Mpumalanga Provincial Eye Care Programme
Department of Social Development
South Africa

The Problem

Describe in no more than 500 words, the problem to which the initiative was a solution, including major issues, trends and conditions, as well as which social groups were affected.
“Every five second one person in the world goes blind and a child goes blind every minute.” 20% of blind people live in the African Continent. Among the causes of blindness 80% are avoidable, of which 60% is treatable and 20% is preventable. (Source: International Agency for the Prevention of Blindness)

Cataract and refractive errors including low vision have been identified as the major causes of preventable blindness. This is according to the available findings from the Bureau for the Prevention of Blindness based in Pretoria, which is a division of South African National Council for Blind.

This posed a big challenge for Dr. Abraham Varghese who has been working at Themba Hospital in the Province since 1991 .The Kangwane homeland , which became part of the new Mpumalanga Province (then Eastern Transvaal) in 1994 did not have any eye care programme. Dr. Varghese in 1991 established the eye care services at Themba Hospital in Kabokweni, the only referral hospital in Kangwane provided the bulk of health care services to mainly the displaced and less privileged predominantly black people during the apartheid era. The same situation prevailed in other home lands such as Kwandebele and Lebowa which finally became incorporated in the new province. Eye care service was minimal and accessible only to rich white minority group in the previously white administered Transvaal Provincial Authority area and it was mainly through the private health sector.

Dr.Varghese, during 1991-1994 took the lead to organize mini out reach projects in the rural areas of the homeland to supply free spectacles and mobilize patients’ for free cataract for operation. During this time he was advocating for the establishment of a Provincial Eye Care Sub Directorate in Mpumalanga which was realised in 1995. Even then the Themba Hospital eye care unit was the only one with full eye care service. A part time eye care service was available at Rob Ferreira in Nelspruit. School Community Eye Care Programme was launched in 1995 with the blessing of the Provincial Minister for Health. The Premier of the Province attended the first anniversary School Eye Care Project as the Chief Guest in 1996, which gave the eye care programme a big boost due to this political support.

During the same time, the newly established Eye Care Programme organized many other eye care projects for the less privileged members, focusing children, adults and elderly in Mpumalanga Province.
The aim of the project is to render an affordable and accessible eye care service to the people in this rural Province, the majority of who have no access to even basic Primary Health Care, not to mention a specialist eye care. This initiative attracted other non-governmental organizations to come forward and help in this venture. The Lions Club of Nelspruit joined the Eye Care Programme in rendering the service, which is even continuing at this point in time.

Cataract patients are blind; their families neglect them because they are a burden to them, except to get their social grant. Even the children with high refractive error, especially albinos are also neglected by society. This Programme took this challenge to render the service at their doorsteps of those who need such care by organizing the out reach projects in rural areas.

Traditionally, patients go to hospital to seek the help from the health professionals. The innovation in this case, requires the eye care professionals to go to the doorsteps of the needy in order to motivate them to come forward for a free service in their own locality, thus being universally accessible. This is the basis of the “Batho Pele”[People First] principles.

Solution and Key Benefits

 What is the initiative about? (the solution)
This Programme has initiated the eye care projects among the poorest of the poor in Mpumalanga, which is a rural province in South Africa. The programme targeted mainly visually disabled people including women, children and the elderly.

Thorough the project, thousands of people have been screened for eye problems and supplied with free spectacles or low vision devices or arrangements for free cataract operations have been made.

Because of the passion, dedication and commitment shown by the Eye Care Programme team, the Nelspruit Lions Club came to support the community out reach eye care project. They collect the used spectacles from different optometrists which were then recycled for use in the project in the rural areas.

In 2004 during the World Sight Day and Eye Care Awareness Week Campaigns at Tonga Hospital, this team screened more than one thousand and eleven people a day; they could not even register the names of massive number of clients, but finished the project at 22h30. During the same week they also did cataract operation for two hundred and eighty one patients. The Premier of the Province addressed the eye care workers, later visited the refraction clinics and operation theatre and promised his support for the fight against blindness. That was one of the recent advocacy campaigns to get the political support recently.

Screening elderly people at pension pay points is an innovation of this Programme, because most of the old people and visually disabled people in rural community in Mpumalanga Province collect their grants in places near to their homes from the mobile pension distributing agency. Empilweni Payout Services - the agency distributing grant in the Province heard about the eye care project and came forward with the sponsorship for free spectacles to all pensioners and learners at the pension pay points.

Because of this sponsorship, the project does not have to use the recycled spectacle any more for senior citizens and learners. New spectacles are purchased from ICEE- International Centre for Eye care Education, another non governmental organization, at a nominal prize.






