Trachoma is the world’s leading infectious cause of blindness and one of 20 neglected tropical diseases (NTDs) that affect over one billion of the world’s poorest people. While countries in Africa are the most affected by trachoma, it is a public health problem in countries in the Middle East, such as Yemen, Egypt, Iraq and Iran. Although trachoma elimination efforts are succeeding, other eye health issues like cataract and refractive error have not had the same focus.
In this interview, as part of our series on avoidable blindness, we speak to Dr. Yeneneh Mulugeta Deneke from The Fred Hollows Foundation about the intensification of trachomatous trichiasis surgery through their comprehensive eye healthcare service project. He also explains why integrated health services help to meet the community-wide eye care needs, such as cataract and refractive error.
What is the TT Plus project?
Dr. Yeneneh Mulugeta Deneke: In 2018, we introduced the “trachomatous trichiasis surgery intensification through provision of comprehensive eye health care service” project in Ethiopia. Known as “TT Plus”. The innovative model is a pilot project which aims to provide a comprehensive healthcare service delivery system for communities in need and deliver a broad range of eyecare services to treat trachoma, cataract and refractive error. The pilot project targeted local communities residing in a semi urban and rural areas.
Why was the TT Plus project set up?
Dr. Yeneneh Mulugeta Deneke: During trachoma elimination outreach services, The Foundation and its partners also received patients with cataract, refractive error, or other eye conditions. We had to turn these requests down as our service was only treating trachoma. So, the question was, why we are only dealing with TT (trachomatous trichiasis)? Why don’t we add services that treat not only trachoma, but also other eye diseases?
Why was the pilot study beneficial to The Foundation and governments?
Dr. Yeneneh Mulugeta Deneke: The Fred Hollows Foundationknew that TT services were not adequate to address the eye care needs of the community. We conducted a pilot study because we knew the findings could help us to identify barriers in the eye healthcare system and identify gaps and opportunities, such as: Governance and leadership; eye healthcare structure and services; financing; infrastructure; human resources; service delivery; information management, and; community demand.
TT Plus wasn’t a donor-driven pilot project but rather a government-driven request. The pilot study gave us the opportunity to align and integrate international development efforts to eliminate avoidable blindness with national efforts such as clearing the cataract backlog. The findings helped us to understand the importance of not only sharing resources, but also how better to utilize them. We were able to see the impact of leveraging existing human, financial, infrastructure, and mobilizing resources through integration to implement a cost-efficient project where trachoma, cataract and refractive error were all being addressed.
In addition, this innovative approach helped us to gain community trust which was a win-win for everyone.
How can local communities benefit from the study?
Dr. Yeneneh Mulugeta Deneke: Community research provides evidence-based practise to identify areas of strength, weaknesses, opportunities and challenges of the project. So, data collected from TT Plus helped us to serve and respond to community demands better, effectively and more efficiently. Data is also important to communicate with potential donors or funders who are interested in supporting similar initiatives.
Did the study provide any interesting findings?
Dr. Yeneneh Mulugeta Deneke: The pilot study was implemented in two different settings (rural and semi-urban areas). The semi urban setting was near to the capital and the hospital was staffed by ophthalmologists. The other hospital was located in a rural area (400km away from the capital) staffed by two cataract surgeons who are trained nurses. The rural hospital was more successful in achieving planned outputs than the semiurban hospital. Our understanding is that the rural hospital had better patient flow due to a relatively higher patient demand than the urban and near urban residing patients. What we have learned is that themore rural the area, the higher the number of patients and the higher the outputs. So, most of the outputs were achieved by cataract surgeons who are not medical doctors, but nurses who are trained to be surgeons. This was something we did for our trachoma projects and is an approach we will start using in Africa.
What are the key lessons learned from the pilot study?
Dr. Yeneneh Mulugeta Deneke: TT Plus provided an integrated system of comprehensive eye health care for communities of high prevalence of trachoma and cataract. The integration component and resource mobilization have strengthened and expanded the existing services’ capabilities, thus increasing the quality of the services. We managed most of the patients with trachomatous trichiasis, cataract and refractive errors who sought medical interventions. By the end of the year, more than 24,000 patients were screened for cataract and trachoma and more than 1252 cataract surgeries were performed.
Also, the findings confirmed that mobilizing resources can help provide better access to services for highly affected populations in rural communities, like women, disabled and old-aged groups. The additional cost for integrated TT and cataract surgery was about AED 200 (US$55) per patient.
Is it possible to implement the research study in other healthcare contexts?
Dr. Yeneneh Mulugeta Deneke: The evidence-based practice proj-ect supported by a pilot study is a must before scaling up comprehensive eye care programming, planning or implementation. The project was successful because the study was piloted in counties with high prevalence of active trachoma. The study confirms that the integration of comprehensive eyecare services and resources is more efficient and beneficial than addressing a single disease. It can be carried out in countries under surveillance, or endemic, for blinding trachoma such as Yemen, Iraq, and Egypt.
The Fred Hollows Foundation
Founded in 1992, The Fred Hollows Foundation is an international development organisation working to eliminate avoidable blindness in more than 25 countries. In 2019, The Foundation performed 646,835 eye operations and treatments; treated 20+ million people with antibiotics for trachoma; trained 68,293 people and; equipped 4,677 facilities. Visit: www.hollows.org
