We Come and The World Be Bright
Bali Mandara Eye Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Blindness and vision problems are physical limitations affecting psychological and socioeconomic conditions of the patients, families, and the neighborhoods. Furthermore, blindness makes the patient has certain limitations to work, hence affecting their domestic condition. If they are within productive age, the blindness can indirectly cause poverty. In 2007, blindness occurrence in Indonesia was 0.9%, which was the highest prevalence in South-East Asia, while the global average was only 0.7% (Indonesian Ministry of Health, 2007). Meanwhile, blindness prevalence in Bali was higher than national average, which amounts of 1% and mainly caused by senile cataract (80%). Senile cataract is an opacification of the lens disorder affected by decreasing of vision ability that may turn into blind. Generally, senile cataract is experienced by people aged over 40 years old, and it is possible at a younger age when accompanied by other risk factors, such as malnutrition and degenerative diseases like diabetes. The data from the Ministry of Health shows that 1.8% of population aged more than 30 years have suffered the senile cataract. These conditions have been experienced by 60% of elderly people which mostly marginalized people. In Bali, it is predicted that 1% of population is blind. From this number, approximately 30,350 of Balinese suffer cataract blindness. This number increases about 0.1% of the population each year. Half of cataract patients are elderly which approximately 9,105 of them are poor people. The large number of global blindness has attracted World Health Organization (WHO) and Indonesian Government attention. On 18th February 1999, WHO declared the Vision of 2020: “The Right to Sight '' which was aimed to prevent and overcome blindness so that every community has an optimal vision in 2020. A year after, Indonesian government adopted similar target to reduce blindness prevalence by 0.5%. To achieve the program, Ministry of Health developed National Strategic Planning for Blindness Prevention and Eradication. Bali provincial government got the similar target with the national goals to reduce blindness by 0.5% through this initiative. Although public health insurances offered free health care for Balinese, the system had caused difficulties for the poor, elderly and those who living in remote areas. They lack access towards advanced health service in secondary and tertiary health care, including eye health service and cataract surgery. In addition, the scarcity of ophthalmologists and eye health care facilities in district hospitals made the blindness rate even worse. Therefore, to reduce the blindness level in Bali, the Government has developed MOBILE EYE CLINIC (MEC) program through Bali Mandara Eye Hospital (BMEH). This initiative provides community-based eye health care, including eye screening and cataract surgery for poor people, elderly and those who live in remote areas. This program aimed to ensure poor people’s right in accessing eye health care and improve their lives quality.

B. Strategic Approach

 2. What was the solution?
Blindness has decreased productivity and life quality of the patients and their family, hence creating social and economic problems. To overcome this problem, Bali government through Bali Mandara Eye Hospital introduced MOBILE EYE CLINIC program (URL: https://youtu.be/sosdUXlPD4M) which basically trying to prevent and eradicate blindness, especially to those who live in countryside areas. This program collaborates with hospitals across Bali province and has successfully reduced blindness rate in Bali from 1% to 0.3% during 2007-2013 period.

