The concept of a civil society as defined by the authors is a crucial component of tackling glaucoma in many less-developed areas. The primary goal is the creation of a self-sustaining system. For those working as individuals, the problems are formidable, and industry often considers these areas unprofitable to support.

Govindappa Venkataswamy, MD, the founder of Aravind Eye Care System in India, would have us remember that health care and eye care initiatives do not occur in a vacuum. Rather, they must be tailored to the needs and potential capabilities of a specific community. The goal is to improve the well-being and eye care of the community, not just that of a group of individuals. Quality and capacity building are crucial to this endeavor.

Partnerships with organizations such as Lions Aravind Institute of Community Ophthalmology, nongovernmental organizations, and interested individuals are all important. Steps include not only examinations and surgery but also recruitment, marketing, outcomes analysis, fundraising, instrument repair, and managerial skills. Diverse partnerships with interested parties will be the key to expanding access to high-quality eye care.

—Alan L. Robin, MD, section editor

Glaucoma is a leading cause of blindness globally, with a disproportionately high impact in Sub-Saharan Africa (SSA), where the estimated prevalence is at least 4% among individuals 40 years of age and older.1 Despite this high burden of disease—which often has devastating psychological, social, and economic consequences for those affected and their communities—glaucoma was not included among the priority diseases in the first draft of the global Vision 2020 The Right to Sight initiative2,3 The reason was the lack of clear-cut public health strategies for controlling glaucoma at the time, unlike with the other major blinding eye diseases. There is, nevertheless, an urgent need for effective and sustainable glaucoma care in SSA. Goals include enhancing community-level awareness of disease, overcoming various barriers to access, providing essential medication and equipment for diagnosis and management, enhancing patients' adherence to treatment, training ophthalmic health care personnel at various levels, and integrating a strong international standard of ophthalmic care into the broader health care infrastructure. Also critical is the adoption of an evidence-based approach to best practices in order to inform and sustain programs and policies over time4 The public sector has made some strides in these areas, but much remains to be done.

His Highness the Aga Khan stated, “In an era of rising expectations and unmet needs, both in the developed, but much more in the developing world, civil society institutions play an essential role in the provision of social services, the protection of the marginalized, and the delivery of development programmes.5 Our deeply held conviction is that civil society can play a key role in strengthening institutional capacity for cost-effective and sustainable glaucoma care within SSA6

CHALLENGES IN GLAUCOMA CARE IN SSA

Eye care in Africa continues to pose enormous challenges, and blindness does not occur in a social vacuum. Rather, it reflects the broader educational, socioeconomic, and developmental obstacles faced by communities throughout SSA. A key issue is the welldocumented shortage of clinically trained eye health professionals at all levels. Resnikoff and colleagues estimated the prevalence of ophthalmologists to be only 1.0 to 3.1 per 1 million population in SSA.7 In addition to inadequate human resources and a lack of effective leadership, there is a paucity of strong institutional infrastructure and strategic management as well as a knowledge gap arising from limited education and research programs, all of which converge to perpetuate the inequities associated with eye care in SSA.6-8 We believe that it is at this systems level that civil society can have a profound impact on glaucoma care in SSA.

THE ROLE OF CIVIL SOCIETY IN GLAUCOMA CARE

The World Health Organization defines civil society as “an aggregate of non-governmental and not-for-profit institutions, powered by private voluntary energies and committed to the public good.”9 In effect, they represent the third sector of society, distinct from and yet simultaneously interdependent on both government and the private sector for social and economic change. Civil societies have increasingly become important drivers of the delivery of social services and the advancement of health-related quality of life; their actions complement those of governments, especially where governmental presence is weak or insufficient.10

Given this mandate, civil societies can form effective partnerships with local, regional, and international partners, within both the public and private spheres, to foster change in glaucoma care in SSA. Opportunities for collaboration are many: sharing of best practices, twinning of institutions, political and other forms of advocacy, quality improvement in the delivery of health care, training and continuing education of health care personnel (including in the areas of leadership and managerial skills), and support of monitoring and evaluation frameworks as well as of research.11

Also important is building capacity for detecting and managing glaucoma at the primary, secondary, and tertiary levels. This step involves identifying needs and opportunities, developing mutual goals, drawing on mutual strengths, and fostering partnerships designed to ensure quality and equitable access for those otherwise deprived of eye care. An organization experienced in this process is the Lions Aravind Institute of Community Ophthalmology. It provides consultative services to enable the building of institutional capacity and strengthening of health systems throughout the developing world (see Lions Aravind Institute of Community Ophthalmology).

Additionally, educational partnerships between academic institutions in SSA and those in developed countries can facilitate the training of eye care professionals. These collaborations can allow bidirectional capacity development and the sharing of best practices. Examples include the Vision 2020 Links Programme, the Aravind Eye Care System's international training course in glaucoma diagnosis and management, and the interinstitutional collabora tive “sandwich” model of education.12,14 The last promotes subspecialty training that meets international standards and the simultaneous development of institutional capacity to foster an environment that will retain the individual. Emphasis is placed on affecting the quality of care and education locally as well as on continued research and knowledge translation. The success of this program is exemplified by one of its recent graduates, Sheila Marco, MD (see The “Sandwich” Model of Education).

CONCLUSION

Given the shifts in demographics, the daunting burden of glaucoma in SSA is likely to grow in the decades ahead. Civil society can be instrumental in meeting the challenge through local and international partnerships to develop institutional capacity, nurture local leaders, and advance the delivery of quality eye care to SSA. As His Highness the Aga Khan noted, “such partnerships will require a profound spirit of reciprocal obligation and mutual accountability—a readiness to share the work, share the costs, share the risks and share the credit.10 We hope that civil society partners vigorously engage in the development and strengthening of sustainable institutional capacity in order to realize the more equitable delivery of glaucoma care throughout SSA.

The authors wish to thank the following colleagues for their valuable feedback on this article: Dr. Fisseha Ayele, Dr. Clare Gilbert, Dr. Faazil Kassam, Dr. Sheila Marco, Dr. R. D. Ravindran, Mr. R. D. Thulasiraj, and Dr. Rengaraj Venkatesh.

Section Editor Alan L. Robin, MD, is an associate professor of ophthalmology at the Wilmer Eye Institute and an associate professor of international health at the Bloomberg School of Public Health, both at Johns Hopkins University in Baltimore. Dr. Robin may be reached at (410) 377-2422; arobin@glaucomaexpert.com.

Karim F. Damji, MD, FRCSC, MBA, is a professor and the director of residency training at the University of Alberta in Edmonton, Alberta, Canada. Dr. Damji may be reached at (780) 735-4200; kdamji@ualberta.ca.

Milad Moddaber, MSc, is a senior medical student at McMaster University in Hamilton, Ontario, Canada.

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