ORIGINAL CLINICAL STUDY
Status of Ophthalmic Education and the Eye Health Workforce in South Asian Association for Regional Cooperation Countries Haroon Awan, MD,* Mohammad Daud Khan, MD,Þ William Felch, BA,þ Bruce Spivey, MD,þ Hugh Taylor, MD,þ Serge Resnikoff, MD,þ and Tina-Marie Gauthier, BAþ
Purpose: This study aimed to assess the capacity for ophthalmic education in the 8 South Asian Association for Regional Cooperation (SAARC) countries and to determine the need and future projections of eye health professionals in the region. Design: This was a retrospective study and comprised desk review and Web-based questionnaire. Methods: Developed in the Asia Pacific region, the Capacity Assessment Tool for SAARC Eye Care Education, a Web-based survey mechanism derived from a 12-point framework, was used to collect data on the number of ophthalmologists and other eye care personnel, training institutions, and capacity for training in each SAARC country. Results: There are an estimated 17,568 practicing ophthalmologists and 4086 ophthalmic subspecialists in the SAARC region. The population per ophthalmologist is approximately 92,270. Allied eye health professionals constitute an important element of the eye health workforce and have a population per allied eye health professional of approximately 99,852; the ophthalmologist to doctor (physician) ratio is 1:61. There are more than 510 centers providing ophthalmology training and more than 32 centers providing subspecialty training; ophthalmic subspecialty training varies from a 3-month observership to a 12-month hands-on training. Conclusions: In the SAARC region, the challenge is to sustain and increase the eye health workforce to meet the needs of a growing and aging population. The demographic transitions, improved child survival and life expectancy rates, and emerging noncommunicable disease trends require training of ophthalmic subspecialists and supporting eye care teams to meet the service delivery demands of changing eye health paradigms. Key Words: ophthalmology, training, education, subspecialty, SAARC (Asia-Pac J Ophthalmol 2014;3: 74Y82)
T
he South Asian Association for Regional Cooperation (SAARC) region is composed of 8 countriesVAfghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and
From the *Avicenna Consulting Pvt Ltd, Islamabad; †Comprehensive Health and Education Foundation International, University Town, Peshawar, Pakistan; and ‡International Council of Ophthalmology, San Francisco, CA. Received for publication August 5, 2013; accepted December 20, 2013. Supported by The Fred Hollows Foundation. The authors declare grant funding for research but no other competing interest. All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare the following: only Haroon Awan had financial support from the International Council of Ophthalmology as consultancy for the submitted work; there were no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years; and there were no other relationships or activities that could seem to have influenced the submitted work. Reprints: Haroon Awan, MD, Avicenna Consulting Pvt Ltd, 18-B Kaghan Rd F-8/4, Islamabad 44000, Pakistan. E-mail: [email protected]. Copyright * 2014 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0000000000000037
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Sri Lanka. The region is home to a total population of 1621 million, which includes more than 100 million people who are visually impaired.1 India alone has approximately 53,000 people visually impaired per million population. Although vision loss due to cataract comes under increasing control with development of district eye care services and the training of general ophthalmologists and eye care teams, the need for subspecialists to manage other eye conditions becomes even greater. For example, childhood survival rates are improving in the region, but changing lifestyles and poor nutritional awareness have led to increasing obesity and a surge in diabetes. Highquality vitreoretinal services will be needed in all SAARC countries to meet the growing demand of ocular complications from diabetes. Glaucoma too remains a persistent challenge to prevention and control programs given its need for highly specialized diagnostic facilities and surgical management. Global prevention of blindness is high on the agenda of VISION 2020: The Right to Sight. This worldwide initiative to eliminate avoidable blindness by the year 2020 is a joint program of the World Health Organization (WHO), the International Agency for the Prevention of Blindness, and international nongovernmental organizations. The goal of global blindness prevention, however, cannot be achieved without superior eye care delivery at all levels, which to large extent is dependent on high-quality training of ophthalmologists and allied eye health professionals (AEHPs). Although there is an immediate need for subspecialist services in the SAARC region along with training of more AEHPs, the number of subspecialty training programs is minimal. The WHO’s World Health Report 2006, Working Together for Health,2 identified the following SAARC regional countries as ‘‘human resources for health’’ crisis countries: Eastern Mediterranean, Afghanistan, Pakistan, Southeast Asia, Bangladesh, Bhutan, India, Nepal. There has been a gradual increase in per capita spending on health in the SAARC region, with a corresponding increase in life expectancy. Global data, however, indicate that Southeast Asia has approximately 28% of the global burden of disease but with only approximately 12% of the global health workforce.2 The 2007 report, Everybody’s Business, presented the WHO’s framework for strengthening health systems to improve health outcomes. The report identified an effective health workforce as a critical component of the health care system.3 The WHO’s Task Force for Scaling Up Education and Training for Health Workers 2008 report, Scaling Up, Saving Lives, built on this point and emphasized the need for quality assurance systems and quality standards for training, service, and monitoring.4
Collaborative Effort At a 2011 meeting in Bangladesh, the council of the SAARC Academy of Ophthalmology (SAO) discussed the high prevalence of avoidable blindness and visual impairment in the SAARC
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region and its interconnection to the difficulty in obtaining quality eye care in the area. The council specifically identified the lack of well-trained and motivated eye care personnel as critically impeding access to quality eye care. Determined to enhance ophthalmic postgraduate education and improve the quality of ophthalmic care in the SAARC region, the SAO council made 2 important decisions; these are as follows: first, to establish the SAARC Foundation whose mandate is to improve the standard of eye health education and ophthalmic research; and second, to collaborate with equally committed partners to develop eye health human resources and improve the quality of ophthalmic care in the SAARC region. As a primary step, the SAO contacted the International Council of Ophthalmology (ICO) in recognition of the ICO’s mission to work with ophthalmologic societies and others to enhance ophthalmic education and improve access to the highest quality eye care. In its 2011 to 2015 strategic plan, the ICO assigns high priority to developing teams of eye care professionals led by well-trained ophthalmologists and to strengthening and supporting systems to improve ophthalmic education. In 2011, a delegation from the SAO met with the president of the ICO and his team in Sydney, Australia, where they agreed to partner together to enhance subspecialty training in the SAARC region. The Fred Hollows Foundation (FHF), a leading nongovernmental organization working in eye care in Australia, the Pacific, South Asia, Southeast Asia, and Africa, joined the collaboration shortly thereafter. With subspecialty development as one of their priorities, the FHF brought technical and generous financial support to the team. At a 2011 meeting in Kuala Lumpur, Malaysia, the SAO, ICO, and the FHF decided that the first steps in improving the quality of ophthalmic care in the SAARC region were as follows: & assess institutional capacity for ophthalmic education, especially subspecialty training, in the SAARC countries; & determine the need and future projections of key AEHP in the region; and & develop an assessment tool that could be used in other regions and countries.
MATERIALS AND METHODS On recommendation of the SAO, ICO, and FHF, a methodology was devised to determine the need and future projections of key AEHPs in the SAARC countries and to assess institutional capacity for ophthalmic education in the region. Desk research of currently available capacity assessment tools and methods was undertaken. Based on research results, a 12-point framework was developed from which a Capacity Assessment Tool for SAARC Eye Care Education (CATSEYE) was designed. The 12-point framework included the following: 1. profileVpopulation of the country and number of categories of eye health professionals; 2. publicVinstitute in public sector attached to a general or eye hospital and sources of funding; 3. privateVinstitute in private sector attached to a general or eye hospital and sources of funding; 4. program OVtypes of ophthalmology training programs offered, duration, and subspecialty rotation; 5. program AVtypes of AEHP training programs offered and duration; 6. peopleVnumber of faculty for ophthalmology and subspecialty training programs; 7. processVselection criteria for enrollment of candidates to ophthalmology and subspecialty training programs and whether curriculum is approved by an accrediting body; 8. practiceVtype of training (eg, theoretical, practical, observational); * 2014 Asia Pacific Academy of Ophthalmology
9. portfolioVtype of subspecialty services offered (eg, vitreoretina, pediatric ophthalmology, cornea); 10. proceduresVsubspecialty procedures available (eg, diagnostic, surgical, therapeutic); 11. performanceVwhether subspecialty training assessment includes experience certificate, competency-based assessment, and/or performance appraisal examination; and 12. productVqualification offered and whether qualification is accredited and registrable with a professional body or council.
