Original Article Resources for Eye Care at Secondary and Tertiary Level Government Institutions in Saudi Arabia Saeed Al Motowa, Rajiv Khandekar1, Abdulelah Al-Towerki2
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ABSTRACT Purpose: To evaluate the number of healthcare personnel and equipment resources for eye care at government institutions in different administrative zones of the Kingdom of Saudi Arabia (KSA) and to recommend measures for increasing resources to address deficiencies. Materials and Methods: Data on resources (personnel and equipment) for eye care were collected from all governmental eye units in 2012. The data was regrouped by zones and administrative areas. The mid‑2012 population projections were used to calculate the ophthalmologist to population ratio and optometrist to population ratio. The equipment available for eye care was reviewed. Results: All 60 institutions in 13 administrative areas and five zones of KSA participated in this study. There were 407 ophthalmologists and 147 optometrists. The ophthalmologist to population ratio was 1:43,000 (1:12,900 in the northern zone to 1:80,300 in the western zone). By 2015, 700 ophthalmologists will be required, and by 2020, 1,100 ophthalmologists will be required. The optometrist to population ratio was 1:95,000 (1:34,100 in the northern zone to 1:146,700 in the western zone). Nearly 2,800 and 4,400 allied eye care personnel will be needed by 2015 and 2020. Diagnostic and treatment equipment such as lasers, electrophysiologic and ultrasound equipment, and fundus cameras were not available at all institutions. Conclusions: Data from the private sector need to be included to draw conclusions on the human resource index for eye care in the Kingdom. An unequal distribution of resources in different zones and administrative areas requires attention. Better utilization of available resources is recommended before fulfilling the demand for additional resources.
Website: www.meajo.org DOI: 10.4103/0974-9233.129761 Quick Response Code:
Key words: Eye Care, Ophthalmologist, Optometrist, Saudi Arabia
INTRODUCTION
S
audi Arabia and other Gulf Cooperation Council (GCC) countries have endorsed their commitment to adopt the ‘VISION 2020’ initiative and prioritized its efforts to eliminate avoidable blindness. One of the recommendations of the global and regional ‘VISION 2020’ document is to undertake a situation analysis of eye healthcare and recommend effective allocation of resources.1 The 2012 population of the Kingdom of Saudi Arabia (KSA) was estimated at 27 million people (including 6 million non‑Saudis). Females and children less than 15 years of age constitute 49 and 50% of the Saudi population, respectively. Saudi adults aged 40 years and older comprise of 14.5% of total population. KSA has a rapidly
evolving robust economy in the last 3 decades. The gross domestic product (GDP) of the Kingdom was 15,836 US$ per capita in 2011.2 The Kingdom spends 4% of its GDP on health services.3 This expenditure has not increased despite an increase in population. Hence, optimum utilization of available resources and improved performance are essential to reach the short‑term national health objectives. The Global Human Development report ranked Saudi Arabia at 56 among 187 countries.4 Hence, the Kingdom has great potential to build the capacity of Saudi youth and professionals to make eye care sustainable. The exact magnitude of blindness and visual impairment in the Kingdom remains unknown. If estimates from other Eastern
Departments of Eye Screening, and 1Research, 2Anterior segment, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia Corresponding Author: Dr. Rajiv Khandekar, Ophthalmic Epidemiology and Low Vision Services, Department of Research, King Khaled Eye Specialist Hospital, POB: 7191, Riyadh 11462, Saudi Arabia. E‑mail: [email protected]
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Motowa, et al.: Resources for Eye Care in Saudi Arabia
Mediterranean countries are applied, then there are potentially 27,000 blind individuals and another 197,000 individuals with low vision disability in the Kingdom. 5 With an increasing burden of disease due to congenital anomalies in children and metabolic syndromes in the adult population in the Kingdom, visual disabilities related to complications of these conditions are likely to remain high in the near future.6 Hence, eye care services will need to be appropriately allocated and there were will a greater demand for skilled personnel for pediatric eye care, geriatric eye care, and rehabilitation experts. Eye care is delivered at government institutions with the help of Saudi professionals as well as experts from other countries. Eye care has undergone rapid changes due to emerging technology and innovation in diagnosis and treatment. Therefore, both manpower and updated technology are essential in providing high quality eye care. An analytical approach to determine the current status of resources and preparing evidence‑based policy briefs for enhancing resources to address any deficiencies and plan for 2020 is crucial for the Kingdom. This report is an evaluation of eye care resources in the governmental institutions, in order to determine the current status, identify the gaps, and propose corrective measures that might be required to address blindness and visual impairment in Saudi Arabia.
