Eye health: the community approach

We know that a coordinated approach to eye health and neglected tropical diseases, at the community level, is the right thing to do. But how do we go about it?

That’s what the CATCH (coordinated approach to community health) programme is leading the way on. The basic mandate of CATCH is to ensure that people in the trachoma-endemic areas of Kenya, Malawi, Mozambique, Uganda and Zambia benefit from improved health through the provision of eye care services. One major activity of the project is coordination with the trachomatous trichiasis (TT) surgery camps, taking care of the people who turn up at the camp but have something other than TT by giving other care on site or facilitating trips for cataract surgery and other issues.

But that’s not all: CATCH is supposed to support cataract operations, bacterial conjunctivitis, capacity building of human resource for eye health, operational research, advocacy and strengthening of health systems for eye health to ensure improved eye health services are available in the future.

CATCH’s larger mandate actually links directly to trachoma elimination and will play a crucial role in the surveillance phase. When TT surgery camps end in a country, ensuring that trained field technicians are available to identify and manage eye health problems, including unmanaged TT cases, is increasingly a challenge. But it is also a necessary step, along with presenting evidence that the prevalence of unmanaged trichiasis is below the elimination threshold, to gain elimination status. So programmes like CATCH can clearly help. Let’s see what they’ve learned so far.

Early communication on programme design is key.

Concerns were raised post-design about CATCH’s potential negative impact on the performance of TT camps. Would CATCH create longer camp times and thus increase the TT surgery vs time spent ratio, or have challenges budgeting at the camp level and increase the costs to run a TT camp? There was never a dispute over whether CATCH was the right approach – that was clear. But the reality is that performance indicators, budgets and implementation plans need to be aligned early on.

Don’t underestimate the logistics and costs.

Coordinating shared vehicles and staff, social mobilisation, tracking referred patients, organising transport and care, reporting for both the project and the MoH – all in limited human resource areas – requires more management and oversight then some other, less complex, programmes do. Budget and hire accordingly!

Positive word of mouth is essential.

Word of mouth really does make or break a programme. CATCH’s advice:

• Make sure visual outcomes are good – obviously the best advertisement for services.
• Provide comprehensive eye health on site where possible – treating of bacterial conjunctivitis and distribution of near vision glasses during the camp spreads the message that turning up at the camp is worthwhile.
• Always counsel post-surgery – knowledge on drug compliance and appropriate follow-up helps avoid negative experiences.

Small changes in process can be huge.

Once we start looking at coordinated approaches we have the tendency to want to reinvent the entire health system. Of course that’s not possible – but small steps can also be powerful. For example, in all of the CATCH countries visual outcome monitoring across the 14 key facilities was non-existent when the project started. Those facilities are now using World Health Organisation cataract outcome monitoring, which means that surgeries and follow-ups can be tracked and that surgeons and facilities can now see their performance over time and understand where they need to improve.