The Web-based application of CATSEYE used MySql, which is an open-source relational database management system that runs as a server providing multiuser access to a number of databases. The CATSEYE was pretested and debugged and was configured to work with the most commonly used Internet browsers and on Windows, Linux, and Apple operating systems. Focal persons were requested to provide a list of SAARC training centers for ophthalmology, including subspecialty training centers. A list of 81 training centers was obtained, which served as the basis for the survey. Before data collection, an e-mail was sent to alert all listed training centers. This served 2 purposes; these are as follows: first, to establish a communication link, and second, to test whether the e-mail was functional. Several e-mail addresses were found to be either nonfunctional or inappropriate; the e-mail addresses were updated, and the appropriate contact names were noted. A second e-mail was then sent to the revised list of contacts providing a brief background of the survey and requesting contacts to open a Web link to the online questionnaire. A reminder email was sent to those who had not completed the survey within 10 days. The data were cleaned for duplicate entries, incomplete forms that were accidentally submitted, or incorrect submissions. The questionnaire included questions on the following areas: & participating institutionVtype of institution (government, private, or nongovernment) and its income source; & type and duration of training program offered in ophthalmologyVresidency or other; & type of AEHP trained and type and duration of training program offered; & number of teaching faculty and students; & type of selection process for postgraduate students and candidates for subspecialty training; & practice of trainingVtheory, observational, or practical; & type of subspecialty services offered at the institution; & areas in which subspecialty training is offered; & type of performance assessment for subspecialty training; and & accreditation status of the subspecialty training program. The following categories of eye health professionals were used for the survey: & ophthalmologists; & ophthalmic subspecialists; and & the AEHPs, which included optometrists, orthoptists, ophthalmic assistants, and ophthalmic nurses.
Fourteen subspecialty areas (corresponding to subspecialty areas used by the ICO) were identified; these are the following: & cataract and lens; & community eye health; & contact lens; & cornea and external diseases; & glaucoma; www.apjo.org
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The survey indicted similar ratios of AEHPs and ophthalmologists to total population. Bhutan and Sri Lanka have 9 or more AEHPs to every ophthalmologist. Sri Lanka and Afghanistan, however, have much fewer ophthalmologists (Table 1). Optometry training is gradually increasing in the SAARC region. In India, there are at least 30 schools and colleges of optometry affiliated with the Association of Schools and Colleges of Optometry in India (further details can be obtained from www.asco-india.org). For India, the numbers of optometrists and orthoptists need to be interpreted as a combined workforce because most orthoptist training is part of the optometry training program. The status of subspecialists in the SAARC region varies from country to country. The highest number is seen in India, where approximately 4000 ophthalmologists practice as subspecialists. Other than India, which has 300,000 population per subspecialist, all other SAARC countries have more than 1.5 million population or more per subspecialist. The type and duration of subspecialty training vary within the SAARC region. This may range from a 3-month observership to a 12-month hands-on training course. Countries such as India, Nepal, Pakistan, and Sri Lanka have nationally approved curricula for subspecialty training. India has nationally approved curricula for 13 of the 14 ICO-defined subspecialties, whereas Nepal, Pakistan, and Sri Lanka have only 3 to 4 of the 14 ICOdefined subspecialties. In Bangladesh, for example, there are well-trained subspecialty fellows with 12 months of training who are practicing in their chosen area of expertise. There is, however, no nationally accredited
low-vision rehabilitation; neuroophthalmology; ocular oncology; oculoplastic surgery and orbit; ophthalmic pathology; pediatric ophthalmology and strabismus; refractive surgery; uveitis and ocular inflammation; and vitreoretinal diseases.
The following subspecialty levels were used: & Level 1Vgeneral ophthalmologist who has an interest in that subspecialty and spends 50% or more time working in it but does not have a formal subspecialty qualification in it; & Level 2Vgeneral ophthalmologist who has been trained in a subspecialty training center for less than 12 months; and & Level 3Vgeneral ophthalmologist who has been trained in a subspecialty training center for at least 12 months or more.
RESULTS There was an 84% response rate of contacts completing the online survey.1 The data received were then analyzed and tabulated. Although variations exist among the regional countries, SAARC as a region has 1 ophthalmologist for approximately 92,000 population (Table 1).5Y24 India and Pakistan have population per ophthalmologist of less than 90,000. Table 1 summarizes the key findings of the SAARC countries.
TABLE 1. Status of the Eye Health Workforce in SAARC Countries
Population in million Doctors Ophthal* Subspecs† OP‡ OR§ OA|| ON¶ Ophthal training centers Subpsec training centers Population per ophthal Ophthal per 75,000 population Ophthal per million population ODR# Population per AEHP** AEHP per 75,000 population AEHP per million population
AFG
BGD
BTN
IND
MDV
NPL
PAK
SLK
SAARC
30 7250 128 3 6 0 46 65 7 0 234,375 0.32 4.27 57 256,410 0.29 3.90
160 57,143 950 30 5 10 500 250 5 4 168,421 0.45 5.94 60 209,150 0.36 4.78
0.7 179 6 0 4 0 49 3 1 0 116,667 0.64 8.57 30 12,500 6.00 80.00
1200 840,000 14,000 4000 9000 1000 3000 100 458 17 85,714 0.88 11.67 60 91,603 0.82 10.92
0.3 600 8 0 4 0 0 4 0 0 37,500 2.00 26.67 75 37,500 2.00 26.67
30 1765 175 20 45 10 350 20 6 2 171,429 0.44 5.83 10 70,588 1.06 14.17
180 157,000 2200 20 300 20 450 70 30 7 81,818 0.92 12.22 71 214,286 0.35 4.67
20 10,000 101 13 320 3 0 600 3 2 198,020 0.38 5.05 99 21,668 3.46 46.15
1621 1,073,937 17,568 4086 9684 1043 4395 1112 510 32 92,270 0.81 10.84 61 99,852 0.75 10.01
Summary of key findings regarding the status of the eye health workforce in SAARC countries. *Ophthalmologists. †Ophthalmic subspecialists. ‡Optometrists. §Orthoptists. ||Ophthalmic assistants. ¶Ophthalmic nurses. #ODR. **AEHPs. AFG indicates Afghanistan; BGD, Bangladesh; BTN, Bhutan; IND, India; MDV, Maldives; NPL, Nepal; PAK, Pakistan; SLK, Sri Lanka.
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curriculum for subspecialty training, nor any formal training program. There is good potential to use the existing faculty for subspecialty training programs in the various SAARC countries. A detailed directory of the participating institutions and organizations has been prepared and is available at www.icoph.org/ SAARC-Ophthalmic-Education-Directory.pdf. Other than India, subspecialty information was obtained directly from each country’s subspecialty organizations. Information for India had to be obtained from multiple sources (eg, SAO secretariat in Delhi, the All India Ophthalmological Society Web site, and the Medical Council of India Web site and statistical reports). There are at least 458 or more centers offering postgraduate training in ophthalmology in India. The National Board of Examination has 141 registered centers that provide postgraduate training in ophthalmology (details at www.natboard.edu.in). The Medical Council of India has 107 registered centers that offer training for a diploma in ophthalmology (details at www.mciindia.org). The Medical Council of India has 210 registered centers that offer training for masters in surgery in ophthalmology (details at www.mciindia.org). The total number of ophthalmologists obtained from the All India Ophthalmological Society may be an underestimate.
Supply and Need Projections Human resource planning for eye health usually tends to be based on need. For instance, the need may be estimated by dividing a given population by the number of ophthalmologists or AEHPs in that particular country. This does not take into account; however, supply mechanisms (ie, how many ophthalmologists does that country produce annually), pull factors such as creation of posts and attraction of further specialization, push factors such as ophthalmologists retiring annually or those who leave a clinical career for something else or who migrate to other countries nor does it take into account urban and rural disparities. In the absence of a more practical option or model to estimate the future supply and need, the use of an arbitrary indicator has provided a useful, if limited, planning formula. Viewing the status of ophthalmologists per million population (Fig. 1)YYBhutan and the Maldives have been omitted from Figure 1 owing to their small population sizeYYit can be observed that there are 2 major benchmarks, 11.9 and 5.2. The benchmarks suggest that India and Pakistan may need to aim in the short to medium term to have 15 ophthalmologists per million population, whereas the remaining 4 countries need to effectively double or even triple their current numbers of ophthalmologists. In comparison with other developed countries, it shows that they (developed countries) have a much higher ophthalmologistto-million population ratio with an average of 38.6 per million (Fig. 1). The comparison of 1 ophthalmologist per total population rates illustrates that developed countries have 3 times as many ophthalmologists compared with India and Pakistan and at least 7 times more than some of the other SAARC countries (Fig. 2).