 3. How did the initiative solve the problem and improve people’s lives?
The initial approach for blindness prevention in Bali was started in 1997, which was established by several stakeholders, including Bali Mandara Eye Hospital (BMEH), Indonesian Ophthalmologists Association Bali Region and Non-Governmental Organizations (NGOs). The main activities were providing public eye health care services for poor people, such as free screening and cataract surgery. However, this program had not been optimally conducted in lowering blindness prevalence in the region since it lacked support from Bali Provincial Government. An optimization strategy was conducted to reduce the number of blindness in Bali during 2008. Bali Provincial Government as the leading sector for Blindness Prevention and Eradication established the Blindness Prevention and Eradication Committee which consist of institutions across sectors, such as Bali Provincial Health Office, BMEH, Indonesian Ophthalmologists Association and Executive Team of Family Welfare Development. Blindness Prevention and Eradication Program (BPEP) Committee encouraged partnerships with the District/City Health Office, Health Centers across Bali province, NGOs, corporations and universities. This cooperation has successfully improved the effectiveness and efficiency of BPEP given every stakeholder actively involved in accomplishing the program. BPEP implemented a strategic approach of community-based cataract screening and cataract surgery activities. MOBILE EYE CLINIC (MEC) provided buses that are fully equipped with tools and surgical equipment. Thus, it made several visits to public health centers spread throughout Bali province, particularly suburb areas, hence expands the coverage of eye's health care services. MEC ensures that eye's health care services are distributed fairly and equitably for all Balinese, especially in terms of curing the blindness caused by cataract. The main target of BPEP is senile cataract patients who experience difficulties in accessing eye health care services. These groups are predominantly poor people, elderly people, productive age group and other vulnerable groups. This program is expecting to eliminate blindness, to improve the quality of life the cataract patients and to alleviate the household burden due to blindness, while at the same time trying to increase the welfare of patients and their family.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The main ideas of Blindness Prevention and Eradication Program (BPEP) are to bring eye health care services closer to the public and to simplify health service access through performing surgery outside the building. It can be implemented by providing buses as MOBILE EYE CLINIC (MEC) equipped with sophisticated facilities to do eye screening and cataract surgeries. This clinic provides facility as complete as surgery room in the hospital. Furthermore, its mobility is meant to expand the outreach of public health across Bali’s countryside. Hence, this initiative offers both extensive facilities and flexibility. . The provision of MEC is more practical, effective and efficient than build a surgery room in public health centers in terms of: (i) Efficiency in investment, procurement, and maintenance costs. The program practically only needs two MECs as cataract surgery facility that could reach all village areas in Bali. (ii) Efficiency of human resources, particularly ophthalmologists and ophthalmology nurses. Since the number of both experts are limited, expansions of surgery rooms in public health centers were ineffective. Moreover, this program is free of charge for the poor, elderly and those who living in remote areas in performing cataract screening and surgery.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Bali Mandara Eye Hospital (BMEH) is a leading institution in terms of promoting eye health care services in Bali. Therefore, Bali Province Government appointed them as the key actor of MOBILE EYE CLINIC (MEC) program. As an eye health care center, BMEH focuses on cataract prevention, treatment and rehabilitation. Additionally, the MEC program has been implemented across sectors with the District/City Health Office, Public Health Centers, health workers, NGOs, corporations and universities. Each stakeholder has clear roles, duties and responsibilities within the program application, start from planning, implementation and evaluation stage. The main target of MEC program is cataract patients who have experienced difficulties in accessing eye health care services. Those are primarily poor people and suburb residents. During 2008 to 2015 period, the number of cataract screenings were 720 times, while surgeries were 574 times throughout villages in Bali. In total, there were about 29,324 people that have been treated in which 55% of them were women. This initiative has resulted in significant progress in supporting BPEP in Bali Province by declining the blindness rate from 1% in 2007 to 0.3% in 2013.
