The Progress of Eye Health Service in

Cambodia

Do SeihaNational PBL & VISION 2020 Coordinator

National Program for Eye Health, MMinistry of Health

1st Congress AOS,February 19-21, 2014 at Bangkok Convention Centre at

Central World , Bangkok, Thailand.

Content of Presentation

I. Country Profile and Indicators

II. Blindness and Visual Impairment

III. Progress on1. Human Resource Development2. Facility Development3. VISION 2020 Disease Control

Cataract, Refractive Errors, Trachoma, Childhood Blindness, Diabetic Retinopathy

IV. Challenges of Eye Care and Opportunity

V. Conclusion

I- Country Profile and Indicatorsmbodia

• Population 14,701,717 (July 2011 est.) 

• Urban 20 %

• Rural 80 %

• Male Life expectancy 60

• Female Life expectancy 65• Annual Population Growth Rate 1.8%

• Total Fertility Rate (TFR) 3.31

• Infant Mortality Rate (IMR) 66 per 1,000 live births

• Under 5 Mortality (MMR) 83 per 1,000 live births

• Crude Birth Rate (CBR) 27.7 per 1,000 population

• Access to Clean Water 36 %

• Access to Latrine ( Rural Area ) 34%

• Gross national income per capita (2012) 2,330

• Blindness rate* 0.38% • Causes of Blindness

• Cataract 74.7 %, • Corneal scars ( of all courses) 8.0 % • Glaucoma 3.1 %• Posterior segment diseases 4.9 %• Refractive errors 2.7 %• Uncorrected Aphakia 1.8%

• All bilateral blindness in Cambodia • 90.2% is avoidable • 79.1% is curable and 11.1% is preventable

II- Blindness and Visual Impairmentin Cambodia

* RAAB- 2007, Source from National Program for Eye Health, MoH

• There are approximately 33,359 people are living with visual impairment and 57,857 of them are severely visually impaired.

• Severe Visual Impairment (VA <6/60 – 3/60 )Cataract - 74.9% Uncorrected Refractive Errors - 16.9%

• Visual impairment( VA <6/18 – 6/60) Refractive Errors - 52.8%Cataract - 43.0%

II- Blindness and Visual Impairmentin Cambodia (Cont.)

Main Eye Care Human Resources Categories : 1. Ophthalmologist- 4 years training at the UHS supported

by FHF and ECF started since 20072. Ophthalmic Nurse Training : 1 year training under started

in 1997. At present the Training run by Kompot Regional Nursing School in collaborate with Takeo Eye Hospital

3. Refractionist Nurse : 3 month and 6 months Course started since 1996 organized by NPEH supported by FHF & BHVI at the KSFH

4. Fellowship in pediatric ophthalmology : 2 years program at UHS , Preah Ang Doung and KSFH

Progress on : 1- Human Resource Development

Formal Training Duration Enrolment Frequency

Ophthalmology Residency 4 years 3 - 4 Once/ y

Ophthalmic Nurse 1 year 10-15 Once/y

Refraction Nurse3 to 6 months 10-12 Once/y

SICS 6 weeks 2 Twice/Y

TOT Primary Eye Care 10 days 10-15 Once/

PEC for HCS 5 days 10-15 2-3 Times/y

PEC for NHV 3 days 20-30 2-3 Times/y

TOTVision Screening 3 days 20-30 Once/y

Progress on : 1- Human Resource Development (Cont.)

Progress on : 1-Human Resource Development ( Cont.)

Category 2000 2007 2013 2020 Gap by 2020

Ophthalmologist 2 18 32 67 35

Sub Specialist on Cornea, Retina , Pediatric 4 10 6

Eye doctor( Discontinue Training ) 10 1 11 0 0

BED ( Discontinue Training, )12 16 13

3 Upgraded0 0

Ophthalmic /Eye Nurse, and BEN 37 88 110 250 140

Refractionist Nurse12 25 33 73 40

1. 1993 - 3 Eye units2. 1998 - 10 Eye units3. 2000 15 Eye units4. 2014 21 Eye UnitsA need of establishing 3 more eye unit by 2020Strengthening and optimized utilization the existing facilities is crucial.

Progress on : 2- Facility Development

Regional Eye HospitalCenter of Referred in

RegionSub Specialized ClinicsTraining Center Eye Care Service DeliveryEye SurgeryEye Screening RefractionOutreach Activities

  

Eye Unit No Eye Doctor Yet No Eye Doctor / Only

have Ophthalmic NurseBasic Eye Treatment &

CounselingReferred Eye PatientOutreach Activities Eye

Screening 

Functioning Eye UnitEye Care Service

DeliveryEye SurgeryEye Screening RefractionOutreach Activities 

National Eye HospitalApex Center of ReferralsSub Specialized ClinicsMain Training Center for

Undergraduate and ResidencyCentral Management &

Coordination of all Eye Care Activities

 

PHNOM PENH

Province

Province

Progress on : 2- VISION 2020 Disease Control

1. Cataract

2. Refractive Errors & Low Vision

3. Trachoma

4. Childhood Blindness

5. Diabetic Retinopathy

6. Glaucoma

VISION 2020 Disease Control1- Cataract

• Estimated 29,300 Blind people and 145,200 eyes blind due to cataract in Cambodia