Ophthalmologist-to-Doctor Predictor Unlike dentists who start their training as dentists, a medical student graduates as a general physician and then chooses a The survey questionnaire was sent to 81 organizations and institutions, of which 84% responded. Telephone follow-up was used to increase the response rate. The directory referred previously includes the names of the organizations identified by National Focal Persons and shows where data were made available and where there is still a need to add data.
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specialty (eg, pediatrics, surgery, ophthalmology). The ‘‘market preference’’ for one medical specialty over another varies from country to country. Using a case study from Pakistan, we attempted to ascertain the relationship between the number of ophthalmologists and doctors because ophthalmology residents come from the pool of available doctors in that country. The number of doctors (physicians) was determined from the Economic Survey of Pakistan and the Pakistan Medical and Dental Council Web site.22 The projection of the number of doctors for 2025 was based on the trend of the compound annual growth rate (CAGR) for the series and retaining the same for year 2035. The actual and projected number of doctors up to the year 2035 is illustrated in Figure 3, which also shows the declining CAGR. Rate 1 shows a continuous declining CAGR based on declining rate, whereas rate 2 shows a steady state that is similar to 2025. The number of ophthalmologists was determined from official planning documents, including the National Eye Health Plans (Ministry of Health, Government of Pakistan 1994Y1998, 1999Y2003, and 2005Y2010). The ratio of ophthalmologist to total doctors was compared, and it was found that during the 30-year period, the ratio remained constant at 1:70. The ophthalmologist-to-doctor ratio (ODR) seems to be a useful and practical predictor of supply. Furthermore, although it was based on the number of doctors and the number of ophthalmologists, the effect of those who are retiring or leaving service would tend to cancel each other. The need and supply of ophthalmologists in Pakistan are illustrated in Figure 4. ‘‘Required’’ (need) was estimated using 1:75,000 ratio. The current ratio is 0.92 per 75,000 population (Table 1). The rationale was to determine the nearest multiple of 5000 population figure for 1 ophthalmologist. Therefore, 1 per 75,000 was taken as the nearest whole number to estimate need. To estimate those who were working, actual figures available are used up to 2012, and ODR is used for future projections. The comparison of ODR of different regional and developed countries was done.25Y36 The SAARC region has an average of 61 ODR, whereas the United Kingdom has an ODR of approximately 115, indicating that the SAARC region has approximately twice the proportion of ophthalmologists to doctors than the United Kingdom (Fig. 5). Nepal has a very low ODR (or high percentage of doctors who are ophthalmologists), suggesting a preference for the specialty of ophthalmology among their doctors. Sri Lanka, Australia, and UK ODRs indicate that these countries probably have a shortage of ophthalmologists, or there are not enough training positions in ophthalmology or that the specialty is not among the top few preferred choices among doctors (Fig. 5).37 The findings indicate that there is a relative consistency in ODR rates among various countries. The 3 SAARC countries, Bangladesh, India, and Pakistan, demonstrate fairly steady ODRs during the 20-year period, whereas the 4 developed countries, Australia, Canada, United Kingdom, United States, indicate a nominal increase in ODRs. Taken individually, for example, in Australia and the United Kingdom, the decadal trend of ODR suggests fewer ophthalmologists in training compared with the pool of available physicians and overall population (Fig. 6). The ODR trend in SAARC and developed countries is likely to have implications for changing disease patterns and aging populations, both of which require greater numbers of ophthalmologists and ophthalmic subspecialists. www.apjo.org
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FIGURE 1. Ophthalmologists per 1 million population. Status of ophthalmologists per 1 million population (Bhutan and the Maldives have been omitted because of their small population size). Two major benchmarks, 11.9 and 5.2, suggest that India and Pakistan may need to aim in the short to medium term to have 15 ophthalmologist per million population, whereas the remaining 4 countries need to effectively double or even triple their current numbers of ophthalmologists. In comparison with other developed countries, it shows that they (developed countries) have a much higher ophthalmologist-to-million population ratio with an average of 38.6 per million.
Figure 7 illustrates a schematic model to estimate ‘‘supply’’ of ophthalmologists at a time in the future. The model has 5 key steps; these are as follows: Step 1Vestimate the population in the future using the population figure from official sources (eg, census departments) and apply a CAGR to make future projections for a time series; Step 2Vestimate the number of doctors (general physicians) by using actual figures from official sources (eg, medical councils) and apply a CAGR to make future projections for the time series used in Step 1; Step 3Vestimate the ‘‘need’’ of ophthalmologists by applying an appropriate ratio for the respective country (eg, we used 1 per 75,000 population as explained earlier; one can also use other variations, such as number per million population; Table 1) for the time series used in Step 1; Step 4Vusing the estimates from Steps 2 and 3, determine the ODR for the past by dividing the number of doctors by the number of ophthalmologists for the past time series used in Step 1. The ODR can then be used for Step 5; and Step 5Vuse the estimates established in Step 2 for the number of doctors in a time series, divide the numbers of doctors by
the ODR to estimate future supply (or likely availability) of ophthalmologists. The difference between need (calculated in Step 3) and supply (calculated in Step 5) would help establish the gap that needs to be addressed.
DISCUSSION The list of training centers in the 8 SAARC countries was provided by focal persons and may not represent a complete list of all training centers. Although there was an 84% response rate, not all of the listed training centers responded, so the percentages obtained may underrepresent the situation in a particular country. The time and limitation of resources did not permit an onsite validation of data for each center that responded to the questionnaire. The survey also did not make any distinction among ophthalmologists who were practicing, retired, and surgically active because this information was considered difficult to obtain. Thus, the total numbers are estimates rather than absolute. This initial study was limited in its ability to collect detailed information about India, and the numbers obtained for
FIGURE 2. Total population per ophthalmologist. Population per ophthalmologist (Bhutan and the Maldives have been omitted because of their small population size). Data from developed countries indicate that they have approximately 1 ophthalmologist for approximately 26,473 population, whereas India and Pakistan have 1 ophthalmologist per 83,766 population, suggesting 3 times difference in the rates. Afghanistan, Bangladesh, Nepal, and Sri Lanka with a 1 ophthalmologist per 193,061 population have a difference of at least 7 times with the developed countries.
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FIGURE 3. Projections for number of doctors in Pakistan. The actual and projected number of doctors to the year 2035 and the declining CAGR. Rate 1 shows a continuous declining CAGR based on declining rate, whereas rate 2 shows a steady state that is similar to 2025.
India are likely an underestimate. Further analysis and a follow-up study in India are warranted. Based on the data obtained by CATSEYE, the following information was learned: & approximately 17,568 ophthalmologists and an estimated 4086 ophthalmic subspecialists practice in the SAARC region; & the ophthalmologist to population ratio in SAARC countries is approximately 1:92,270 and 10.84 per million population; & the AEHPs constitute an important element of the region’s eye health workforce and have a population ratio of approximately 1:99,852 and 10.01 per million population; & the ODR (physician) is 1:61 in the region; and & more than 510 centers provide ophthalmology training and more than 32 centers provide subspecialty training across the region. An interesting finding of the survey was the similar ratios of AEHPs and ophthalmologists to total population. In this regard, Bhutan and Sri Lanka have 9 or more AEHPs to every ophthalmologist. Sri Lanka and Afghanistan, however, have much fewer ophthalmologists (Table 1). This indicates that
ophthalmology training would be a priority in these countries, whereas Pakistan, for instance, might need to intensify efforts to train more AEHPs. Countries with a shortage of ophthalmologists or fewer ophthalmologists in training compared with the pool of available physicians and overall population (Figs. 5, 6) support the necessity to train eye care teams led by ophthalmologists to meet the requirements of communities. This need is especially critical when considering the implications of changing disease patterns and aging populations. In the SAARC region, the challenge is to sustain and increase the eye health workforce to meet the needs of a growing and aging population. The demographic transitions, improved child survival and life expectancy rates, and emerging noncommunicable disease trends require training of ophthalmic subspecialists and supporting eye care teams to meet the service delivery demands of changing eye health paradigms.