The project is now well sustainable because of the partnership with the Bureau for the Prevention of Blindness, a division of SA National Council for Blind, Sight Savers International, an UK based organization, Nelspruit Lions Club, Empileweni Payout Services and later Ster-Kinekor- the cinema organization.

Ster- Kinekor is supporting the team in conducting refractions of Primary School learners from rural schools and the supply of good quality spectacles in addition to a movie environment - a children’s movie in hall, popcorn and coke as in any cinema house.

Each year 2500 to 3000 Cataract operations have been undertaken in the Province. The cataract surgery rate aimed for the project is to do 1000 per million of the population. This target in 2007 has been already achieved in the Province.

The Project has screened 15309 people, refracted 6324 and supplied 3948 free spectacles already. In addition189 free low vision devices have been supplied, to visually impaired people during the year.

All cataract operations are done with intra ocular lenses and the team assesses the quality of visual outcome before the patients are discharged.
All visual out come after refractions are also recorded and if ready made spectacles are not available, special orders are sent for quick delivery of prescription lenses. The Project always aims for quality out come after each operation or refraction.


In rural areas the screening is done at nearby clinics or schools or even at an open space under a tent depending upon the condition of the area. Patients, who need cataract operations, are transported free to the nearest district facilities, where the touring cataract surgery team attends to them

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
In no more than 500 words, specify who contributed to the design and/or implementation of the initiative, including relevant civil servants, public institutions, organizations, citizens, NGOs, private sector, etc.
The project was initiated by Dr Abraham Varghese, now assisted by Mr. Aron Segodi and a newly appointed team of 3 District Coordinators and three District Optometrists. All of them are working as a dedicated team with passion for community eye care service delivery under the mentorship of Dr. Andrew Shija Director of Specialized Services Mpumalanga Dept: of Health & Social Services.

The Department is at the forefront in the implementation of the project through the Provincial Eye Care Programme. The following stakeholders are key in the implementation of the project thus being a multistake holder project.

During each and every project Nelspruit Lions committed their support with volunteers, volunteer Optometrists and re cycled spectacles.

Empilweni Payout Services provides now free spectacles to all the eye care projects at pension pay points in the province; they also supply free transport to the senior citizens for cataract operations.

Sight Savers International and South African National Council have entered in to service level agreement with Mpumalanga Province, because of their effort, to render “Comprehensive Eye Care Service” in Mpumalanga. They provide training, equipments, consumables and low vision devices to the Eye Care programme.

The present partnership with Ster-Kinekor is another proof of sustainability; they are willing to support with good quality new spectacles for the projects among the Primary School learners.


Retina South Africa, an organization fighting to prevent the retinal blindness, is in fact established a branch in Nelspruit because of the effort of this programme and on 29 September 2007 they organized an awareness campaign and street collection for them with the assistance of other members of Lions Cub.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The buy in of political support in order to fulfil the National and the Provisional vision of “A better life for all” and the vision of the Programme
“A developed society in which all people in Mpumalanga have access to affordable Comprehensive Eye Service on the basis of Batho Pele principles”

Their mission is to eradicate the avoidable blindness by year 2020 through the “Vision 2020” “The Right to Sight” initiative of World Health Organization (WHO) and International Agency for Prevention of Blindness (IAPB).

Other strategies:
Identify the key target group and their habitat
Identifying the challenges/constraints and means to overcome them
Re cycling of used spectacles
Provide transport
To woe stakeholders and sponsors
Showing the gains achieved and uses it to gain more resources.


Dr Abraham Varghese took the initiative single handedly to render a comprehensive eye care programme in the erstwhile Kangwane in 1991 and he was joined by Mr Aron Segodi in 1993. After the inception of the new democratic government, by 1995 a coordinated structure was motivated by this two member team. They had several challenges in their journey and finally they were recognized as a sub directorate and now under Specialized Services with Dr Andrew Shija as their Director since 2003.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
Establishment of Eye Care Unit by Dr Varghese at Themba Hospital in Kangwane homeland 1991

Regular out reach Community Eye Care Projects with Lions Club 1992

Mr. Aron Segodi joined as an Ophthalmic Nurse in the one man team 1993

New democratic government in South Africa 1994

Launching of School Eye Care projects VIP Minister 1995

First anniversary of School Eye Care Project VIP Premier 1996

Community Eye care Projects for Farm workers 1997

Service Level Agreement with Bureau for Prevention of Blindness 1998

Mpumalanga Provincial Eye Care Forum established 1999
Several nurses were trained in Ophthalmology 1999
Agreement with Sight savers International 1999
Established first Permanent Eye Centre at Ermelo 1999

First Eye Care workshop 2000
Sub directorate with a Manager and budget 2000
Vision 2020 launched in the Province 2000

Empilweni Payout Services support 2001
Regular outreach projects at Pension pay points 2001