 6. How was the strategy implemented and what resources were mobilized?
The preparations of Blindness Prevention and Eradication Program (BPEP) are started from: (i). Assessment of Public Health Needs. Bali Mandara Eye Hospital (BMEH) carried out risk management by identifying those who potentially suffer from blindness, such as poor people and elderly. This assessment has been performed through literature review from Basic Health Research of Indonesian Ministry of Health in 2007 regarding blindness prevalence in Bali province. From the annual report, it could be concluded that what they had done was still far from the goals. (ii). Committee Establishment. The next step was establishing BPEP Committee. During the first meeting, they resulted Bali Governor's Decree on the formation and composition of Blindness Prevention and Eradication Committee. The committee consists of BMEH, Bali Provincial Health Office and Indonesian Ophthalmologists Association of Bali Region. The following meeting then designed master plan, identified facilities and infrastructure required, determined implementation team, proposed action plan and defined each stakeholder’s role in the program. Furthermore, a coordination meeting with District/City Health Authority was held to discuss further steps. (iii). The mobilization of public, private, community and donor agencies' resources. The Australian Government through AusAID has donated two MOBILE EYE CLINIC (MEC) surgery buses, supported by local budget funds plus Corporate Social Responsibility fund from the companies to prepare equipment and cover operational costs. (iv). Improving the quality and quantity of human resources. It has been done by organizing capacity improvement, including doctors and nurses' training. The curriculum focused on finding cataracts cases and following up post-surgery treatment. Moreover, BMEH has promoted community empowerment by involving students and young generations in early detection of blindness using a simple method namely 4 meters finger counting. Two major activities of BPEP Committee were community-based screening and cataract surgery on the MEC. It performed in public health centers or in a village hall. Public Health Centers are liable for searching cataract patients and pre-screening them. The next step is MEH makes a schedule of screening and cataract surgery in coordination with the District/City Health Office. The screening performed by one general practitioner and two BMEH nurses according to the schedule. In certain circumstances or upon special request, screening activities can be conducted out of schedule. The patients who have been diagnosed with cataracts then take blood sugar and eye pressure tests to determine whether the patient is eligible to undertake the surgery. Cataract surgery is an action of replacing the eye lens that has been damaged using the artificial eye lens. Cataract patients who are eligible then undertake surgery on the MEC. After surgery, public health center examines post-surgery activities, which are recorded on the post-surgery examination form. This form will be sent back to BMEH for evaluation purpose. Furthermore, program evaluation was performed annually by assessing screening and cataract surgery data, as well as by observing the changing trend of blindness prevalence derived from basic health survey every 5 years. The underlying costs that have been used to implement the program were as follows: (i). During preparation stage, the amount of US$ 147.500 has been utilized for committee establishment; dissemination and advocacy; purchasing MEC buses; obtaining surgical equipment; training for doctors, nurses and volunteers. This funding amount consists of US$ 3,800 from Bali local budget and US$ 143.700 from AusAID grant. (ii). During implementation stage, the amount of US$ 8, 300/years was spent for screening and US$ 77/patient for cataract surgery. The fund was derived from Bali local budget and Corporate Social Responsibility fund. (iii). For evaluation stage, the amount of US$ 800/years were used for the evaluation meeting program. It came from Bali local budget.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
As an effort to accelerate the reduction of blindness rate, this program involves several stakeholders. Each of them has different roles and responsibilities, as follows: (i). Bali Provincial Government as initiator, policymaker, primary contact as well as the fund provider. The local government has responsibility to fulfill public rights, including equality of opportunity to access eye health care services. Hence, they require to allocate budget and prepare policies to implement this initiative. As an executor, the government should conduct advocacy, dissemination, coordination, synchronization of activities and foster partnerships with other stakeholders. (ii). Indonesian Ophthalmologists Association as an active party in conducting advocacy, dissemination, health promotion and providing competent specialist doctors. (iii). The District/City Health Offices as facilitator of Blindness Prevention and Eradication Program (BPEP) were deemed to promote the program and actively assist public health center in delivering the program. (iv). Public Health Centers as a unit that directly delivering the services to the public. They are the spearhead of BPEP by carrying out pre-screening activities, facilitating the screening process and undertaking examination of cataract post-surgery. (v). Family Welfare Development team as a government partner that facilitates public health activities to educate people on how to prevent and cure blindness caused by cataract. They also perform pre-screening along with the public health center. (vi). Students as part of university that eager to serve the community as part of their social responsibility. They have an important role in pre-screening activities and in educating people about basic knowledge to prevent and treat the symptoms of blindness. (vii). The corporations are actively involved in financing the BPEP through their Corporate Social Responsibility budget as the contribution towards public health in the community