Recommendations Based on a combination of desk research, telephone interviews with the national coordinators for eye health and the findings obtained by CATSEYE to access the capacity for
FIGURE 4. Predicting the need and supply of ophthalmologists in Pakistan. The need and supply of ophthalmologists in Pakistan is illustrated. Required (need) is estimated using 1:75,000 ratio; ‘‘working’’ actuals are used up to 2012, and ODR is used for future projections. * 2014 Asia Pacific Academy of Ophthalmology
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FIGURE 5. Selected countries and ODR. The comparison of ODR of different regional and developed countries was done. The SAARC region has an average of 61 ODR, and the United Kingdom has an ODR of approximately 115, indicating that the SAARC region has approximately twice the proportion of ODR than the United Kingdom. Nepal has a very low ODR, suggesting a preference for ophthalmology among their doctors. Sri Lanka, Australia, and UK ODRs indicate that these countries probably have a shortage of ophthalmologists, or there are not enough training positions in ophthalmology or that the specialty is not among the top few preferred choices among doctors.
ophthalmic training in the 8 SAARC countries, the ICO, SAO, and the FHF suggest the following policy recommendations for the SAARC region: & facilitate a high-level meeting of heads and specialty coordinators of ophthalmic professional bodies in SAARC countries to develop a regional policy/strategy on ophthalmic education (including subspecialty training) and determine priority areas for joint action; & launch a regional forum or task force on human resources for eye health, whose purview may include standardization of definitions, to act as a catalyst in developing guidelines for roles and responsibilities of different professionals in the eye health workforce; recommend minimum service delivery standards for human resources for eye health; develop an
essential subspecialty training curriculum and practical requirements for the subspecialties; design performance appraisal modalities, monitor quality, etc; & mobilize a regional faculty to promote technical cooperation among developing countries to participate in subspecialty training across countries; & define standards for subspecialty training centers by analyzing gaps and initially strengthening centers that have the capability and capacity to provide subspecialty training; and & foster collaboration with international partners to actively promote ophthalmic graduate and subspecialty training and to support the functioning of a regional forum, such as eye health partnership for professional advancement to accelerate efforts in this regard.
FIGURE 6. Selected countries and ODR decadal trends. Bangladesh, India, and Pakistan demonstrate fairly steady ODRs during the 20-year period, whereas Australia, Canada, United Kingdom, and United States indicate a nominal increase in ODRs. Taken individually, for example, in Australia and the United Kingdom, the decadal trend of ODR suggests fewer ophthalmologists in training compared with the pool of available physicians and overall population.
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FIGURE 7. Five-step ODR supply predictor model. A 5-step ODR supply predictor model is proposed. The model uses CAGR to estimate the future projections of population and the numbers of doctors from past time series using data from official sources. It also estimates need of ophthalmologists by applying an appropriate ophthalmologist-to-population ratio. The ODR calculated from this model can be used to predict the future supply of ophthalmologists and thus assist in human resource planning.
To meet the goal of global blindness prevention in the SAARC countries and beyond, superior eye care delivery at all levels is needed, and it is dependent to large extent on high-quality training of ophthalmologists and AEHP workers. ACKNOWLEDGMENTS We wish to recognize with deep appreciation the contributions of the following people: Profs Ava Hossain and Rajvardhan Azad (SAO); Ms Lesley Podesta (The FHF); Drs Mohammad Babar Qureshi and Irfan Baig (Advisors); Dr Ahmad Shah Salam (Afghanistan); Profs Deen Mohammad Nurul Huq and Enayet Hosein (Bangladesh); Prof Nor Tshering Lepcha and Mr Chandra Kumar Chhetri (Bhutan); Profs Ashok Grover and Namrata Sharma (India); Dr Abdullah Junaid (Maldives); Prof OK Malla and Mr Sunu Dulal (Nepal); Profs Asad Aslam Khan, Mohammad Saleh Memon, and Nasir Saeed and Dr Riaz Baloch (Pakistan); and Drs Mangala Gamage, Saman Senanayake, and Sunil Fernando (Sri Lanka). We are especially thankful to Mr Jabbar Bangash and his team at CREOLOOM for developing the Web-based application, to our colleagues at Avicenna Consulting Pvt Ltd, and Mr Niaz Ullah Khan and Mr Mohammad Bashir Khan for their technical assistance.
REFERENCES 1. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol. 2012;96:614Y618. Epub 2011 Dec 1. 2. Working Together for Health. World Health Report 2006. World Health Organization. Available at: http://www.who.int/whr/2006/en/ index.html. Accessed July 1, 2013.
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3. Everybody’s BusinessVStrengthening Health Systems to Improve Health Outcomes. WHO’s Framework for Action. World Health Organization 2007. Available at: http://www.who.int/healthsystems/ strategy/everybodys_business.pdf. Accessed July 1, 2013. 4. Scaling Up, Saving Lives. Task Force for Scaling Up Education and Training for Health Workers. Global Health Workforce Alliance. World Health Organization 2008. Available at: http://www.who.int/ workforcealliance/documents/ Global_Health%20FINAL%20REPORT.pdf. Accessed July 1, 2013. 5. Afghanistan Health Profile. World Health Organization 2010. Available at: http://www.who.int/countries/afg/en/. Accessed July 1, 2013. 6. Country Cooperation Strategy for WHO and Afghanistan 2009Y2013. EM/ARD/043E. World Health Organization 2010. Available at: http:// www.who.int/countryfocus/cooperation_strategy/ccs_afg_en.pdf. Accessed July 1, 2013. 7. Bangladesh Health Profile. World Health Organization 2010. Available at: http://www.who.int/countries/bgd/en/. Accessed July 1, 2013. 8. WHO Bangladesh Country Cooperation Strategy 2008Y2013. World Health Organization 2007. Available at: http://www.who.int/ countryfocus/cooperation_strategy/ccs_bgd_en.pdf. Accessed July 1, 2013. 9. HRD Data Sheet 2011. Government of the People’s Republic of Bangladesh. Ministry of Health and Family Welfare. Human Resources Development Unit. Available at: http://www.google.com/ #hl=en&tbo=d&output=search&sclient=psy-ab&q=9.%09HRD+Data+ Sheet+2011.+Government+of+the+Peoples+Republic+of+Bangladesh.+ &oq=9.%09HRD+Data+Sheet+2011.+Government+of+the+Peoples+ Republic+of+Bangladesh.+&gs_l=hp.3...1103.1103. 0.1756.1.1.0.0.0.0.129.129.0j1.1.0.les%3B..0.0...1c.2. fKPn6Dd756I&pbx=1&bav=on.2,or.r_gc.r_pw.r_qf.&bvm=bv.
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41248874,d.b2U&fp=171f1ce03d5b6aef&biw=1496&bih=893. Accessed July 1, 2013. 10. National Eye Care Plan for Implementation of VISION 2020 in Bangladesh. Ministry of Health and Family Welfare 2005. Available at: http://www.who.int/blindness/bangladesh_plan1.pdf. Accessed July 1, 2013. 11. Bhutan Health Profile. World Health Organization 2010. Available at: http://www.who.int/countries/btn/en/. Accessed July 1, 2013. 12. WHO Country Cooperation Strategy for Bhutan 2009Y2013. World Health Organization 2010. Available at: http://www.who.int/ countryfocus/cooperation_strategy/ccs_btn_en.pdf. Accessed July 1, 2013. 13. India Health Profile. World Health Organization 2010. Available at: http://www.who.int/countries/ind/en/. Accessed July 1, 2013. 14. WHO Country Cooperation Strategy India 2012Y2017. World Health Organization 2012. http://www.who.int/countryfocus/ cooperation_strategy/ccs_ind_en.pdf. Accessed on January 22, 2014. 15. Annual Report 2010Y2011. Medical Council of India. Available at: http://www.mciindia.org/pdf/Annual%20Report.pdf. Accessed July 1, 2013. 16. Maldives Health Profile. World Health Organization 2010. Available at: http://www.who.int/countries/mdv/en/. Accessed July 1, 2013. 17. WHO Country Cooperation Strategy Republic of Maldives 2007Y2011. World Health Organization 2007. Available at: http://www.who.int/ countryfocus/cooperation_strategy/ccs_mdv_en.pdf. Accessed July 1, 2013.
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28. Number of Physicians by Province/Territory and Specialty, Canada, 2012. CMA Masterfile, January 2012, Canadian Medical Association. Available at: http://www.cma.ca/multimedia/CMA/Content_Images/ Inside_cma/Statistics/01Spec&Prov.pdf. Accessed July 1, 2013. 29. Medical Specialty Workforce Fact Sheet. Ophthalmology. Centre for Workforce Intelligence 2010. Available at: http://www.google.com/ #hl=en&sugexp=les%3B&gs_rn=1 &gs_ri=hp&gs_mss=29.%09Medical%20Specialty% 20Workforce%20Fact%20Sheet.%20Ophthalmology.%20Centre% 20for%20Workforce%20Intelligence%202010&qe= TWVkaWNhbCBTcGVjaWFsdHkgV29ya2ZvcmN lIEZhY3QgU2hlZXQuIE9waHRoYWxtb2xvZ3kuIENlbnRyZ SBmb3IgV29ya2ZvcmNlIEludGVsbGlnZW5jZS AyMDEw&qesig=AFfzl2h0KfbTn7Yt2AeirQ&pkc=AFgZ2tlR56d DSJQg0EU-AyBHK8xXadmirb5YH5m5uXm2gZoI25DvGQs I4KmvaDqccFNTawcSKx2-5MS7rY9EVJK2B7FPiKMK7Q &cp=0&gs_id=b&xhr=t&q=Medical%20Specialty% 20Workforce%20Fact%20Sheet.%20Ophthalmology.% 20Centre%20for%20Workforce%20Intelligence% 202010&es_nrs=true&pf=p&tbo=d&sclient=psy-ab&oq=Medical+ Specialty+Workforce+Fact+Sheet.+Ophthalmology.+Centre+for+ Workforce+Intelligence+2010&gs_l=&pbx=1 &bav=on.2,or.r_gc.r_pw.r_qf.&bvm=bv.41248874,d.b2U &fp=171f1ce03d5b6aef&biw=1496&bih=893&bs=1. Accessed July 1, 2013.