MATERIALS AND METHODS This was a situation analysis related to eye care that evaluated healthcare personnel and equipment available at different ministr y institutions in KSA. The Institution Research Board (IRB) approved this study. This study was performed between May 2012 and January 2013. Information from King Khaled Eye Specialist Hospital (KKESH) was excluded as it is a referral institution and draws patients from other governmental institutions that were already included in this review.7 The administrator of KKESH sent a letter to the heads of ophthalmology departments in KSA. The number of ophthalmologists and optometrists present in the institution were noted. Data were collected on the number of diagnostic machines and therapeutic equipment. There are 13 administrative areas and five administrative zones in the Kingdom. “The population of these areas in 2012 was estimated based on the last census result and the annual growth rate.8 For the population projections for 2015 and 2020, estimates from the United Nations were referred.9 The data from each institute were regrouped by the administrative area and zones of the Kingdom. The ophthalmologist to population ratio and optometrist to population ratio for each area and zone were calculated. The equipment available to diagnose and manage important blinding eye diseases (e.g., glaucoma, diabetic retinopathy,
cataract, childhood blindness, posterior segment pathologies, refractive error, and corneal diseases) such as digital fundus camera, visual field machines, A‑ and B‑scan ultrasound, refraction facilities, contact lens related equipment, optical coherence tomography machines, and different types of laser for ocular disease management were grouped by administrative areas and zones to calculate the equipment per 100,000 population. The eye care provider indices from our study were compared to World Health Organization (WHO) and Gulf Cooperation Council’s (GCC) recommendations.10,11
RESULTS All 60 eye care governmental institutions of the Kingdom provided the data. The response rate after frequent communication was 100%. The status of qualified ophthalmologists and optometrists in the governmental institutions per administrative zone and areas is presented in Table 1. The Central and Eastern zones had more than 60% of the ophthalmologists. The ophthalmologist and optometrist to population ratios by zones of the Kingdom are mapped in Figure 1. The allied eye care personnel include optometrists, ophthalmic assistants, and ophthalmic photographers. The proportion of allied eye care personnel to ophthalmologist was less than 1:4. The need in the Kingdom for eye care in 2020 was also calculated. Ophthalmic equipment for basic workup for chronic and blinding eye diseases in the different zones is presented in Table 2.
DISCUSSION To our knowledge, this is the first report of eye care resources at government institutions in Saudi Arabia. To effectively implement the ‘Action Plan for the Prevention of Blindness 2014-2019’, the results published in this paper could be used by the national planners and public health policy analysts.12 The ophthalmologist to population ratio recommended by the WHO has been achieved in Saudi Arabia. But, there is wide variation in the administrative zones. To ensure each zone and administrative area is adequately self‑sufficient for eye care needs, both human resources and technological support have to be provided in view of the increasing population. A global exercise to review the distribution of practicing ophthalmologists showed that there is a wide gap between the need and the existing human resource both in high and low income countries.13 The WHO has recommended that there
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Motowa, et al.: Resources for Eye Care in Saudi Arabia Table 1: Distribution of ophthalmologists and optometrists in administrative areas and zones in the Kingdom of Saudi Arabia Zone
Administrative areas
Population 2012
Ophthalmologists
Ratio
Needed in 2013
Optometrists
Ratio
Need for allied eye care personnel
Central
Al Riyadh Hail Makkah Madinah Qaseem Eastern region Tabouk Al Jouf Northern borders Jazan Najran Al Baha Aseer Total
4,000,000 474,000 3,761,950 1,215,525 864,800 2,712,375 635,675 326,900 253,175 1,046,400 375,450 366,700 1,490,000 17,523,000
139 12 52 10 10 76 4 4 41 13 19 5 22 385
29,000 39,500 72,345 121,550 86,480 35,700 158,900 81,725 6,175 80,500 19,750 73,350 67,728 45,500
200 24 188 61 43 136 32 16 13 52 19 18 75 802
60 2 25 9 5 45 3 1 16 7 4 2 6 179
66,650 237,000 150,500 135,000 173,000 60,300 211,900 326,900 15,800 149,500 93,850 183,350 248,350 97,900
800 95 752 243 173 542 127 65 51 209 75 73 298 3,207
Western Eastern
Northern Southern
Ratio = One ophthalmologist/optometrist to Saudi population
Table 2: Status of equipment for care of blinding eye diseases by zone in the Kingdom of Saudi Arabia in 2012 Zone of the Kingdom Saudi Arabia
Population
Central Eastern Western Northern Southern Total
4,474,000 4,977,475 4,212,840 580,075 3,278,550 17,523,000
Digital camera
Argon laser
YAG laser
Optical coherence tomographer
Visual find analyzer
Ultrasound
No.