 8. What were the most successful outputs and why was the initiative effective?
Below are MOBILE EYE CLINIC (MEC) outputs according to Blindness Prevention and Eradication Program (BPEP) evaluation program in 2017 and was conducted by Indonesian Ophthalmologists Association and Medical Faculty of Udayana University: (i). Significant improvement of cataract patients' health condition Cataract Surgical Rate (CSR) is a cataract surgery number per one million populations per annum. CSR is an indicator to measure the success rate of cataract blindness prevention program. Indonesian Ophthalmologists Association stated that BMEH had largely contributed by 50% in increasing Cataract Surgical Rate (CSR) in Bali. There was an increase of CSR from 1.020,6 per million populations in 2010 to 1.468,2 per million populations in 2013. The achievement of Blindness Prevention and Eradication through MEC has also contributed to the blindness rate decline from 1% in 2007 to 0.3% in 2013. This made Bali province achieved the target of WHO VISION 2020, which is 0.5% in seven years earlier. Over the eight years, 24.285 screening activities and 5.039 cataract surgeries have been undertaken. It consists of 55% female’s patients and 95% elderly patients. MEC program has served 103 out of 112 Public Health Centers in Bali province. Overall, the initiative has helped patients to improve their general health condition, particularly eye health. It is considered supporting the third of Sustainable Development Goals (SDG) which ensure healthy lives and promote well-being for all at all ages generally. (ii). Improvement of patient’s mental health in relation with their social life. Cataract patients have experienced some mental issues, such as feeling stress, anxious and embarrassed due to their sight inability. It also develops a mental block that they cannot perform any activities, ride vehicles and eventually feel too dependent to others. After running the program, statistical evaluation test showed a significant decrease of these above mentioned points. (iii). Increase of Productivity and Welfare The demographics of the countryside population generally dominated by those who live from agriculture and plantation. Assuming that the average of annual household income as much as US$ 320, it is estimated that loss caused by suffering cataract that could be prevented is approximately US$ 7,771,200 yearly (Ministry of Agriculture, 2014). Moreover, the program keeps people in good health, which enables them to live more productive in improving their lives quality. At the end, it may enhance their socioeconomic status and reduce the poverty in the long run.

 9. What were the main obstacles encountered and how were they overcome?
There were some constraints during program implementation as the following: (i) The program did not reach the main population target due to lack of program knowledge and poor coordination. Staff from all public health centers in Bali helped the promotion activities; however, they did not receive enough information of Blindness Prevention and Eradication Program (BPEP). As the consequence, people who joined screening procedures were not the ones as expected. The solution was the integration of BPEP to all public health centers. (ii) Most people were afraid to perform cataract surgery. The solution was to increase promotion of eye health care and risks to the public audience. (iii) Limited number of ophthalmologists and trained general practitioners trained. In 2013, registered ophthalmologists in Bali were 35. In average, one ophthalmologist serves more than 118,277 people, a very low ratio compared to the WHO standard, 1: 20,000. The solution was to encourage and facilitate general practitioners to upgrade their competency to be ophthalmologists (iv) Lack of facilities to detect eye diseases in public health centers because the eye health program was not prioritized, and resources were limited. The solution was to educate key stakeholders about the importance of the eye health program. (v) Lack of trained human resources to conduct early detection of blindness. The solution was to train doctors and nurses in public health centers on screening and post-surgery eye treatments. (vi) Problem to cover the whole areas of Bali. The solution was to deploy MOBILE EYE CLINIC (MEC) operators before sunrise to arrive in remote areas on time; (vii) Limited capacity of MEC bus. For each deployment, the maximum number of patients for surgery in one bus is 20. The solution was to increase the number of visit in order to meet the sterilization target.