18. Nepal Health Profile. World Health Organization 2010. Available at: http://www.who.int/countries/npl/en/. Accessed July 1, 2013.
30. The State of Medical Education and Practice in the UK. General Medical Council 2011. Available at: http://www.gmc-uk.org/ The_state_of_medical_education_and_practice_in_the_ UK_2012_0912.pdf_49843330.pdf. Accessed July 1, 2013.
19. WHO Country Cooperation Strategy Nepal 2006-2011. World Health Organization 2007. Available at: http://www.who.int/countryfocus/ cooperation_strategy/ccs_npl_en.pdf. Accessed July 1, 2013.
31. List of Registered Medical PractitionersVStatistics. Available at: http://www.gmc-uk.org/doctors/register/search_stats.asp. Accessed July 1, 2013.
20. Pakistan Health Profile. World Health Organization 2010. Available at: http://www.who.int/countries/pak/en/. Accessed July 1, 2013. 21. Country Cooperation Strategy for WHO and Pakistan 2005Y2009. World Health Organization 2006. Available at: http://www.who.int/ countryfocus/cooperation_strategy/ccs_pak_en.pdf. Accessed July 1, 2013. 22. Pakistan Medical and Dental Council. Available at: http:// www.pmdc.org.pk/. Accessed July 1, 2013. 23. Sri Lanka Health Profile. World Health Organization 2010. Available at: http://www.who.int/countries/lka/en/. Accessed July 1, 2013. 24. WHO Country Cooperation Strategy 2006Y2011 Democratic Socialist Republic of Sri Lanka. World Health Organization 2006. Available at: http://www.who.int/countryfocus/cooperation_strategy/ ccs_lka_en.pdf. Accessed July 1, 2013. 25. Australia’s Health Workforce Series. Doctors in Focus 2012. Health Workforce Australia. Available at: https://www.hwa.gov.au/sites/ uploads/australias_health_workforce_series_doctors_in_focus_ 20120322.pdf. Accessed July 1, 2013.
32. Market Scope, Harmon D, Merritt J. Demand for ophthalmic services and ophthalmologistsVa resource assessment market resource white paper. Market Scope. 2009. Available at: http://www.meditec.zeiss.com/ C1256CAC0038CEFF/EmbedTitelIntern/Market_Resource_White_ Paper_04-2009/$File/Market_Resource_White_Paper_04-2009.pdf. Accessed on January 22, 2014. 33. Estimating Eye Care Provider Supply and Workforce Requirements. RAND 1995. Available at: http://www.rand.org/content/dam/rand/pubs/ monograph_reports/2006/MR516.pdf. Accessed July 1, 2013. 34. Physicians by Sex and Specialty: 1980 to 2009. Health and Nutrition. US Census Bureau, Statistical Abstract of the United States; 2012. Available at: http://www.census.gov/compendia/statab/2012/tables/ 12s0165.pdf. Accessed January 22, 2014. 35. State Physician Workforce Data Book. Center for Workforce Studies. Association of American Medical Colleges. Available at: https:// www.aamc.org/data/workforce/. Accessed July 1, 2013.
26. Medical Workforce 2010. National Health Workforce Series Number 1. Australian Institute of Health and Welfare. Available at: http:// www.aihw.gov.au/publication-detail/?id=10737421480. Accessed July 1, 2013.
36. The Surgical Workforce in the United States: Profile and Recent Trends 2010. American College of Surgeons. Health Policy Research Institute. Available at: http://www.acshpri.org/documents/ ACSHPRI_Surgical_Workforce_in_US_apr2010.pdf. Accessed July 1, 2013.
27. Building on ValuesVThe Future of Health Care in Canada. Commission on the Future of Health Care in Canada 2002. Available at: http:// www.hc-sc.gc.ca/hcs-sss/com/fed/romanow/index-eng.php. Accessed July 1, 2013.
37. Resnikoff S, Felch W, Gauthier TM, et al. The number of ophthalmologists in practice and training worldwide: a growing gap despite more than 200,000 practitioners. Br J Ophthalmol. 2012;96:783Y787. Epub 2012 Mar 26.
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Status of Ophthalmic Education and the Eye Health Workforce in South Asian Association for Regional Cooperation Countries Haroon Awan, MD,* Mohammad Daud Khan, MD,Þ William Felch, BA,þ Bruce Spivey, MD,þ Hugh Taylor, MD,þ Serge Resnikoff, MD,þ and Tina-Marie Gauthier, BAþ
Purpose: This study aimed to assess the capacity for ophthalmic education in the 8 South Asian Association for Regional Cooperation (SAARC) countries and to determine the need and future projections of eye health professionals in the region. Design: This was a retrospective study and comprised desk review and Web-based questionnaire. Methods: Developed in the Asia Pacific region, the Capacity Assessment Tool for SAARC Eye Care Education, a Web-based survey mechanism derived from a 12-point framework, was used to collect data on the number of ophthalmologists and other eye care personnel, training institutions, and capacity for training in each SAARC country. Results: There are an estimated 17,568 practicing ophthalmologists and 4086 ophthalmic subspecialists in the SAARC region. The population per ophthalmologist is approximately 92,270. Allied eye health professionals constitute an important element of the eye health workforce and have a population per allied eye health professional of approximately 99,852; the ophthalmologist to doctor (physician) ratio is 1:61. There are more than 510 centers providing ophthalmology training and more than 32 centers providing subspecialty training; ophthalmic subspecialty training varies from a 3-month observership to a 12-month hands-on training. Conclusions: In the SAARC region, the challenge is to sustain and increase the eye health workforce to meet the needs of a growing and aging population. The demographic transitions, improved child survival and life expectancy rates, and emerging noncommunicable disease trends require training of ophthalmic subspecialists and supporting eye care teams to meet the service delivery demands of changing eye health paradigms. Key Words: ophthalmology, training, education, subspecialty, SAARC (Asia-Pac J Ophthalmol 2014;3: 74Y82)
T
he South Asian Association for Regional Cooperation (SAARC) region is composed of 8 countriesVAfghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and
From the *Avicenna Consulting Pvt Ltd, Islamabad; †Comprehensive Health and Education Foundation International, University Town, Peshawar, Pakistan; and ‡International Council of Ophthalmology, San Francisco, CA. Received for publication August 5, 2013; accepted December 20, 2013. Supported by The Fred Hollows Foundation. The authors declare grant funding for research but no other competing interest. All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare the following: only Haroon Awan had financial support from the International Council of Ophthalmology as consultancy for the submitted work; there were no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years; and there were no other relationships or activities that could seem to have influenced the submitted work. Reprints: Haroon Awan, MD, Avicenna Consulting Pvt Ltd, 18-B Kaghan Rd F-8/4, Islamabad 44000, Pakistan. E-mail: [email protected]. Copyright * 2014 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0000000000000037
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Sri Lanka. The region is home to a total population of 1621 million, which includes more than 100 million people who are visually impaired.1 India alone has approximately 53,000 people visually impaired per million population. Although vision loss due to cataract comes under increasing control with development of district eye care services and the training of general ophthalmologists and eye care teams, the need for subspecialists to manage other eye conditions becomes even greater. For example, childhood survival rates are improving in the region, but changing lifestyles and poor nutritional awareness have led to increasing obesity and a surge in diabetes. Highquality vitreoretinal services will be needed in all SAARC countries to meet the growing demand of ocular complications from diabetes. Glaucoma too remains a persistent challenge to prevention and control programs given its need for highly specialized diagnostic facilities and surgical management. Global prevention of blindness is high on the agenda of VISION 2020: The Right to Sight. This worldwide initiative to eliminate avoidable blindness by the year 2020 is a joint program of the World Health Organization (WHO), the International Agency for the Prevention of Blindness, and international nongovernmental organizations. The goal of global blindness prevention, however, cannot be achieved without superior eye care delivery at all levels, which to large extent is dependent on high-quality training of ophthalmologists and allied eye health professionals (AEHPs). Although there is an immediate need for subspecialist services in the SAARC region along with training of more AEHPs, the number of subspecialty training programs is minimal. The WHO’s World Health Report 2006, Working Together for Health,2 identified the following SAARC regional countries as ‘‘human resources for health’’ crisis countries: Eastern Mediterranean, Afghanistan, Pakistan, Southeast Asia, Bangladesh, Bhutan, India, Nepal. There has been a gradual increase in per capita spending on health in the SAARC region, with a corresponding increase in life expectancy. Global data, however, indicate that Southeast Asia has approximately 28% of the global burden of disease but with only approximately 12% of the global health workforce.2 The 2007 report, Everybody’s Business, presented the WHO’s framework for strengthening health systems to improve health outcomes. The report identified an effective health workforce as a critical component of the health care system.3 The WHO’s Task Force for Scaling Up Education and Training for Health Workers 2008 report, Scaling Up, Saving Lives, built on this point and emphasized the need for quality assurance systems and quality standards for training, service, and monitoring.4