• Accounted for 75 % of blindness

• Cataract backlog 80,000

• Annual incidence 20,000

• To eliminate Cataract Blindness at least 29,300 people with bilateral cataract blindness have to be operated in one eye or CSR need to increase to 3000/million /year

Cataract and Eye Operation 2008-2013

2008 2009 2010 2011 2012 20130

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

16,150 16,667

19,738

22,76223,900

25,09524,46325,934

29,944 29,278

34,291

39,434

Cataract Eye Operation

Cataract Surgical Rate : 2004-2013

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20200

500

1000

1500

2000

2500

3000

3500

463

788 839933

1145 11821409

16141707 1800

3000

Cataract Surgical Rate per Province in 2012-13

3000

2500

2000

1500

1000

500

0

VISION 2020 Disease Control2- Refractive Errors

• Assuming prevalence of RE in Cambodia :• 5-15 years ( 3,141,177 ) - 3% • 16-40 years (7,151,137) - 8%• 40+ years ( 1,730,753 ) - 80%

• Assuming uptake of spectacles between 50-80%

• Over 1,200,000 spectacles required each year

• The prevalence of refractive error in urban schools was 13.7% and 2.8% in rural schools.

Current refractive error services

Refractive Error Service Provider:

Govt NGO Private Total

Clinics 20 6 150 176

Spec/year 4,400 (1.4%)

50,160 (15.7%)

264,000 (82.9%)

318,560

VISION 2020 Disease Control3- Trachoma3-Trachoma

To date the SAFE strategy of WHO is implementing S : Lid Surgery A : Antibiotic For Active Trachoma F : Face washing / Hygiene E : Environmental Change/ Good living Environment

Active Trachoma has been declined for the last 10 years however , Blinding Trachoma still a challenge.

Cambodia is preparing for Trachoma Elimination by 2016

The National Trachoma Survey is underway in 24 provinces supported by USAID and FHI360

VISION 2020 Disease Control4- Childhood Blindness

4- Childhood Blindness• Estimated Number of Blind Children 7,650 (1.5/1000

children)

• Blind School Survey in 2009• Main Causes of Childhood Blindness

• Corneal Scar of all causes 55 %• Congenital Cataract 10 %• Eye injuries 3%• Other 32 %

A approximately 10,000 school Children were screened for refractive errors at schools and in outreach program across the country in 2013

Conjunctiva

Refracti

ve Er

rors

Catarac

t

Eye I

njury Lid

Cornea

Evisc

eration

Uveitis

Glauco

ma

Dry Ey

e

Retinal

Detach

ment

Other0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,5003,

874

688

256

189

659

1,86

4

38

150

120 36

7

94

3,29

3

Children Consultation 2012-13

Consultation

VISION 2020 Disease Control5- Diabetic Retinopathy

• The prevalence of Adult Diabetic is 2.9 % ( M 2.5%, F 3.3%)

• There are an estimated 250,000 diabetics in the country.

• Diabetic Retinopathy accounted for 17 % and blindness due to DR accounted for 10 % ,which need medical intervention.

• Diabetic Retinopathy Treated by Laser and Avastin Injection

• Challenges :• More people poor control of diabetic• Expensive management• Treatment only available in City• Additional Training• Equipment

• Blindness due to Glaucoma accounted for 3.1 % and approximately about 30,000 Cambodian have Chronic Glaucoma and three times more 90,000 are glaucoma suspects.

• Approximately 6% of all eye surgery is Trabeculectomy

• Challenges • Late presentation of cases• Un awareness• Un-diagnosis• Non compliant for treatment• No medication

VISION 2020 Disease Control 6- Glaucoma

Eye Health Care Financing Sources

• Government• International Agencies and Bilateral• INGOs• Local NGOs• Private• CharitiesAnnually over 3 million USD is spend for eye care .

• The distribution of HRH is inequitably divided throughout the country

• Health system governance and management capacity limited

• Insufficiently reliable information system and reporting system,

• Eye health is available only in provincial referral hospitals (21 eye units).

• Depending on support from INGOs/ Agencies

Eye Health Challenges Supply Side

• Low level of utilization • Inappropriate health practices and health seeking

behavior. • Poverty issues, education, sanitation, perceptions,

compliance to treatment,

• The referral system of PEC is poor

• The fund for eye care from government is still limited

Eye Health Challenges Demand Side

• Support from Government/ MoH

• National strategic plan 2008-2015

• Eye health coverage has been improved to OD

• PEC is integrated into PHC ( MPA CPA1, CPA2, CPA3)

• Eye health infrastructure has been developed and strengthen

• The identification of posts for all residents is effective in reducing the mal-distribution of HRH.

• HEF and subsidize are effective in reducing the barrier for eye health service delivery for poor people.

Opportunities

1. Cambodia has made tremendous achievement of Eye System Development in • Human Resource, • Facilities• Blinding Disease Control• Fund Mobilization• Advocacy

2. Scaling up all activities and strengthening existing strategies along with the National Health Strategic Plan will ensue long term sustainability

3. Private, National and International Partnership is crucial for success.

Conclusion

International NGO/ Agencies

THANK YOU FOR

YOUR ATTENTION