye center. It is facing the problem with the space and the human resources (mainly Ophthalmologist). Eye Care Himalaya has planned to construct a new building of the hospital and train required human resources. We hope that after completion of the new hospital building and with proper and sufficient number of trained manpower at least one thousand patients can be examined and two hundred patients can be operated every day. Thus, the Hospital will be a gift to the blind people of this region to prevent and cure their blindness and at the same time, it could play a significant role to eliminate the avoidable blindness in this part of the world and contribute to the Mission Vision 2020:The Right to Sight.


Mechi
It is facing the problem with the space and the human resources (mainly Ophthalmologist).Eye Care Himalaya has planned to construct a new building of the hospital and train required human resources.We hope that after completion of the new hospital building and with proper and sufficient number of trained manpower at least one thousand patients can be examined and two hundred patients can be operated every day.Thus, the Hospital will be a gift to the blind people of this region to prevent and cure their blindness and at the same time, it could play a significant role to eliminate the avoidable blindness in this part of the world and contribute to the Mission -Vision 2020:The Right to Sight.

INTRODUCTION
Nepal is one of the ten poorest countries in the world with an average family income of less than $ 150 per year. 1 Nepal is divided into five development regions, 14 zones and 75 districts.Geographically, Terai (plain land) covers 33%, hill region covers 42%, and mountain region covers 25%.According to National Population Census of 2001, Nepal's population was 23.2 million.
The reported prevalence of blindness varies from 1-4 per 1000 population in the communities with good economic and health status, compared with 5-15 per 1000 in communities with poor economic and health status. 2,3,4,5,6,7,8,9Age related macular degeneration, Glaucoma, Diabetic Retinopathy and congenital diseases are the major causes of blindness in the communities with good economic and health status whereas Cataract, Glaucoma, Trachoma/Scar, Onchocerciasis, Xerophthalmia and other causes of childhood blindness are the major causes of blindness in the communities with poor economic and health status. 10,11,12,13According to the Nepal Blindness Survey of 1981, 14 prevalence of blindness in Nepal was 0.87%.Cataract, Corneal opacity, Glaucoma and Retinal diseases were found to be the major causes of blindness.80.2% of the blindness was avoidable or curable.
Mechi Eye Care Center was established in a rented building in Birtamod, Jhapa in November 1996.In the beginning a surgical eye camp was carried out where 442 cataract surgeries were performed and more than five thousand patients were examined and treated.Clinical services were started from December 1, 1996 with the help of one Ophthalmologist and five ophthalmic assistants.Since the very beginning Mechi Eye Care Center is providing the eye care services to the people of this zone through the hospital based service and the community based programs.

It consists of Out patient department, Operation theatre,
In-patient department, and Administrative office.

OUTPATIENT DEPARTMENT
It is situated in the ground floor in about 1800 Sq. feet.To function the outpatient department smoothly an outpatient department protocol has been developed and is in use.Initial screening of patients are done by the ophthalmic assistants and if needed they are referred to the ophthalmologist.Minor surgical procedures like entropion/ectropion correction; chalazian incision and curettage are carried out in the treatment room on the OPD basis.

OPERATION THEATRE
It is situated on the top floor.The setup of Operation theatre is mainly for the surgery of the anterior segment disorders.It is well supported by good microscopes, vitrectomy machine and phacomachine.Fumigation is carried out weekly in the operation theatre.

IN-PATIENT DEPARTMENT
It is in the first floor.There are fifteen beds in paying ward and fourty beds in the general ward, which is in the 'hut' like setting.

MICROBIOLOGY LABORATORY
A small microbiology laboratory with a microscope has been setup in the duty room of in patient department section.Facility for Gram staining and KOH mount is available.

SUPPORTING SERVICES
Yag Laser facility, facility for central visual field analysis and biometry are also available.

HUMAN RESOURCES
At present one ophthalmologist (supported by a second ophthalmologist from time to time), two senior ophthalmic assistants, seven ophthalmic assistants, one senior administrative assistant, one registration clerk, two primary eye care workers, three cleaners, four guards and one driver are working in the Center.

HOSPITAL SERVICES
Ophthalmic assistants do regular screening of the patient.They usually dispose the patients with refractive error and patients with minor ophthalmic problems.

Mechi Eye Care Center
Major equipment: Projections show that by increasing the number of cataract surgeries to 3,500 and maintaining right mix of subsidized and paying patients, cost recovery of 100% of the running cost can be attained.

PROBLEMS
At present Mechi Eye Care Center is facing problem because of the lack of adequate space and sufficient human resources, mainly Ophthalmologist.Existing premises is overcrowded with the increased numbers of patient flow.Absence of waiting lobby in the out patient department and for the patients undergoing operations makes the situation worse.To cope with the increasing patient load, there is a need for at least two full time ophthalmologists with part time support from one more ophthalmologist during the peak season.

DISCUSSIONS
The great challenge that Mechi Eye Care Center is facing is to provide quality eye care that is appropriate, affordable and accessible to everyone, especially to the poor of the community.The center is gradually moving towards high volume, low cost approach to eye care delivery so that it can be affordable to everyone and at the same time sustainable in the long run.Hospital charges for operations are provided in a package form to the patients.Patients do not have to buy anything other than the postoperative medicines.Hospital charges are different for the paying patients and the subsidized patients.Patients from the rich group have to pay more so that the patients from the low paying group can be subsidized.Attracting high paying groups require tailoring of services to suit their requirements.
To solve the problem of space, Eye Care Himalaya is planning to build a new well-equipped hospital in a 140,000 Sq. feet land donated by a family trust.This hospital will include all subspecialties in ophthalmology, six modern operation theatres, and two hundred in patient beds.It will also include other support services required for the hospital like microbiology, pathology, radiology departments; eye bank and a low vision clinic.The reason for establishing this large facility is to provide comprehensive eye care to Nepalese population and patients from neighboring India.

Services / Year
Eye Care Center was established in a rented building in Nov. 1996 with the help of Eye Care Himalaya, The Netherlands.In the last four and half years patient flow has increased gradually and the present facility is stretched to the limit.Provision of efficient and good quality treatment, close monitoring on attainment of good surgical quality and visual outcome are the main aims of this eye centre.Community involvement (such as active participation in screening camp and land donation for new proposed eye hospital) has been exemplary.Trained Ophthalmic assistants are fully utilized thus enabling Ophthalmologists to devote their time in surgery and examination of referred patients.Preventive maintenance of instruments & equipment is a routine practice in this eye center.