Collaborative Effort At a 2011 meeting in Bangladesh, the council of the SAARC Academy of Ophthalmology (SAO) discussed the high prevalence of avoidable blindness and visual impairment in the SAARC
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region and its interconnection to the difficulty in obtaining quality eye care in the area. The council specifically identified the lack of well-trained and motivated eye care personnel as critically impeding access to quality eye care. Determined to enhance ophthalmic postgraduate education and improve the quality of ophthalmic care in the SAARC region, the SAO council made 2 important decisions; these are as follows: first, to establish the SAARC Foundation whose mandate is to improve the standard of eye health education and ophthalmic research; and second, to collaborate with equally committed partners to develop eye health human resources and improve the quality of ophthalmic care in the SAARC region. As a primary step, the SAO contacted the International Council of Ophthalmology (ICO) in recognition of the ICO’s mission to work with ophthalmologic societies and others to enhance ophthalmic education and improve access to the highest quality eye care. In its 2011 to 2015 strategic plan, the ICO assigns high priority to developing teams of eye care professionals led by well-trained ophthalmologists and to strengthening and supporting systems to improve ophthalmic education. In 2011, a delegation from the SAO met with the president of the ICO and his team in Sydney, Australia, where they agreed to partner together to enhance subspecialty training in the SAARC region. The Fred Hollows Foundation (FHF), a leading nongovernmental organization working in eye care in Australia, the Pacific, South Asia, Southeast Asia, and Africa, joined the collaboration shortly thereafter. With subspecialty development as one of their priorities, the FHF brought technical and generous financial support to the team. At a 2011 meeting in Kuala Lumpur, Malaysia, the SAO, ICO, and the FHF decided that the first steps in improving the quality of ophthalmic care in the SAARC region were as follows: & assess institutional capacity for ophthalmic education, especially subspecialty training, in the SAARC countries; & determine the need and future projections of key AEHP in the region; and & develop an assessment tool that could be used in other regions and countries.
MATERIALS AND METHODS On recommendation of the SAO, ICO, and FHF, a methodology was devised to determine the need and future projections of key AEHPs in the SAARC countries and to assess institutional capacity for ophthalmic education in the region. Desk research of currently available capacity assessment tools and methods was undertaken. Based on research results, a 12-point framework was developed from which a Capacity Assessment Tool for SAARC Eye Care Education (CATSEYE) was designed. The 12-point framework included the following: 1. profileVpopulation of the country and number of categories of eye health professionals; 2. publicVinstitute in public sector attached to a general or eye hospital and sources of funding; 3. privateVinstitute in private sector attached to a general or eye hospital and sources of funding; 4. program OVtypes of ophthalmology training programs offered, duration, and subspecialty rotation; 5. program AVtypes of AEHP training programs offered and duration; 6. peopleVnumber of faculty for ophthalmology and subspecialty training programs; 7. processVselection criteria for enrollment of candidates to ophthalmology and subspecialty training programs and whether curriculum is approved by an accrediting body; 8. practiceVtype of training (eg, theoretical, practical, observational); * 2014 Asia Pacific Academy of Ophthalmology
9. portfolioVtype of subspecialty services offered (eg, vitreoretina, pediatric ophthalmology, cornea); 10. proceduresVsubspecialty procedures available (eg, diagnostic, surgical, therapeutic); 11. performanceVwhether subspecialty training assessment includes experience certificate, competency-based assessment, and/or performance appraisal examination; and 12. productVqualification offered and whether qualification is accredited and registrable with a professional body or council.
The Web-based application of CATSEYE used MySql, which is an open-source relational database management system that runs as a server providing multiuser access to a number of databases. The CATSEYE was pretested and debugged and was configured to work with the most commonly used Internet browsers and on Windows, Linux, and Apple operating systems. Focal persons were requested to provide a list of SAARC training centers for ophthalmology, including subspecialty training centers. A list of 81 training centers was obtained, which served as the basis for the survey. Before data collection, an e-mail was sent to alert all listed training centers. This served 2 purposes; these are as follows: first, to establish a communication link, and second, to test whether the e-mail was functional. Several e-mail addresses were found to be either nonfunctional or inappropriate; the e-mail addresses were updated, and the appropriate contact names were noted. A second e-mail was then sent to the revised list of contacts providing a brief background of the survey and requesting contacts to open a Web link to the online questionnaire. A reminder email was sent to those who had not completed the survey within 10 days. The data were cleaned for duplicate entries, incomplete forms that were accidentally submitted, or incorrect submissions. The questionnaire included questions on the following areas: & participating institutionVtype of institution (government, private, or nongovernment) and its income source; & type and duration of training program offered in ophthalmologyVresidency or other; & type of AEHP trained and type and duration of training program offered; & number of teaching faculty and students; & type of selection process for postgraduate students and candidates for subspecialty training; & practice of trainingVtheory, observational, or practical; & type of subspecialty services offered at the institution; & areas in which subspecialty training is offered; & type of performance assessment for subspecialty training; and & accreditation status of the subspecialty training program. The following categories of eye health professionals were used for the survey: & ophthalmologists; & ophthalmic subspecialists; and & the AEHPs, which included optometrists, orthoptists, ophthalmic assistants, and ophthalmic nurses.
Fourteen subspecialty areas (corresponding to subspecialty areas used by the ICO) were identified; these are the following: & cataract and lens; & community eye health; & contact lens; & cornea and external diseases; & glaucoma; www.apjo.org
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The survey indicted similar ratios of AEHPs and ophthalmologists to total population. Bhutan and Sri Lanka have 9 or more AEHPs to every ophthalmologist. Sri Lanka and Afghanistan, however, have much fewer ophthalmologists (Table 1). Optometry training is gradually increasing in the SAARC region. In India, there are at least 30 schools and colleges of optometry affiliated with the Association of Schools and Colleges of Optometry in India (further details can be obtained from www.asco-india.org). For India, the numbers of optometrists and orthoptists need to be interpreted as a combined workforce because most orthoptist training is part of the optometry training program. The status of subspecialists in the SAARC region varies from country to country. The highest number is seen in India, where approximately 4000 ophthalmologists practice as subspecialists. Other than India, which has 300,000 population per subspecialist, all other SAARC countries have more than 1.5 million population or more per subspecialist. The type and duration of subspecialty training vary within the SAARC region. This may range from a 3-month observership to a 12-month hands-on training course. Countries such as India, Nepal, Pakistan, and Sri Lanka have nationally approved curricula for subspecialty training. India has nationally approved curricula for 13 of the 14 ICO-defined subspecialties, whereas Nepal, Pakistan, and Sri Lanka have only 3 to 4 of the 14 ICOdefined subspecialties. In Bangladesh, for example, there are well-trained subspecialty fellows with 12 months of training who are practicing in their chosen area of expertise. There is, however, no nationally accredited
low-vision rehabilitation; neuroophthalmology; ocular oncology; oculoplastic surgery and orbit; ophthalmic pathology; pediatric ophthalmology and strabismus; refractive surgery; uveitis and ocular inflammation; and vitreoretinal diseases.
The following subspecialty levels were used: & Level 1Vgeneral ophthalmologist who has an interest in that subspecialty and spends 50% or more time working in it but does not have a formal subspecialty qualification in it; & Level 2Vgeneral ophthalmologist who has been trained in a subspecialty training center for less than 12 months; and & Level 3Vgeneral ophthalmologist who has been trained in a subspecialty training center for at least 12 months or more.