Unit: pop
No.
Unit: pop
No.
Unit: pop
No.
Unit: pop
No.
Unit: pop
No.
Unit: pop
10 15 6 4 3 38
44,7450 280,850 829,575 145,000 596,200 422,000
11 12 6 4 4 37
406,800 351,100 829,600 145,000 447,150 472,800
9 12 6 4 6 37
497,150 351,100 829,600 145,000 298,100 472,800
7 5 4 2 2 20
639,200 842,600 1,244,400 290,000 894,300 874,700
12 14 6 5 1 12
373,000 301,000 829,600 116,000 1,788,600 372,900
10 7 10 9 4 10
447,450 601,800 497,750 64,450 447,150 447,450
YAG: Yttrium aluminium garnet, Unit: pop: Population being served by one unit of equipment
Figure 1: Distribution of ophthalmologists and optometrists in different administrative zones in the Kingdom of Saudi Arabia
should be one ophthalmologist per 50,000 population in Asian countries by the year 2020.10 In other gulf countries, this rate varies from 1:26,000 in Oman and Qatar, 1:32,000 in Kuwait, 144
and 1:60,000 in Bahrain. In 2003, researchers reported that the ophthalmologist to population ratio in Saudi Arabia was 1:71,227.10 The rate found in our study in 2012 is better,
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Motowa, et al.: Resources for Eye Care in Saudi Arabia
compared to previous reports. The ophthalmologist to population ratio in the Kingdom exceeds that of some countries that report wide gaps in the healthcare personnel needed to adequately provide care for a population. For example, a Nigerian study reported an ophthalmologist to population ratio of 1:300,000.14 Pakistan had reported an ophthalmologist to population ratio of 1:85,000.15 Ophthalmologists are generally categorized as ophthalmic surgeons and medical ophthalmologists, depending on their job responsibilities. 16 Medical ophthalmologists (also termed specialist ophthalmologists) could support consultant ophthalmologists in comprehensive eye assessment (basic work up) and medical treatment of chronic, age‑related diseases such as diabetic retinopathy, glaucoma, dry eye syndrome, etc., Consultant ophthalmologists, thus, could focus on surgical management of avoidable blinding eye diseases.17 Thus, future evaluation of manpower for eye care should gather information on medical ophthalmologists and ophthalmic surgeons to ensure a rational distribution of both subgroups. The facilities in the Kingdom have capacity to train 30 ophthalmologists a year. This is inadequate if the gap of 293 and 700 additional ophthalmologists is to be filled by 2015 and 2020, respectively. Until local manpower is available, the Kingdom will need to depend on professionals hired from other countries. In addition, private sector ophthalmologists in the Kingdom could contribute to eye care at government institutions. Senior Saudi ophthalmologists will retire in the next 7 years and this will result in a serious shortfall of experienced surgeons and clinicians. Unfortunately in this study, we could not collect data on the duration (years) an eye care professional is likely to work at government institutions. Further studies are recommended to generate this vital information. Ophthalmic care in industrialized countries has changed in the past decades. Increasingly, day care surgeries and short hospital stays are preferred. The diagnostic and treatment modalities have also become more sophisticated and less invasive. These technologies need to be handled by trained assistants, technicians, and optometrists. Hence, more support staff is required. This will enable ophthalmologists to spend less time in performing measurements and focus on providing therapeutic or surgical eye care.18 Countries such as Saudi Arabia are at crossroads. On one side, they are in the process of developing high quality human resources; and on the other side, they have to address avoidable blindness due to eye diseases on urgent basis in order to mitigate a substantial backlog. To some extent, this could be addressed by hiring trained allied eye care personnel. Additionally, experts could manage blinding eye diseases at state of the art institutions. A proposal for establishing five medical cities in each zone is a step
towards improving eye care.19 Satellite eye care centers staffed with allied eye care professionals, outreach eye screening programs, implementation of teleconsultation (teleophthalmology), and enhancing primary eye care through primary health centers are fundamental for addressing the problem of the limited number of ophthalmologists in the Kingdom.20‑23 Equipment, both for diagnosis and management of eye diseases, appear to be available in all zones. However, in order to ensure each administrative area of the Kingdom has adequate resources to manage cases without referral for additional investigation, further support is required. To ensure long‑term sustainability and cost‑effectiveness of eye care services, it is essential that certain productivity benchmarks are established.24 We recommend a similar review as performed for the current study, to monitor the progress and enhancement in eye care resources periodically in the Kingdom. Additionally a review of the quality of eye care delivery should be performed. This review will ensure optimal utilization of the resources available in zones and nationwide, prior to considering additional demands for both human resources as well as equipment. There are some limitations of this study. Our estimation of resources was focused on secondary level eye care services in the government sector only. There are 660 ophthalmologists in the private sector.