1. © Sightsavers `. ADVOCACY FOR PEC RONNIE GRAHAM, DIRECTOR, HUMAN RESOURCES FOR HEALTH, SIGHTSAVERS

2. © Sightsavers The first step in any advocacy activity is to know what you want to change. We can seek to change policy or practice In 2012 a WHO Discussion Paper noted ‘In particular, it appears that there has been insufficient attention paid to integrating eye care into primary health’. Our Proposition, or change theme: In the case of PEC, we want to see a change from isolated examples of best practice, often INGO funded, to the systematic integration of eye health into existing Primary Health Care systems. In other words, we are trying to change practice 1. CHANGE

3. © Sightsavers 1. Know what you want to change 2. Identify the best influencing strategy. 3. Develop an Action Plan 4. Implement Action Plan 5. Monitor and evaluate progress 2. STRATEGIC ADVOCACY

4. © Sightsavers Global Policy: 1978: THE ALMA-ATA DECLARATION ‘HEALTH FOR ALL’ 2008:WORLD HEALTH REPORT ‘NOW MORE THAN EVER’ 2008:THE OUAGOUDOUGOU DECLARATION ON PHC AND HEALTH SYSTEMS National Policy 15 NATIONAL HEALTH PLANS SURVEYED - 14 WITH PHC AS ‘GUIDING PRINCIPLE’ Eye Health Policy 1999 Vision 2020 2000> National Eye Health Plans 2004 Technology Guidelines +++WHA Resolutions: 56.26, 59.25 and 62.1 3. The Policy Context is Favourable In Mali, 58% of population lives within 5k of a Front Line Health Facility, rising to 67% in Zambia and 97% in Tanzania

5. © Sightsavers 4.1 Ocular Morbidities: ‘Ocular morbidity descries a range of diseases that are self- limiting, unlikely to cause permanent visual impairment and can usually be managed in primary care... Studies that explore the prevalence of ocular morbidity show that there are significant numbers of people who experience these conditions. Lindfield, 2010. Study in Pakistan (2004) demonstrated a prevalence of NVICs of 14.6%. A pilot study in Kenya (2011) showed a high prevalence (nearly 13%) of ocular morbidity. Follow-up studies underway in Nigeria and Cameroon. 4. But The Evidence Base is Weak

6. © Sightsavers 1.Cameroon Study in Mamfe and Kumba District Hospitals. ‘ Overall, patients with ocular morbidities represented about 18% of all patients attending the two district hospitals’ Sightsavers, 2010 2. Pakistan Study: Baseline data on the burden of ocular morbidity at primary, secondary and tertiary levels in 8 districts. ‘Evidence suggests that ocular morbidity accounts for at least 7% of all outpatient health visits to secondary hospitals and 10% to tertiary hospitals.... and 18% of all patients seen by Lady Health Workers’. Sightsavers, 2010 4.2 HOSPITAL DATA

7. © Sightsavers In a recent review of 103 articles, three provided evidence of the effectiveness of PEC. Advises testing and documenting the actual contribution of PEC to the delivery of eye care. *Courtright, Seneadza, Mathenge et al. ‘Primary Eye Care in Sub-Saharan Africa: Do We Have the Evidence Needed to Scale up Training and Service Delivery’, Annals of Tropical Medicine and Parasitology, Vol. 104, No. 5. 4.3 PEC IN PRACTICE

8. © Sightsavers Old and New Priorities must be anchored in the community. 1. NTDs: Focal Diseases – Interventions are Community owned and directed 2. NCDs: New priorities – importance of establishing surveillance mechanisms 3. Childhood Blindness - Early identification is critical 4. RE/LV Emergence of the African Vision Centre - grounded in PEC 5. Other Ocular Morbidities – Treat at most appropriate level - ‘free up’ the clinics 5. Disease Control The recent WHO Discussion Paper noted that ‘there may have been missed opportunities to link disease specific initiatives.... with the broader development of comprehensive eye care systems... which need to become integrated with primary health care’.

9. © Sightsavers But where the evidence is weak, how should we proceed?  Strengthen the evidence.... But it takes time !  Take a policy decision and address known weaknesses 5. The Advocacy Challenge ? NOT IF.............BUT HOW

10. © Sightsavers 1.PEC IN THE EMRO REGION: –Compelling evidence of impact from Pakistan. – New Guidelines under development. (Creating Synergies for Health System Strengthening, Khan, Khan, Bile and Awan, Eastern Med. Health Journal, Vol. 16, 2010) 2. PEC IN THE AFRO REGION: Package of interventions under development 3. INTEGRATING EYE HEALTH INTO BASIC NURSE TRAINING: Eye Health to be included as a priority issue in a new competency based nurse training curricula. 6. Advocacy Success

11. © Sightsavers How many psychiatrists does it take to change a light bulb ? Only one...... But the light bulb has to want to change ! The point is that health systems unlikely to change to accommodate eye health. So we need to change to be accommodated by health systems. WHAT NEEDS TO CHANGE ?

12. © Sightsavers A new paradigm of eye health service delivery is emerging. It moves us away from vertical and parallel approaches and seeks to generate programme and national success as well as ‘project success’. The parameters of the new paradigm are well understood: –Strengthen health systems –Expand the eye health workforce –Integrate eye health into primary health care –Strengthen linkages with wider health systems –A new set of eye health indicators linked to Global Health Observatories –Adequate, predictable and sustained financial resources 6. Now More Than Ever

13. © Sightsavers At the beginning of the presentation, I proposed the change we would like to see “....from isolated examples of best practice, often INGO funded, to the systematic integration of eye health into existing Primary Health Care systems”. The capacity to finally consumate this change lies in our hands: 1.The policy environment is supportive 2. The evidence base is growing stronger – OM, hospital data, programme success 3. A new paradigm of eye health service delivery is emerging based on integration, alignment and universal coverage. CHANGE REVISITED

14. © Sightsavers Can we now utilise a common approach to strategic advocacy to make the necessary programme shifts ? Key Question