RESULTS There was an 84% response rate of contacts completing the online survey.1 The data received were then analyzed and tabulated. Although variations exist among the regional countries, SAARC as a region has 1 ophthalmologist for approximately 92,000 population (Table 1).5Y24 India and Pakistan have population per ophthalmologist of less than 90,000. Table 1 summarizes the key findings of the SAARC countries.
TABLE 1. Status of the Eye Health Workforce in SAARC Countries
Population in million Doctors Ophthal* Subspecs† OP‡ OR§ OA|| ON¶ Ophthal training centers Subpsec training centers Population per ophthal Ophthal per 75,000 population Ophthal per million population ODR# Population per AEHP** AEHP per 75,000 population AEHP per million population
AFG
BGD
BTN
IND
MDV
NPL
PAK
SLK
SAARC
30 7250 128 3 6 0 46 65 7 0 234,375 0.32 4.27 57 256,410 0.29 3.90
160 57,143 950 30 5 10 500 250 5 4 168,421 0.45 5.94 60 209,150 0.36 4.78
0.7 179 6 0 4 0 49 3 1 0 116,667 0.64 8.57 30 12,500 6.00 80.00
1200 840,000 14,000 4000 9000 1000 3000 100 458 17 85,714 0.88 11.67 60 91,603 0.82 10.92
0.3 600 8 0 4 0 0 4 0 0 37,500 2.00 26.67 75 37,500 2.00 26.67
30 1765 175 20 45 10 350 20 6 2 171,429 0.44 5.83 10 70,588 1.06 14.17
180 157,000 2200 20 300 20 450 70 30 7 81,818 0.92 12.22 71 214,286 0.35 4.67
20 10,000 101 13 320 3 0 600 3 2 198,020 0.38 5.05 99 21,668 3.46 46.15
1621 1,073,937 17,568 4086 9684 1043 4395 1112 510 32 92,270 0.81 10.84 61 99,852 0.75 10.01
Summary of key findings regarding the status of the eye health workforce in SAARC countries. *Ophthalmologists. †Ophthalmic subspecialists. ‡Optometrists. §Orthoptists. ||Ophthalmic assistants. ¶Ophthalmic nurses. #ODR. **AEHPs. AFG indicates Afghanistan; BGD, Bangladesh; BTN, Bhutan; IND, India; MDV, Maldives; NPL, Nepal; PAK, Pakistan; SLK, Sri Lanka.
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curriculum for subspecialty training, nor any formal training program. There is good potential to use the existing faculty for subspecialty training programs in the various SAARC countries. A detailed directory of the participating institutions and organizations has been prepared and is available at www.icoph.org/ SAARC-Ophthalmic-Education-Directory.pdf. Other than India, subspecialty information was obtained directly from each country’s subspecialty organizations. Information for India had to be obtained from multiple sources (eg, SAO secretariat in Delhi, the All India Ophthalmological Society Web site, and the Medical Council of India Web site and statistical reports). There are at least 458 or more centers offering postgraduate training in ophthalmology in India. The National Board of Examination has 141 registered centers that provide postgraduate training in ophthalmology (details at www.natboard.edu.in). The Medical Council of India has 107 registered centers that offer training for a diploma in ophthalmology (details at www.mciindia.org). The Medical Council of India has 210 registered centers that offer training for masters in surgery in ophthalmology (details at www.mciindia.org). The total number of ophthalmologists obtained from the All India Ophthalmological Society may be an underestimate.
Supply and Need Projections Human resource planning for eye health usually tends to be based on need. For instance, the need may be estimated by dividing a given population by the number of ophthalmologists or AEHPs in that particular country. This does not take into account; however, supply mechanisms (ie, how many ophthalmologists does that country produce annually), pull factors such as creation of posts and attraction of further specialization, push factors such as ophthalmologists retiring annually or those who leave a clinical career for something else or who migrate to other countries nor does it take into account urban and rural disparities. In the absence of a more practical option or model to estimate the future supply and need, the use of an arbitrary indicator has provided a useful, if limited, planning formula. Viewing the status of ophthalmologists per million population (Fig. 1)YYBhutan and the Maldives have been omitted from Figure 1 owing to their small population sizeYYit can be observed that there are 2 major benchmarks, 11.9 and 5.2. The benchmarks suggest that India and Pakistan may need to aim in the short to medium term to have 15 ophthalmologists per million population, whereas the remaining 4 countries need to effectively double or even triple their current numbers of ophthalmologists. In comparison with other developed countries, it shows that they (developed countries) have a much higher ophthalmologistto-million population ratio with an average of 38.6 per million (Fig. 1). The comparison of 1 ophthalmologist per total population rates illustrates that developed countries have 3 times as many ophthalmologists compared with India and Pakistan and at least 7 times more than some of the other SAARC countries (Fig. 2).
Ophthalmologist-to-Doctor Predictor Unlike dentists who start their training as dentists, a medical student graduates as a general physician and then chooses a The survey questionnaire was sent to 81 organizations and institutions, of which 84% responded. Telephone follow-up was used to increase the response rate. The directory referred previously includes the names of the organizations identified by National Focal Persons and shows where data were made available and where there is still a need to add data.
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specialty (eg, pediatrics, surgery, ophthalmology). The ‘‘market preference’’ for one medical specialty over another varies from country to country. Using a case study from Pakistan, we attempted to ascertain the relationship between the number of ophthalmologists and doctors because ophthalmology residents come from the pool of available doctors in that country. The number of doctors (physicians) was determined from the Economic Survey of Pakistan and the Pakistan Medical and Dental Council Web site.22 The projection of the number of doctors for 2025 was based on the trend of the compound annual growth rate (CAGR) for the series and retaining the same for year 2035. The actual and projected number of doctors up to the year 2035 is illustrated in Figure 3, which also shows the declining CAGR. Rate 1 shows a continuous declining CAGR based on declining rate, whereas rate 2 shows a steady state that is similar to 2025. The number of ophthalmologists was determined from official planning documents, including the National Eye Health Plans (Ministry of Health, Government of Pakistan 1994Y1998, 1999Y2003, and 2005Y2010). The ratio of ophthalmologist to total doctors was compared, and it was found that during the 30-year period, the ratio remained constant at 1:70. The ophthalmologist-to-doctor ratio (ODR) seems to be a useful and practical predictor of supply. Furthermore, although it was based on the number of doctors and the number of ophthalmologists, the effect of those who are retiring or leaving service would tend to cancel each other. The need and supply of ophthalmologists in Pakistan are illustrated in Figure 4. ‘‘Required’’ (need) was estimated using 1:75,000 ratio. The current ratio is 0.92 per 75,000 population (Table 1). The rationale was to determine the nearest multiple of 5000 population figure for 1 ophthalmologist. Therefore, 1 per 75,000 was taken as the nearest whole number to estimate need. To estimate those who were working, actual figures available are used up to 2012, and ODR is used for future projections. The comparison of ODR of different regional and developed countries was done.25Y36 The SAARC region has an average of 61 ODR, whereas the United Kingdom has an ODR of approximately 115, indicating that the SAARC region has approximately twice the proportion of ophthalmologists to doctors than the United Kingdom (Fig. 5). Nepal has a very low ODR (or high percentage of doctors who are ophthalmologists), suggesting a preference for the specialty of ophthalmology among their doctors. Sri Lanka, Australia, and UK ODRs indicate that these countries probably have a shortage of ophthalmologists, or there are not enough training positions in ophthalmology or that the specialty is not among the top few preferred choices among doctors (Fig. 5).37 The findings indicate that there is a relative consistency in ODR rates among various countries. The 3 SAARC countries, Bangladesh, India, and Pakistan, demonstrate fairly steady ODRs during the 20-year period, whereas the 4 developed countries, Australia, Canada, United Kingdom, United States, indicate a nominal increase in ODRs. Taken individually, for example, in Australia and the United Kingdom, the decadal trend of ODR suggests fewer ophthalmologists in training compared with the pool of available physicians and overall population (Fig. 6). The ODR trend in SAARC and developed countries is likely to have implications for changing disease patterns and aging populations, both of which require greater numbers of ophthalmologists and ophthalmic subspecialists. www.apjo.org
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FIGURE 1. Ophthalmologists per 1 million population. Status of ophthalmologists per 1 million population (Bhutan and the Maldives have been omitted because of their small population size). Two major benchmarks, 11.9 and 5.2, suggest that India and Pakistan may need to aim in the short to medium term to have 15 ophthalmologist per million population, whereas the remaining 4 countries need to effectively double or even triple their current numbers of ophthalmologists. In comparison with other developed countries, it shows that they (developed countries) have a much higher ophthalmologist-to-million population ratio with an average of 38.6 per million.