*If we include data from the private sector to calculate the ophthalmologist to population (Saudi + non‑Saudi) ratio, it is 1:23,000. Unfortunately, the data on subspecialist ophthalmologists in the private sector is not available, so it is assumed that all of them provide comprehensive eye care. Data on the resources at KKESH were not included in the government sector data. With most of the services offered in this institution is related to subspecialty eye care, hence it is difficult to assess the contribution to comprehensive eye care by ophthalmologists at KKESH. However, in view of nearly 22,554 surgeries in last 2 years, #inclusion of ophthalmologists in the anterior segment unit at KKESH could have provided a more accurate status of resources for eye care in the Kingdom. In conclusion, if we include those working in the private sector, the number of ophthalmologists seems to be adequate for the population of the Kingdom. But their distribution in the zones outside the central zone (mainly capital) should be planned. Optometrists and other allied eye care personnel are too few for standard eye care in the ministry of health institutions. Training and hiring more optometrists and other allied eye care personnel is proposed. * Saad Ali Hajar. Eye healthcare resources related to diabetic retinopathy services. Presentation at the Saudi Ophthalmology Society Conference 2013. Number of eye surgeries in KKESH between July 2010 and June 2012. Information form Quality Management Department, KKESH.
#
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ACKNOWLEDGMENTS We thank individuals at the different eye institutes who provided the information of eye resources required for this paper.
REFERENCES 1.
14.
Zero draft of Action plan for the prevention of avoidable blindness and visual impairment for 2014‑2019. Available from: http://www.who.int/blindness/Zerodraftactionplan2014‑19. pdf. [Last accessed on 2013 Jul 23]. 2. World Health Organization. Country statistical profile in ‘The work of WHO in the Eastern Mediterranean Region: Annual report of the Regional Director 1 January–31 December 2011’. Available from: http://www.emro.who.int/countries/sau/. [Last accessed on 2013 Jan 7]. 3. Strategic context in Strategic priorities for Advanced Medical and health research. King Abdulaziz City for Science and Technology. P: 12. Riyadh, Saudi Arabia. Available from: www. kacst.edu.sa [Last accessed on 2013 Jan 29]. 4. United Nations Development Project (UNDP). Human Development Index (HDI)‑2011 Rankings in Human Development Report 2011. Available from: http://hdr.undp.org/en/reports/ global/hdr2011/. [Last accessed on 2013 Jan 29]. 5. Bourne R, Price H, Stevens G; GBD Vision Loss Expert Group. Global burden of visual impairment and blindness. Arch Ophthalmol 2012;130:645‑7. 6. Institute for Health Metrics and Evaluation, USA. GDP profile: Saudi Arabia. Available from: http://www. healthmetricsandevaluation.org/sites/default/files/ country‑profiles/GBD%20Country%20Report%20‑%20 Saudi%20Arabia.pdf. [Last accessed on 2013 Jul 22]. 7. About KKESH in Available from: http://www.kkesh.med.sa/ kkeshweb/en/[Last accessed on 2013 Jan 29]. 8. Ministry of Economy and Planning. Saudi Arabia. Population by Saudi/Non Saudi from the census conducted in the Kingdom in Statistical Year book. 2010 Available from: http://www.cdsi.gov. sa/yb46/Figures/Figure 1.gif. [Last accessed on 2013 Jan 29]. 9. Population Saudi Arabia 2020 34.8 million. Available from: http://data.un.org/Data.aspx?q=saudi+arabia+2020 and d=PopDiv and f=variableID%3a12%3bcrID%3a682%3btime ID%3a1071. [Last accessed on 2013 Jan 29]. 10. World Health Organization. Human Resource development in VISION 2020 Global Initiative for the Elimination of Avoidable Blindness: Action Plan 2006-2011. Published by WHO Geneva: Switzerland; 2007. p. 42‑5. 11. Report on the conference on ‘VISION 2020’ Planning for the Eastern Mediterranean Region, December 2003, Cairo, Egypt. Cairo, World Health Organization, Eastern Mediterranean Regional Office. 2003. 12. World Health Organization. International Agency for the Prevention of Blindness. Universal Access to Eye Health:
