Guidelines For Evaluating International Community Eye Care Work

Unite For Sight is a recognized leader in providing high quailty, cost-effective care to the world's poorest people. As with all health programs, eye care programs must be founded on best practice principles in public health.  The worst practices that are often employed by some organizations involved with eye care can do significant harm and create more substantial barriers to care. These guidelines provide a framework by which one can evaluate the programs of eye care organizations worldwide.

1. Does the organization work with local eye clinics?

Best Practice: Consistent, quality health care must be provided by local eye clinics to the population on a daily basis and year-round. Quality organizations provide support and assistance to local eye clinics. Visiting optometrists and ophthalmologists work collaboratively with local eye doctors and focus on providing training and professional development opportunities.

Worst Practice: Short-term interventions (i.e. optometric medical missions and "surgical safaris") often fail to partner with local eye doctors, thereby undermining the local healthcare systems in developing countries.  Additionally, patients who encounter such "medical mission" groups will leave believing they have received a complete ophthalmic exam, no matter how cursory the vision screening, even if they are explicitly told otherwise. If a patient with cataracts, for example, is told that eyeglasses will not correct their sight, but an option for subsidized or free cataract surgery is not provided, the patient will continue to believe that nothing can be done to restore their sight. This visit to the “medical mission” group is often the only time that a patient will seek eye care.

Of all the worst practices in global eye-care, short-term surgical missions can be considered the worst offenders. Even the best efforts of the most experienced ophthalmic surgical teams cannot overcome the risks of short-lived surgical missions. Patients receiving surgery must have access to follow-up care in order to prevent or treat infection. When visiting doctors do not work with their local counterparts, there is no ophthalmologist to provide follow-up care or to treat infections that may arise after the operating surgeons depart, which is sometimes the day after operating.

When visiting eye doctors do not work with local eye clinics, it undermines the local health care system. Patients may decide to wait until another time a Western doctor visits instead of seeking care by the local ophthalmologist. Oftentimes, it is rich patients who take advantage of free surgical care provided by visiting surgeons despite being able to pay, simply because they incorrectly believe that the Western visitors provide higher quality surgery.

“While [Western medical] teams provide temporary but sporadic access to health care, overall, they do not improve long-term access and they may, in fact, undermine existing services. It is unclear whether the short-term projects are treating only individuals who under current circumstances would have absolutely no access to medical care because of an inability to pay for it, or if they are diverting some otherwise paying or potentially paying patients from local practitioners and facilities. Local practitioners who must earn a living in the community cannot compete with the volunteers who donate their services. Furthermore, they cannot provide the same volume of free care over sustained periods and remain financially viable. Because the patient population… has not been closely analyzed, it is difficult to assess the precise impact on the local health care delivery system. If these groups actually do compete with local providers, the possibility exists that they could be put out of business, further restricting access to health care.”(1)

(1) Montgomery, L.M. “Short-Term Medical Missions: Enhancing or Eroding Health?” Missiology: An International Review. 21.3 (1993): 333-341. Accessed on 20 October 2008.

2. Does the organization provide care by local eye care professionals?

Best practice: All eye care services must be provided by or in collaboration with local eye doctors.

Worst practice: Allowing medical and non-medical providers to practice beyond their abilities, or without collaboration with local eye care professionals who are familiar with local eye disease pathology and treatment, is one of the worst practices. 

There are numerous examples of short-term medical missions involving students or other non-eye care professionals dispensing prescription eyeglasses and medication, which is highly problematic and harmful for various reasons.  First, prescribing corrective distance eyeglasses requires refraction by a skilled optometrist or ophthalmologist.  In the Western world, it is illegal for anyone but a licensed professional to prescribe eyeglasses or medication.  Patients provided with the wrong eyeglass prescription – which is nearly always inevitable if non-eye care professionals are distributing glasses without refraction or examination – will experience headaches, discomfort, and not wear the eyeglasses.  This can create or perpetuate distrust of health providers. 

Non-eye care professionals who prescribe or dispense reading or distance eyeglasses have no formal training in eye care and cannot identify the difference between refractive error and other eye diseases such as cataracts or infections. Some organizations claim to train their volunteers to use advanced optometric equipment, but such training is cursory and does not and cannot qualify non-medical personnel to prescribe eyeglasses. It is important for organizations and NGOs to recognize that it is unethical and can be harmful for non-eye care professionals to prescribe reading glasses or distance glasses to unknowing patients. 

Additionally, visiting physicians on short-term medical trips often feel compelled to treat patients outside their specialty, simply because there is no specialist available, or because the patients are not able to afford the cost of receiving care by the local specialist. In Western countries, internists do not treat children and general surgeons do not prescribe eyeglasses – why should this be different in the developing world? Lowering the standard of medical care for those in developing communities is unprofessional, unsafe, and unethical.