Figure 7 illustrates a schematic model to estimate ‘‘supply’’ of ophthalmologists at a time in the future. The model has 5 key steps; these are as follows: Step 1Vestimate the population in the future using the population figure from official sources (eg, census departments) and apply a CAGR to make future projections for a time series; Step 2Vestimate the number of doctors (general physicians) by using actual figures from official sources (eg, medical councils) and apply a CAGR to make future projections for the time series used in Step 1; Step 3Vestimate the ‘‘need’’ of ophthalmologists by applying an appropriate ratio for the respective country (eg, we used 1 per 75,000 population as explained earlier; one can also use other variations, such as number per million population; Table 1) for the time series used in Step 1; Step 4Vusing the estimates from Steps 2 and 3, determine the ODR for the past by dividing the number of doctors by the number of ophthalmologists for the past time series used in Step 1. The ODR can then be used for Step 5; and Step 5Vuse the estimates established in Step 2 for the number of doctors in a time series, divide the numbers of doctors by
the ODR to estimate future supply (or likely availability) of ophthalmologists. The difference between need (calculated in Step 3) and supply (calculated in Step 5) would help establish the gap that needs to be addressed.
DISCUSSION The list of training centers in the 8 SAARC countries was provided by focal persons and may not represent a complete list of all training centers. Although there was an 84% response rate, not all of the listed training centers responded, so the percentages obtained may underrepresent the situation in a particular country. The time and limitation of resources did not permit an onsite validation of data for each center that responded to the questionnaire. The survey also did not make any distinction among ophthalmologists who were practicing, retired, and surgically active because this information was considered difficult to obtain. Thus, the total numbers are estimates rather than absolute. This initial study was limited in its ability to collect detailed information about India, and the numbers obtained for
FIGURE 2. Total population per ophthalmologist. Population per ophthalmologist (Bhutan and the Maldives have been omitted because of their small population size). Data from developed countries indicate that they have approximately 1 ophthalmologist for approximately 26,473 population, whereas India and Pakistan have 1 ophthalmologist per 83,766 population, suggesting 3 times difference in the rates. Afghanistan, Bangladesh, Nepal, and Sri Lanka with a 1 ophthalmologist per 193,061 population have a difference of at least 7 times with the developed countries.
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FIGURE 3. Projections for number of doctors in Pakistan. The actual and projected number of doctors to the year 2035 and the declining CAGR. Rate 1 shows a continuous declining CAGR based on declining rate, whereas rate 2 shows a steady state that is similar to 2025.
India are likely an underestimate. Further analysis and a follow-up study in India are warranted. Based on the data obtained by CATSEYE, the following information was learned: & approximately 17,568 ophthalmologists and an estimated 4086 ophthalmic subspecialists practice in the SAARC region; & the ophthalmologist to population ratio in SAARC countries is approximately 1:92,270 and 10.84 per million population; & the AEHPs constitute an important element of the region’s eye health workforce and have a population ratio of approximately 1:99,852 and 10.01 per million population; & the ODR (physician) is 1:61 in the region; and & more than 510 centers provide ophthalmology training and more than 32 centers provide subspecialty training across the region. An interesting finding of the survey was the similar ratios of AEHPs and ophthalmologists to total population. In this regard, Bhutan and Sri Lanka have 9 or more AEHPs to every ophthalmologist. Sri Lanka and Afghanistan, however, have much fewer ophthalmologists (Table 1). This indicates that
ophthalmology training would be a priority in these countries, whereas Pakistan, for instance, might need to intensify efforts to train more AEHPs. Countries with a shortage of ophthalmologists or fewer ophthalmologists in training compared with the pool of available physicians and overall population (Figs. 5, 6) support the necessity to train eye care teams led by ophthalmologists to meet the requirements of communities. This need is especially critical when considering the implications of changing disease patterns and aging populations. In the SAARC region, the challenge is to sustain and increase the eye health workforce to meet the needs of a growing and aging population. The demographic transitions, improved child survival and life expectancy rates, and emerging noncommunicable disease trends require training of ophthalmic subspecialists and supporting eye care teams to meet the service delivery demands of changing eye health paradigms.
Recommendations Based on a combination of desk research, telephone interviews with the national coordinators for eye health and the findings obtained by CATSEYE to access the capacity for
FIGURE 4. Predicting the need and supply of ophthalmologists in Pakistan. The need and supply of ophthalmologists in Pakistan is illustrated. Required (need) is estimated using 1:75,000 ratio; ‘‘working’’ actuals are used up to 2012, and ODR is used for future projections. * 2014 Asia Pacific Academy of Ophthalmology
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FIGURE 5. Selected countries and ODR. The comparison of ODR of different regional and developed countries was done. The SAARC region has an average of 61 ODR, and the United Kingdom has an ODR of approximately 115, indicating that the SAARC region has approximately twice the proportion of ODR than the United Kingdom. Nepal has a very low ODR, suggesting a preference for ophthalmology among their doctors. Sri Lanka, Australia, and UK ODRs indicate that these countries probably have a shortage of ophthalmologists, or there are not enough training positions in ophthalmology or that the specialty is not among the top few preferred choices among doctors.
ophthalmic training in the 8 SAARC countries, the ICO, SAO, and the FHF suggest the following policy recommendations for the SAARC region: & facilitate a high-level meeting of heads and specialty coordinators of ophthalmic professional bodies in SAARC countries to develop a regional policy/strategy on ophthalmic education (including subspecialty training) and determine priority areas for joint action; & launch a regional forum or task force on human resources for eye health, whose purview may include standardization of definitions, to act as a catalyst in developing guidelines for roles and responsibilities of different professionals in the eye health workforce; recommend minimum service delivery standards for human resources for eye health; develop an
essential subspecialty training curriculum and practical requirements for the subspecialties; design performance appraisal modalities, monitor quality, etc; & mobilize a regional faculty to promote technical cooperation among developing countries to participate in subspecialty training across countries; & define standards for subspecialty training centers by analyzing gaps and initially strengthening centers that have the capability and capacity to provide subspecialty training; and & foster collaboration with international partners to actively promote ophthalmic graduate and subspecialty training and to support the functioning of a regional forum, such as eye health partnership for professional advancement to accelerate efforts in this regard.
FIGURE 6. Selected countries and ODR decadal trends. Bangladesh, India, and Pakistan demonstrate fairly steady ODRs during the 20-year period, whereas Australia, Canada, United Kingdom, and United States indicate a nominal increase in ODRs. Taken individually, for example, in Australia and the United Kingdom, the decadal trend of ODR suggests fewer ophthalmologists in training compared with the pool of available physicians and overall population.
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FIGURE 7. Five-step ODR supply predictor model. A 5-step ODR supply predictor model is proposed. The model uses CAGR to estimate the future projections of population and the numbers of doctors from past time series using data from official sources. It also estimates need of ophthalmologists by applying an appropriate ophthalmologist-to-population ratio. The ODR calculated from this model can be used to predict the future supply of ophthalmologists and thus assist in human resource planning.
To meet the goal of global blindness prevention in the SAARC countries and beyond, superior eye care delivery at all levels is needed, and it is dependent to large extent on high-quality training of ophthalmologists and AEHP workers. ACKNOWLEDGMENTS We wish to recognize with deep appreciation the contributions of the following people: Profs Ava Hossain and Rajvardhan Azad (SAO); Ms Lesley Podesta (The FHF); Drs Mohammad Babar Qureshi and Irfan Baig (Advisors); Dr Ahmad Shah Salam (Afghanistan); Profs Deen Mohammad Nurul Huq and Enayet Hosein (Bangladesh); Prof Nor Tshering Lepcha and Mr Chandra Kumar Chhetri (Bhutan); Profs Ashok Grover and Namrata Sharma (India); Dr Abdullah Junaid (Maldives); Prof OK Malla and Mr Sunu Dulal (Nepal); Profs Asad Aslam Khan, Mohammad Saleh Memon, and Nasir Saeed and Dr Riaz Baloch (Pakistan); and Drs Mangala Gamage, Saman Senanayake, and Sunil Fernando (Sri Lanka). We are especially thankful to Mr Jabbar Bangash and his team at CREOLOOM for developing the Web-based application, to our colleagues at Avicenna Consulting Pvt Ltd, and Mr Niaz Ullah Khan and Mr Mohammad Bashir Khan for their technical assistance.
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