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A Global Action Plan, 2014‑2019” with in Prevention and control of non‑communicable diseases. Resnikoff S, Felch W, Gauthier TM, Spivey B. The number of ophthalmologists in practice and training worldwide: A growing gap despite more than 200,000 practitioners. Br J Ophthalmol 2012;96:783‑7. World Health Organization Eastern Mediterranean Region. Human resources in the Eastern Mediterranean region in VISION 2020. Regional Planning Workshop Report. p. 10. Khan AA, Khan NU, Bile KM, Awan H. Creating synergies for health systems strengthening through partnerships in Pakistan: A case study of the national eye health programme. East Mediterr Health J 2010;16:S61‑8. Adepoju FG, Ayanniyi AA, Pam V, Akanbi TB. Human resource development for Vision 2020 in developing countries: A change from absolute numbers. Eur J Ophthalmol 2011;21:820‑5. Advisory Appointments Committees and Job Plans in The Royal College of Ophthalmologist. Available from: http://www. rcophth.ac.uk/page.asp?section=429 and sectionTitle=Adv isory+Appointments+Committees+and+Job+Plans. [Last accessed on 2013 Jul 23]. Bertram B, Gante C, Hilgers RD. Age, sex and diagnostic distribution of patients in ophthalmological medical practice in Germany. Dtsch Med Wochenschr 2012;137:1629‑34. Minister of Health Ratifies the Contracts of Five Health Projects in Ministry of Health Portal. 12th February 2012. Available from: http://www.moh.gov.sa/en/Ministry/MediaCenter/News/Pages/ News‑2012‑02‑11‑003.aspx. [Last accessed on 2013 March 09]. du Toit R, Palagyi A, Brian G. The development of competency‑based education for mid‑level eye care professionals: A process to foster an appropriate, widely accepted and socially accountable initiative. Educ Health (Abingdon) 2010;23:368. Kovai V, Rao GN, Holden B, Krishnaiah S, Bhattacharya SK, Marmamulla S, et al. An estimate of patient costs and benefits of the new primary eye care model utilization through vision centers in Andhra Pradesh, India. Asia Pac J Public Health 2010;22:426‑35. John S, Sengupta S, Reddy SJ, Prabhu P, Kirubanandan K, Badrinath SS. The Sankara Nethralaya mobile teleophthalmology model for comprehensive eye care delivery in rural India. Telemed J E Health 2012;18:382‑7. Rao GN, Khanna RC, Athota SM, Rajshekar V, Rani PK. Integrated model of primary and secondary eye care for underserved rural areas: The L V Prasad Eye Institute experience. Indian J Ophthalmol 2012;60:396‑400. Thulsiraj RD, Mohideen M. Resource allocation in Assignment Report on Assessment of Vision 2020 in Oman. World Health Organization consultant’s report; 2009. p. 12.
Cite this article as: Al Motowa S, Khandekar R, Al-Towerki A. Resources for eye care at secondary and tertiary level government institutions in Saudi Arabia. Middle East Afr J Ophthalmol 2014;21:142-6. Source of Support: Nil, Conflict of Interest: None declared.
Middle East African Journal of Ophthalmology, Volume 21, Number 2, April ‑ June 2014
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ABSTRACT Purpose: To evaluate the number of healthcare personnel and equipment resources for eye care at government institutions in different administrative zones of the Kingdom of Saudi Arabia (KSA) and to recommend measures for increasing resources to address deficiencies. Materials and Methods: Data on resources (personnel and equipment) for eye care were collected from all governmental eye units in 2012. The data was regrouped by zones and administrative areas. The mid‑2012 population projections were used to calculate the ophthalmologist to population ratio and optometrist to population ratio. The equipment available for eye care was reviewed. Results: All 60 institutions in 13 administrative areas and five zones of KSA participated in this study. There were 407 ophthalmologists and 147 optometrists. The ophthalmologist to population ratio was 1:43,000 (1:12,900 in the northern zone to 1:80,300 in the western zone). By 2015, 700 ophthalmologists will be required, and by 2020, 1,100 ophthalmologists will be required. The optometrist to population ratio was 1:95,000 (1:34,100 in the northern zone to 1:146,700 in the western zone). Nearly 2,800 and 4,400 allied eye care personnel will be needed by 2015 and 2020. Diagnostic and treatment equipment such as lasers, electrophysiologic and ultrasound equipment, and fundus cameras were not available at all institutions. Conclusions: Data from the private sector need to be included to draw conclusions on the human resource index for eye care in the Kingdom. An unequal distribution of resources in different zones and administrative areas requires attention. Better utilization of available resources is recommended before fulfilling the demand for additional resources.