Training of Ophthalmic Nurses in refraction by ICEE 2003

Eye care Programme under Specialized Services 2004
Letter of appreciation from President of South Africa 2004

Excellence in Health Care award for Dr Varghese 2005
Mpumalanga Premiers Award for Eye Care 2005

Comprehensive Eye Service agreement with Sight Savers 2006
Appointment of three District Coordinators 2006
Appointment of three District Optometrists 2006
Pan African Health finalist Award for eye care 2006
First Low Vision Service in South Africa under public sector 2006

National Excellence in Health Care Award for Mr Segodi 2007
Public sector innovator of the Year Award for eye care 2007

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
Obstacles, specific:
Refraction Service (Spectacles and low vision devices)
Logistic including surgical consumables and transport
Human resource

In the initial stage, funding for spectacles was the main challenge. When the Lions Club joined with this doctor, he also became a member of their organization; they solved it by collecting old spectacles for recycling.

Cataract Surgery in rural places:
Dr. Varghese, himself started working in a homeland referral hospital,
where he performed thousands of cataract operations.
He realized that he cannot render this service alone throughout the Province, he took the partnership with Bureau for the Prevention of Blindness, thus extended this service to all rural hospitals.

Now Sight Savers International has entered in to an agreement for a “Comprehensive Eye Service” which comprises of eye care, community based rehabilitation and inclusive education.
Department has recruited six more ophthalmologists, four medical officers, six optometrists and thirty nine Ophthalmic nurses to render service delivery.

Awareness Campaigns and Workshops for health professionals:
It was a problem in the early stages; he approached local news papers
and radio stations to give enough publicity for eye care programme.
Presently due to increased budget from the department this challenge has been solved.

Logistics:

Transporting patients from their home to nearest hospital facilities for cataract procedure was alleviated initially by getting the vehicles from sponsors, later due to increase budget, Department has purchased two transport vehicles. Now they are on the process of procuring the third vehicle for this purpose.

Human Resource:

Human resource in respect of qualified Ophthalmologist is still a challenge, in few centres, even though they managed to recruit six of them to work in different provincial hospitals. Now they are training four doctors as Cataract Surgeons and negotiated successfully with University of Pretoria, to launch a Registrars training programme in Mpumalaga’s two tertiary hospitals, so these Registrars can become Specialists after passing the examination.

Motivation to overcome the obstacles:

The eleven principles of “Batho-Pele”[ People First], are designed to assist service providers to render excellent service to their customers in South Africa. The improvement of service delivery and compliance with Principles has been an endeavour to break from the traditional ways of doing things in respect of transforming public service delivery.

This project which is based on these principles, have successfully reduced the waiting time for eye care management in respect of refraction (spectacle) and cataract surgery in provincial hospitals, because through these projects people get their service at their door steps.

Citizens in particular vulnerable people in the community do not have to wait for long for service delivery in hospitals due to this turn around plan of Community Eye Care Project.

This project reduced the steps in getting the eye care service – no need for a referral letter, no need for any registration fee, no payment for spectacles and no cataract surgery fee.

They trained all ophthalmic nurses in Optometry to become Refractionist, thus solved the deficiency of Optometrists.

Partnership with other stake holders became a “key word” for the projects of this programme. Their partnership with Nelspruit Lions Club, Bureau for the Prevention of Blindness of SA National Council for Blind, Sight Savers International UK, Retina South Africa and Ster- Kinekor Primedia helped the less privileged to access the eye care service in the Province.


They have also successfully organized several workshops for traditional healers, so that they can help in referring Refractive Error and Cataract patients to hospital.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
Mpumalanga Provincial Eye Care Programme has received sponsorship from several partners and presently well budgeted by provincial Administration.

Lions Club of Nelspruit until 1999- average per year
Spectacles 5000 per year [500 x 50 ] R 25,000

Empilweni Payout Services since 2000 [1000x50] R 50,000

Lions Volunteers + Optometrists (time) [5x800x5 projects] R 20,000

Sight Savers International per year R 1 M

Ster Kinekor Primedia per year R 90.000

SA National Council for Blind [Bureau] per year R100, 000

Dept: of Health & Social Services per year R 5.6 M

Lions Club supplies the spectacles, volunteers and Optometrists. Since 2000 Empilweni provide funding for spectacles through Lions Club of Nelspruit.

Sight Savers support the finance through the SA National Council for Blind for Cataract projects, training, consumables and equipments.

Ster Kinekor supplies new spectacles show the movie and provide refreshments to Primary School learners.

SA National Council for Blind provides the Cataract Surgery tours and Low Vision Mobile services in the Province.