There are other problematic examples of organizations that "train" local community members to prescribe or dispense reading glasses. Reading glasses are medical products, and comprehensive eye exams and treatment by medical professionals must be promoted and provided. When glasses are dispensed as consumer products, it creates more substantial barriers to care while also promoting a false and commonly-held belief that eyeglasses are fashion accessories. When receiving reading glasses from a local community member, it can be impossible for a village patient to understand that receiving reading glasses does not constitute a complete eye exam by an eye care professional. Additionally, it is often believed that when one's hair goes grey, one's eyes go grey with cataracts, and nothing can be done to eliminate blindness or restore sight. For those patients who may be aware that there is a treatment option, most all of those patients are under the false impression that eyeglasses are the only treatment option for eye disease. It is therefore highly problematic for a patient to be given reading glasses that will have no effect on a serious eye condition such as a cataract, and equally precarious if they are told that reading glasses cannot help and are therefore "referred" to an eye clinic without reducing the significant barriers to care such as transportation barriers, financial barriers, awareness and fear barriers, etc. When patients seek eye care from local community members who represent themselves as "trained" eyeglass providers, but are not offered proper examination, diagnosis, and treatment for treatable conditions such as cataracts, they will believe that there is nothing that can be done for their eye condition. Trained local community members must be integrated into a local eye clinic's ongoing outreach programs by eye care professionals at the same location.  The primary role of the community members should be to help reduce barriers to patient care, and their close involvement with local eye clinics can be highly beneficial to the patients.

There are many patient barriers to eye care, and unfortunately the worst practices employed by many organizations cause harm and further perpetuate existing barriers while creating new and oftentimes more substantial barriers to care.

3. Does the organization provide comprehensive eye care for all treatable conditions?

Best practice: The eye care services must be comprehensive, including examinations by local eye doctors, diagnosis and care for all treatable conditions, and education. This full range of services needs to be delivered to the population year-round.

Worst practice: Oftentimes short-term eye care programs provide only eyeglasses and do not provide treatment for other treatable conditions such as infections, cataracts, pterygium, etc. There is a common belief among patients that eyeglasses will help any visual problem.  If a patient is given eyeglasses, but they in fact have cataracts, eyeglasses will not benefit the patient.  Nevertheless, the patient will often believe that they were given glasses to cure their eye ailment; since the glasses didn’t work, they will believe that there is no cure for their visual problem. They will likely never seek eye care again. There are many eye diseases that cause visual impairment that can only be detected and diagnosed by an eye care professional.

“It is also important to recognize that while spectacles provide an easy answer to the need for presbyopic correction, the mere handing out of spectacles without an appropriate eye examination biases against quality eye care for everyone regardless of socioeconomic status, sex, or geographic circumstance. Coupling spectacle distribution to meaningful eye care is an important link in the blindness prevention chain from community to hospital. Random spectacle distribution breaks the chain of patient care and is counterproductive.”(2)

(2) Holden, B.A., Fricke, T.R., Ho, M., Wong, R., Schlenther, G., Cronjé, S., Burnett, A., Papas, E., Naidoo, K.S., and Frick, K.D. “Global Vision Impairment Due to Uncorrected Presbyopia.” Archives of Ophthalmology. 126.12 (2008) 1731-1739. Accessed on 15 January 2009.

4. Does the organization "refer" patients to local eye doctors, or reduce barriers to ensure that they can access care?

Best practice: Eliminate patient barriers to care by fully funding surgeries, bringing eye care services to the patients, providing transportation from remote villages to the eye clinic for surgery as needed, and educating communities about blindness elimination.

Worst practice: Organizations that claim to “refer” patients to local eye care professionals in developing countries must reduce barriers to care.  “Referring” without reducing barriers to care will not enable a patient’s access to locally available resources.  It is the responsibility of the organization to facilitate transportation from remote villages and subsidize financial cost, as well as maintain data on the number of patients receiving care by the local eye clinics.  Hundreds of thousands of patients can be told to go to an eye doctor, but what actually matters is the number of patients who are connected with the available eye care services and therefore receive quality care.

5. Do participating volunteers receive training?

Best practice: All visitors - non-medical or medical professionals - must be trained in cultural competency, volunteer ethics and professionalism, community eye health, and they must understand the logistics and dynamics of the organization and local eye clinic operations. Visitors must be locally led, managed, and supervised by local eye care professionals.

Worst practice: Without training, volunteers will be psychologically and culturally unprepared to work amidst poverty in a developing country. Volunteers who are overwhelmed by culture shock or sadness can burden the rest of the team. Additionally, volunteers unfamiliar with cultural norms can unintentionally offend locals, thereby becoming a liability. Most importantly volunteers must avoid an ethnocentric attitude and respect local partners and patients. Additionally, volunteers involved in local education, for example, risk propagating incorrect public health information if not trained properly. In general, volunteers who have not been prepared cannot contribute, become a burden to local clinics and to local communities, and can hinder local eye care efforts.

6. Does the organization provide quality medical equipment?

Best practice: Provide quality medical equipment only if and when requested by the local eye clinic.

Worst practice: Special attention should be paid to the WHO donation guideline regarding expressed need; distant donors are not aware of local needs, and unsolicited donation of any and all medical supplies is costly, wasteful, cumbersome, and rarely helpful.

“Recipient hospitals often cannot use the donations because they do not serve their needs. And worse, unsolicited donations commonly cause additional problems for the recipient hospitals, creating storage problems or necessitating the disposal of medical garbage."(3)

“Another hospital I visited had received funds specifically donated for the construction of a new wing, even though their greatest need was a rebuilt sewage and electrical system. Had the donor not directed the funds, the hospital could have spent the money much more productively. Large donations may make the donor feel warm and fuzzy, and entitled to decide on the use of the money. Unfortunately, that doesn't always lead to the best use of desperately needed funds. Donors are not always aware of current needs.”(3)

(3) Kowal, C. “Is Something Better Than Nothing?” Canadian Journal of Emergency Medicine. 5.1 (2003): 54. Accessed on 16 January 2009.