Website: www.meajo.org DOI: 10.4103/0974-9233.129761 Quick Response Code:
Key words: Eye Care, Ophthalmologist, Optometrist, Saudi Arabia
INTRODUCTION
S
audi Arabia and other Gulf Cooperation Council (GCC) countries have endorsed their commitment to adopt the ‘VISION 2020’ initiative and prioritized its efforts to eliminate avoidable blindness. One of the recommendations of the global and regional ‘VISION 2020’ document is to undertake a situation analysis of eye healthcare and recommend effective allocation of resources.1 The 2012 population of the Kingdom of Saudi Arabia (KSA) was estimated at 27 million people (including 6 million non‑Saudis). Females and children less than 15 years of age constitute 49 and 50% of the Saudi population, respectively. Saudi adults aged 40 years and older comprise of 14.5% of total population. KSA has a rapidly
evolving robust economy in the last 3 decades. The gross domestic product (GDP) of the Kingdom was 15,836 US$ per capita in 2011.2 The Kingdom spends 4% of its GDP on health services.3 This expenditure has not increased despite an increase in population. Hence, optimum utilization of available resources and improved performance are essential to reach the short‑term national health objectives. The Global Human Development report ranked Saudi Arabia at 56 among 187 countries.4 Hence, the Kingdom has great potential to build the capacity of Saudi youth and professionals to make eye care sustainable. The exact magnitude of blindness and visual impairment in the Kingdom remains unknown. If estimates from other Eastern
Departments of Eye Screening, and 1Research, 2Anterior segment, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia Corresponding Author: Dr. Rajiv Khandekar, Ophthalmic Epidemiology and Low Vision Services, Department of Research, King Khaled Eye Specialist Hospital, POB: 7191, Riyadh 11462, Saudi Arabia. E‑mail: [email protected]
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Mediterranean countries are applied, then there are potentially 27,000 blind individuals and another 197,000 individuals with low vision disability in the Kingdom. 5 With an increasing burden of disease due to congenital anomalies in children and metabolic syndromes in the adult population in the Kingdom, visual disabilities related to complications of these conditions are likely to remain high in the near future.6 Hence, eye care services will need to be appropriately allocated and there were will a greater demand for skilled personnel for pediatric eye care, geriatric eye care, and rehabilitation experts. Eye care is delivered at government institutions with the help of Saudi professionals as well as experts from other countries. Eye care has undergone rapid changes due to emerging technology and innovation in diagnosis and treatment. Therefore, both manpower and updated technology are essential in providing high quality eye care. An analytical approach to determine the current status of resources and preparing evidence‑based policy briefs for enhancing resources to address any deficiencies and plan for 2020 is crucial for the Kingdom. This report is an evaluation of eye care resources in the governmental institutions, in order to determine the current status, identify the gaps, and propose corrective measures that might be required to address blindness and visual impairment in Saudi Arabia.
MATERIALS AND METHODS This was a situation analysis related to eye care that evaluated healthcare personnel and equipment available at different ministr y institutions in KSA. The Institution Research Board (IRB) approved this study. This study was performed between May 2012 and January 2013. Information from King Khaled Eye Specialist Hospital (KKESH) was excluded as it is a referral institution and draws patients from other governmental institutions that were already included in this review.7 The administrator of KKESH sent a letter to the heads of ophthalmology departments in KSA. The number of ophthalmologists and optometrists present in the institution were noted. Data were collected on the number of diagnostic machines and therapeutic equipment. There are 13 administrative areas and five administrative zones in the Kingdom. “The population of these areas in 2012 was estimated based on the last census result and the annual growth rate.8 For the population projections for 2015 and 2020, estimates from the United Nations were referred.9 The data from each institute were regrouped by the administrative area and zones of the Kingdom. The ophthalmologist to population ratio and optometrist to population ratio for each area and zone were calculated. The equipment available to diagnose and manage important blinding eye diseases (e.g., glaucoma, diabetic retinopathy,
cataract, childhood blindness, posterior segment pathologies, refractive error, and corneal diseases) such as digital fundus camera, visual field machines, A‑ and B‑scan ultrasound, refraction facilities, contact lens related equipment, optical coherence tomography machines, and different types of laser for ocular disease management were grouped by administrative areas and zones to calculate the equipment per 100,000 population. The eye care provider indices from our study were compared to World Health Organization (WHO) and Gulf Cooperation Council’s (GCC) recommendations.10,11
RESULTS All 60 eye care governmental institutions of the Kingdom provided the data. The response rate after frequent communication was 100%. The status of qualified ophthalmologists and optometrists in the governmental institutions per administrative zone and areas is presented in Table 1. The Central and Eastern zones had more than 60% of the ophthalmologists. The ophthalmologist and optometrist to population ratios by zones of the Kingdom are mapped in Figure 1. The allied eye care personnel include optometrists, ophthalmic assistants, and ophthalmic photographers. The proportion of allied eye care personnel to ophthalmologist was less than 1:4. The need in the Kingdom for eye care in 2020 was also calculated. Ophthalmic equipment for basic workup for chronic and blinding eye diseases in the different zones is presented in Table 2.