Human Resource:

During each project Lions volunteers x 5, Optometrists volunteers x 2 One Provincial Ophthalmologist, Provincial Optometrists x 3, Provincial refractionists x 5 and Ophthalmic Nurses x 5.
Each cataract surgery team from Bureau also consists of 3 nurses but province normally gives their Ophthalmologist to perform operation.
Empilweni Payout Services also provide administration staff x 3, in addition to snacks and bottled water for the patients.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
In no more than 500 words, describe how the initiative is being sustained (for example in terms of financial, social and economic, cultural, environmental, institutional and regulatory sustainability). Describe whether the initiative is being replicated or disseminated throughout the public service at the national and/or international levels and/or how it could be replicated.
The government and the Political leadership have acknowledged the programme. This is a boost to sustainability.

Since this Programme has achieved several awards, Department has increased its budget from 1.3 million Rand to 5.6 million Rand.

Partnership with NGOs [Service Organizations] like Lions Club helped this programme to sustain with supply of re cycled spectacle initially.
Later Empilweni Pay out Services has agreed to pay the cost of new spectacles for senior citizens and learners.

Bureau for the Prevention of Blindness/ South African National Council for blind and Sight Savers International committed for cataract surgery tours and comprehensive eye service in the province through a service level agreement.

Community buy in of the programme, many local organizations are willing to support the project.

Recently Ster - Kinekor the cinema people has joined this Programme to supply spectacles for Primary School learners.

This is definitely a sustainable programme.


Replicability:

Recycling of old spectacles:
This can be replicated to any place, where they do not have enough
funds to buy new spectacles.

Visiting Pension Pay Points:
This is an easy way to screen the senior citizens among the less
privileged, they all collect their grants thorough agencies in rural
provinces. So this project at Pension Pay points can be replicated. In
other countries it can be done at religious or traditional festivals or
even after regular religious services.

Refraction training:

Rural provinces do not have enough Optometrists in Public Sector to render service delivery, so they trained all ophthalmic nurses in refraction by a service provider- International Centre for Eye care Education. This skill transfer alleviated the problem of shortage of Optometrists in public sector. So these professionals can work as Eye care nurses as well as refractionists. This attempt can be replicated in other countries, to provide service in rural areas, where Optometrists do not want to serve.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
In no more than 500 words, describe the key elements that made your initiative a success.
If there is a will, there is a way to do any thing, provided you have
dedication, passion and commitment and willingness to go an extra
mile.
Initially this programme had severe challenge for funding, but once the
partners observed the commitment of these people, they came forward
with support.
Now more and more organizations want to be their partners to render
the service to the poor and less privileged especially old people.

By the perseverance and dedication, they have literally “brought light” to many of these previously disadvantaged poorest among the poor, who otherwise would not have their sight restored. These are simple rural people, whose eye care has hitherto been largely neglected for lack of trained eye doctors to work in rural areas.

They have successfully negotiated to establish Permanent Eye Centres at Ermelo [Gert Sibande District], Phlialdelphia [Nkangala District] and presently negotiating for another one at Ehlanzeni District with the sponsorship of Sight Savers International. They have established a Low Vision centre attached to Ermelo, the first of its kind in Public Sector in South Africa. This is a cost effective way to render eye care to the less privileged.

They learned that funding is not at all a challenge, once they have commitment and passion to render service to the less privileged at their door steps, funding will follow them. That is why they are being approached by new sponsors each and every year.

Political as well as senior management support is very crucial to get recognitions in own department, province and country.

There must be a leader, who can go extra miles beyond the specification of Public Service can attain the goal.

Show the gains by giving statistics, figures as well as few witness statements from patients who regained the vision after management.

Attract the partnership from stake holders, including the local community and their representatives.

Attainment of awards and recognitions definitely boost the morale of the workers in the Programme.
Team awards/recognitions
Appreciation from President of South Africa Letter 2004
Mpumalanga Premiers Service Excellence Award Trophy 2005
Pan African Award for Excellence in Health Care Certificate 2006
Mpumalanga Health Ministers Award for Excellence Trophy 2006
Public Sector Innovator of the year Award CPSI Trophy 2007

Individual Awards:

Dr A Varghese Excellence in Health Care Award National 2005
Dr A Varghese Excellence in Health Care Award Provincial 2005

Mr A Segodi Excellence in Health Care Provincial 2004
Mr A Segodi Excellence in Health Care Provincial & National 2007

Contact Information

Institution Name:   Department of Social Development
Institution Type:   Government Department  
Contact Person:   Abraham Vargahese
Title:   Dr  
Telephone/ Fax:   + 2713 766 34 37
Institution's / Project's Website:   + 2713 766 34 70
E-mail:   abrahamv@social.mpu.gov.za  
Address:   Private Bag X 11285 Nelspruit
Postal Code:   1200
City:   Nelspruit
State/Province:   Mpumalanga
Country:   South Africa

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