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Before MOBILE EYE CLINIC (MEC) implemented, people had limited access to blindness prevention services. It was difficult to the elders, women with children; people live in remote areas, the poor people, and people with disabilities to perform screening and cataract surgery because they need to travel to secondary and tertiary health facilities located in the city areas. Therefore, they could not afford to pay for transportation, accommodation, and other related costs aside from screening and cataract surgery costs. Moreover, they must take a work absence and lost daily income. It was a costly option to conduct an eye health care procedure for Balinese people who live spread over 716 villages and areas of 153 kilometers square. MECis the most useful instruments of Blindness Prevention and Eradication Program (BPEP) because it provides fair and equitable health care services for all people regardless of their gender, social class, income level, and other backgrounds. The program has benefited the poor people, women, elderly, and other vulnerable groups. The following is some of the positive impacts of MEC after eight-year implementation: (i) Blindness rate in Bali has declined significantly. Since the program implementation, the blindness rate has decreased from 1% in 2007 to 0.3% in 2013. The number of blind people has dropped by 59% from 30,350 in 2007 to 12,377 cases in 2013. Total activities are 24,285 screening services and 5,039 of cataract surgeries consist of 55% women and 95% elder. When projected financially, the program has provided economic benefits approximately USD 5,000,000 to people and USD 4,400,797 to the government; (ii) Equal distribution of eye health care services in Bali province. Qualitatively, the direct benefits perceived by the public are equality of eye health care services because they are accessible to all society. Furthermore, a family that is free from blindness is reducing family’s burden, increasing the productivity of patients and their family members, preventing poor people from becoming poorer, and increasing family’s income level. (iii) Increasing and strengthening the synergy between government and other organizations: private companies, universities, Non-Governmental Organizations (NGOs), and other communities. Corporate Social Responsibility (CSR) is also utilized to support MEC. The format has exhibited that all parties can work together to address eye health problems and to provide the benefits to the community; (iv) Improving community empowerment in Bali Province. MEC program has involved and provided empowerment of the community for early detection (pre-screening) blindness cases either by health center/clinic official, volunteers of Family Welfare Development units, and on-job-training students in villages to be reported to program holders in public health centers. (v) The program is in line with the third goal of Sustainable Development Goals: Ensure healthy lives and promote well-being for all at all ages on the target 3C: Substantially increase of health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least-developed countries and small island developing states. Specifically, it aims on the target 3.8: achieve Universal Health Coverage.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
MOBILE EYE CLINIC (MEC) has improved integrity and accountability of public service in Bali. Since many parties, including private companies and civil-society organizations support the program, the monitoring process is undertaken rigorously. Several agencies, e.g. the Audit Board of the Republic of Indonesia and the Regional Government Inspectorate, have conducted audit procedures to maintain the program’s integrity and accountability. Within the hospital, the Internal Control Unit and the Medical Committee have monitored the business process. The audit procedures assess the program’s plan, implementation activities, and all costs associated. The program also encourages people to monitor public service delivery and held the government accountable. The program target is widely disseminated that stated the government is responsible to achieve blindness prevalence at 0.5% in 2020. The common knowledge and goal will stimulate government and the society to work together by providing fair and equitable eye health services to the whole society regardless their gender, social, and economic differences. In addition, the target has pushed down the treatment care borne by patients to the zero level treatment cost or free. Since everyone knows that the treatment if provided for free and without discrimination, no one is willing to bribe officials. It breaks the corruption chain that has been flourished in public service units.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
MOBILE EYE CLINIC (MEC) brings benefits to society, specifically to elders, women, poor and vulnerable people. From the activities' evaluation conducted in 2015-2016, the proportion of women and elders who received cataract surgery was 55% and 95%, consecutively. In addition, as a tropical country, Indonesian are more vulnerable to cataract disease, especially for people who are more often exposed to ultraviolet light, such as those living in coastal areas in Bali. Unfortunately, the regular cataract surgery is expensive that make many people cannot afford to pay for medical treatments. Basic Health Research in 2013 found out that as many as 11.6% of cataract patients do not have money to perform cataract surgery. MEC has made the poor and vulnerable people, especially those who live in areas far from eye health care services to receive a good cataract surgery free of charge.

Contact Information

Institution Name:   Bali Mandara Eye Hospital
Institution Type:   Local Government  
Contact Person:   Widiastuti Putu Ayu
Title:   General Practitioner  
Telephone/ Fax:   +6281246796540
Institution's / Project's Website:  
E-mail:   wiactk@yahoo.co.id  
Address:   Angsoka 8 Street
Postal Code:   80233
City:   Denpasar

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