DISCUSSION To our knowledge, this is the first report of eye care resources at government institutions in Saudi Arabia. To effectively implement the ‘Action Plan for the Prevention of Blindness 2014-2019’, the results published in this paper could be used by the national planners and public health policy analysts.12 The ophthalmologist to population ratio recommended by the WHO has been achieved in Saudi Arabia. But, there is wide variation in the administrative zones. To ensure each zone and administrative area is adequately self‑sufficient for eye care needs, both human resources and technological support have to be provided in view of the increasing population. A global exercise to review the distribution of practicing ophthalmologists showed that there is a wide gap between the need and the existing human resource both in high and low income countries.13 The WHO has recommended that there
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143
Motowa, et al.: Resources for Eye Care in Saudi Arabia Table 1: Distribution of ophthalmologists and optometrists in administrative areas and zones in the Kingdom of Saudi Arabia Zone
Administrative areas
Population 2012
Ophthalmologists
Ratio
Needed in 2013
Optometrists
Ratio
Need for allied eye care personnel
Central
Al Riyadh Hail Makkah Madinah Qaseem Eastern region Tabouk Al Jouf Northern borders Jazan Najran Al Baha Aseer Total
4,000,000 474,000 3,761,950 1,215,525 864,800 2,712,375 635,675 326,900 253,175 1,046,400 375,450 366,700 1,490,000 17,523,000
139 12 52 10 10 76 4 4 41 13 19 5 22 385
29,000 39,500 72,345 121,550 86,480 35,700 158,900 81,725 6,175 80,500 19,750 73,350 67,728 45,500
200 24 188 61 43 136 32 16 13 52 19 18 75 802
60 2 25 9 5 45 3 1 16 7 4 2 6 179
66,650 237,000 150,500 135,000 173,000 60,300 211,900 326,900 15,800 149,500 93,850 183,350 248,350 97,900
800 95 752 243 173 542 127 65 51 209 75 73 298 3,207
Western Eastern
Northern Southern
Ratio = One ophthalmologist/optometrist to Saudi population
Table 2: Status of equipment for care of blinding eye diseases by zone in the Kingdom of Saudi Arabia in 2012 Zone of the Kingdom Saudi Arabia
Population
Central Eastern Western Northern Southern Total
4,474,000 4,977,475 4,212,840 580,075 3,278,550 17,523,000
Digital camera
Argon laser
YAG laser
Optical coherence tomographer
Visual find analyzer
Ultrasound
No.
Unit: pop
No.
Unit: pop
No.
Unit: pop
No.
Unit: pop
No.
Unit: pop
No.
Unit: pop
10 15 6 4 3 38
44,7450 280,850 829,575 145,000 596,200 422,000
11 12 6 4 4 37
406,800 351,100 829,600 145,000 447,150 472,800
9 12 6 4 6 37
497,150 351,100 829,600 145,000 298,100 472,800
7 5 4 2 2 20
639,200 842,600 1,244,400 290,000 894,300 874,700
12 14 6 5 1 12
373,000 301,000 829,600 116,000 1,788,600 372,900
10 7 10 9 4 10
447,450 601,800 497,750 64,450 447,150 447,450
YAG: Yttrium aluminium garnet, Unit: pop: Population being served by one unit of equipment
Figure 1: Distribution of ophthalmologists and optometrists in different administrative zones in the Kingdom of Saudi Arabia
should be one ophthalmologist per 50,000 population in Asian countries by the year 2020.10 In other gulf countries, this rate varies from 1:26,000 in Oman and Qatar, 1:32,000 in Kuwait, 144
and 1:60,000 in Bahrain. In 2003, researchers reported that the ophthalmologist to population ratio in Saudi Arabia was 1:71,227.10 The rate found in our study in 2012 is better,
Middle East African Journal of Ophthalmology, Volume 21, Number 2, April ‑ June 2014
Motowa, et al.: Resources for Eye Care in Saudi Arabia
compared to previous reports. The ophthalmologist to population ratio in the Kingdom exceeds that of some countries that report wide gaps in the healthcare personnel needed to adequately provide care for a population. For example, a Nigerian study reported an ophthalmologist to population ratio of 1:300,000.14 Pakistan had reported an ophthalmologist to population ratio of 1:85,000.15 Ophthalmologists are generally categorized as ophthalmic surgeons and medical ophthalmologists, depending on their job responsibilities. 16 Medical ophthalmologists (also termed specialist ophthalmologists) could support consultant ophthalmologists in comprehensive eye assessment (basic work up) and medical treatment of chronic, age‑related diseases such as diabetic retinopathy, glaucoma, dry eye syndrome, etc., Consultant ophthalmologists, thus, could focus on surgical management of avoidable blinding eye diseases.17 Thus, future evaluation of manpower for eye care should gather information on medical ophthalmologists and ophthalmic surgeons to ensure a rational distribution of both subgroups. The facilities in the Kingdom have capacity to train 30 ophthalmologists a year. This is inadequate if the gap of 293 and 700 additional ophthalmologists is to be filled by 2015 and 2020, respectively. Until local manpower is available, the Kingdom will need to depend on professionals hired from other countries. In addition, private sector ophthalmologists in the Kingdom could contribute