Revised Guidelines on the Implementation of the National Prevention of Blindness Program ( DOH Administrative Order No. 2013-0010 )

March 5, 2013

DOH ADMINISTRATIVE ORDER NO. 2013-0010

 

I. Background

Blindness as a health problem leads to enormous human suffering, due to the loss of functional ability and self-esteem, and contributes to significant reduction of quality of life and a shortened life span. It has considerable economic implications manifesting in loss of productivity and income, and can lead to social dependency.

Worldwide, 285 million people are visually impaired, with 39 million of them blind. Within the Western Pacific Region, the World Health Organization (WHO) estimates that there are more than 8 million people blind, with more than 80% living in only three countries — China, Vietnam and the Philippines. Ninety percent (90%) of visually impaired people worldwide live in low- and middle-income countries, which includes the Philippines.

Globally, of all the main causes of blindness, cataract accounts for more than half (50%). Up to 80% of all blindness in adults is preventable or treatable, while among children, the major causes of avoidable blindness include cataract, refractive errors, glaucoma, and low vision, retinopathy of prematurity, corneal scarring.

The 3rd Philippine National Survey of Blindness conducted in 2002 showed that about 3,500,000 (4.62%) Filipinos are visually impaired in one or both eyes. They are either afflicted with bilateral low vision (1.64%), monocular low vision (1.33%), monocular blindness (1.07%), or bilateral blindness (0.58%). Cagayan Valley had the highest prevalence of visual impairment (blind and low vision), which reached 7.75%, while the lowest was found in CARAGA at 1.67%. The age group between 60 to 74 years old showed the highest prevalence rates, while the age groups 0 to 20 age groups had the lowest. In the Philippines, the top three main causes of bilateral blindness are cataract (62.1%), error of refraction (10.3%), and glaucoma (8.0%). The main causes of low vision are refractive errors (53%), cataract (40.8%) and maculopathy (2.2%). ETHIDa

The poorer sectors of the population, where a greater percentage of the burden of blindness lies, face the challenging barriers in accessing eye health care, wherein many of those who are already blind will likely remain blind and those at risk of becoming blind will likely become blind. Aligning with the objectives of Vision 2020 impact program, the health reform agenda of the DOH is directed towards improving access of the poor to quality health care, including eye health care, guided by the strategic priorities of the Universal Health Care framework of the Aquino Health Agenda (AO 2010-0036).

To prevent blindness, all stakeholders, through the leadership of the Department of Health, need to strengthen the Prevention of Blindness Program. The program aims to reduce the current prevalence of bilateral blindness due to all causes to less than 0.5%.

A comprehensive eye and visual health program is envisioned through effective disease control for avoidable blindness, capacity enhancement of government health facilities, provision of capable public health oriented eye care professionals, and strategic partnerships. With the central feature of facilities and infrastructure enhancement of government facilities, at national and local government level, to provide eye care services, referral systems connecting all health facilities from community level up to tertiary level facilities will be established to ensure adequate intervention for all eye diseases and conditions.

This policy provide updates on the guidelines according to international and local situation.

II. Coverage and Scope

This Administrative Order covers all Health and health related professionals, facilities, offices, bureaus and all other organizations and individuals involved in blindness prevention activities.

III. Objectives

General objective:

To reduce the current prevalence of bilateral blindness due to all causes to less than 0.5%.

Specific objective 1:

To reduce the prevalence of cataract blindness by 50% by year 2016.

Strategies: aTEADI

1. Perform at least 216,000 good outcome cataract surgeries by year 2016.

2. Ensure that all health facilities are actively linked to a cataract referral center by year 2016.

3. Advocate for more equitable access to cataract intervention services and enabled facilities.

4. Develop quality assurance system for all ophthalmologic service facilities by year 2016.

5. Ensure that DOH and local government hospitals shall provide specialized services (manpower, equipment, facilities) using appropriate techniques and technology.

6. Maximize the utilization of services in DOH and local government hospitals.

Specific objective 2:

To reduce blindness and visual impairment due to refractive errors by 10% per year by the year 2016.

Strategies:

1. Institutionalize visual acuity screening for all sectors by 2016.

2. Create a database for refractive errors in all optometric centers linked with DOH Blindness Registry System.

3. Ensure that all health facilities are actively linked to an optometric center by year 2016.

4. Advocate for the coverage of optometric services for blinding and disabling visual impairment cause by refractive errors by PhilHealth.

5. Facilitate institutionalization of vision screening programs for public school children at Grade 1 level to reach at least 30% in provinces by year 2016.

Specific objective 3:

To reduce the prevalence of blindness and visual impairment in children by 50% by the year 2016.

Strategies:

1. Identify and register visually impaired and blind children in the community for timely intervention.

2. Establish referral mechanism and identify referral facilities for visually impaired and blind children (0-19 years).

3. Establish a pediatric eye referral center in at least one government tertiary hospital for Luzon, Visayas and Mindanao by the year 2016. aESTAI

IV. Definition of Terms

A. Blind — person whose presenting distance visual acuity in the better eye is worse than 3/60 (20/400), or cannot count fingers at 3 meters.

B. Cataract — results from a change of transparency of the normal crystalline lens in the eye. This condition causes gradual loss of vision and blindness.