to eye care at government institutions. Senior Saudi ophthalmologists will retire in the next 7 years and this will result in a serious shortfall of experienced surgeons and clinicians. Unfortunately in this study, we could not collect data on the duration (years) an eye care professional is likely to work at government institutions. Further studies are recommended to generate this vital information. Ophthalmic care in industrialized countries has changed in the past decades. Increasingly, day care surgeries and short hospital stays are preferred. The diagnostic and treatment modalities have also become more sophisticated and less invasive. These technologies need to be handled by trained assistants, technicians, and optometrists. Hence, more support staff is required. This will enable ophthalmologists to spend less time in performing measurements and focus on providing therapeutic or surgical eye care.18 Countries such as Saudi Arabia are at crossroads. On one side, they are in the process of developing high quality human resources; and on the other side, they have to address avoidable blindness due to eye diseases on urgent basis in order to mitigate a substantial backlog. To some extent, this could be addressed by hiring trained allied eye care personnel. Additionally, experts could manage blinding eye diseases at state of the art institutions. A proposal for establishing five medical cities in each zone is a step
towards improving eye care.19 Satellite eye care centers staffed with allied eye care professionals, outreach eye screening programs, implementation of teleconsultation (teleophthalmology), and enhancing primary eye care through primary health centers are fundamental for addressing the problem of the limited number of ophthalmologists in the Kingdom.20‑23 Equipment, both for diagnosis and management of eye diseases, appear to be available in all zones. However, in order to ensure each administrative area of the Kingdom has adequate resources to manage cases without referral for additional investigation, further support is required. To ensure long‑term sustainability and cost‑effectiveness of eye care services, it is essential that certain productivity benchmarks are established.24 We recommend a similar review as performed for the current study, to monitor the progress and enhancement in eye care resources periodically in the Kingdom. Additionally a review of the quality of eye care delivery should be performed. This review will ensure optimal utilization of the resources available in zones and nationwide, prior to considering additional demands for both human resources as well as equipment. There are some limitations of this study. Our estimation of resources was focused on secondary level eye care services in the government sector only. There are 660 ophthalmologists in the private sector.*If we include data from the private sector to calculate the ophthalmologist to population (Saudi + non‑Saudi) ratio, it is 1:23,000. Unfortunately, the data on subspecialist ophthalmologists in the private sector is not available, so it is assumed that all of them provide comprehensive eye care. Data on the resources at KKESH were not included in the government sector data. With most of the services offered in this institution is related to subspecialty eye care, hence it is difficult to assess the contribution to comprehensive eye care by ophthalmologists at KKESH. However, in view of nearly 22,554 surgeries in last 2 years, #inclusion of ophthalmologists in the anterior segment unit at KKESH could have provided a more accurate status of resources for eye care in the Kingdom. In conclusion, if we include those working in the private sector, the number of ophthalmologists seems to be adequate for the population of the Kingdom. But their distribution in the zones outside the central zone (mainly capital) should be planned. Optometrists and other allied eye care personnel are too few for standard eye care in the ministry of health institutions. Training and hiring more optometrists and other allied eye care personnel is proposed. * Saad Ali Hajar. Eye healthcare resources related to diabetic retinopathy services. Presentation at the Saudi Ophthalmology Society Conference 2013. Number of eye surgeries in KKESH between July 2010 and June 2012. Information form Quality Management Department, KKESH.
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ACKNOWLEDGMENTS We thank individuals at the different eye institutes who provided the information of eye resources required for this paper.
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Cite this article as: Al Motowa S, Khandekar R, Al-Towerki A. Resources for eye care at secondary and tertiary level government institutions in Saudi Arabia. Middle East Afr J Ophthalmol 2014;21:142-6. Source of Support: Nil, Conflict of Interest: None declared.
Middle East African Journal of Ophthalmology, Volume 21, Number 2, April ‑ June 2014
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