C. Childhood Blindness — refers to diseases or conditions that happen in early life, that lead to blindness, which includes congenital cataract, retinopathy of prematurity, amblyopia, xerophthalmia, among others. Childhood blindness can't always be treated in the same way as adult blindness, as a child's eye is smaller and less developed. Specialist training, equipment, and facilities, including additional support funds, are often required.

D. Error of Refraction — is a condition where the refractive power of the eye (which is a combined function mostly of the cornea and lens) reduces the distance visual acuity of to less than 20/30 or of the near vision to less than 20/70 in one or both eyes (including those with eyeglasses) with no other eye disease present and without confirmation by refraction.

E. Low Vision — A person with low vision refers to one who has impairment of visual functioning even after treatment and/or standard refractive correction, and has a visual acuity of less than 6/18 to light perception, or a visual field of less than 10 degrees from the point of fixation, but who uses, or is potentially able to use vision for planning and/or execution of a task if provided with a low vision aid.

F. Primary Eye Care — comprises of simple but comprehensive set of preventive, promotive and educational activities to address minor eye diseases that can be carried out by appropriately trained primary health care workers.

G. Visual acuity — measurement of the person's sharpness of vision. A person's visual acuity is his ability to see objects clearly, and this ability is tested by the use of a visual acuity chart or other ways like ability to count fingers or to perceive light.

H. Vitamin A Deficiency — is a condition in which the body's stores of Vitamin A are depleted to the extent that physiological functions are impaired. Depletion of stored Vitamin A occurs over time when the diet contains too little to replace the amount used by body tissues.

I. Visual Impairment — refers to blindness or low vision.

V. General Policies

The program shall be guided by the following policies:

A. The DOH as the lead agency for the promotion and protection of people's health shall ensure the provision of the highest quality of appropriate eye care through the development of national standards for ethical practice, facility development and service provision. cHSIAC

B. The DOH shall establish strong collaboration and partnership with other stakeholders in all levels of government, all sectors, and civil society, including the academe, the medical or paramedical specialty societies, non-government organizations, people's organizations, business, local government units, and others who can contribute to quality eye care.

C. The DOH and its partners and other stakeholders shall empower and actively involve persons who are at risk of acquiring eye diseases, and those with visual illnesses already and/or the immediate family of these persons in every phase before, during and after the disease process.

D. Eye care providers shall be adequately trained to become competent health providers at every level of government from the devolved local government units to specialty hospitals of both government and private sectors by DOH and its partner agencies.

E. Vision 2020 shall be adopted as the framework for evolving strategies and activities in the implementation of this memorandum, supported by the recommendations in the five objectives of WHO Action Plan for the Prevention of Avoidable Blindness and Visual Impairment 2009-2013 and the Universal Access to Eye Health: A Global Action Plan, 2014-2019, as applicable.

VI. Program Vision, Mission, and Goals

A. Vision:

All Filipinos enjoy the right to sight by year 2020.

B. Mission:

The Department of Health, Local Health Units, partners and stakeholders commit to:

1. Provide access to quality eye care services for all.

2. Strengthen partnerships among and with stakeholders to eliminate avoidable blindness in the Philippines.

3. Empower communities to take proactive roles in the promotion of eye health and prevention of blindness.

4. Work towards the preservation, restoration and rehabilitation of sight of indigent Filipinos as a strategy in poverty alleviation.

C. Goal:

Reduce the prevalence of avoidable blindness in the Philippines through the provision of quality eye care.

VII. Program Components

A. Advocacy and Health Education

This includes patient information and education, public information and education and inter-sectoral collaboration on eye health promotion and the nature and extent of visual impairments particularly its risk factors and complications and the need/urgency of early diagnosis and management.

B. Capability Building

This component shall focus on ensuring the capability of national and local government health facilities in delivering the appropriate eye health care services especially to the indigent sector of the population. Program shall provide training for coordinators at regional and provincial levels; will ensure the availability of and access to training programs by program implementers. It shall include strengthening treatment/management capabilities of existing personnel and operating capabilities of facilities conducting cataract operations among others, taking into outmost consideration the basic quality assurance and standardization of procedures and techniques appropriate to each facility/locality.

C. Information Management

The program shall develop an information management system for purposes of reporting and recording. As far as practicable, this system shall consider and will build on any existing mechanism. The system shall be national in scope, although the mechanism shall consider the regional and local needs and capabilities. DHEaTS

D. Networking, Partnership Building and Resource Mobilization

An important component of the program is networking and partnership building to ensure that services are available at the local level. This shall include public-private and public-public partnerships aimed at building coalitions and networks for the delivery of appropriate eye health care services at affordable cost especially to the indigent sector. This component shall also focus on ensuring that the highest appropriate quality services are made available and accessible to the people.

E. Supervision, Monitoring and Evaluation

The program shall be coordinated by a national program coordinator from the Degenerative Disease Office of the National Center for Disease Prevention and Control, Department of Health. The national program coordinator shall oversee the implementation of program plans and activities with the assistance of the regional coordinators from the Centers for Health Development.

A system of monitoring program plans and activities shall be developed and implemented taking into consideration the provisions of the local government code as well as the organic act of Muslim Mindanao, and any similar issuance/laws that will be passed in the future.

A program review shall be conducted as needed. Results of program evaluation shall be used in formulating policies, program objectives and action plans.

F. Research and Development

The program shall encourage the conduct of researches for purposes of developing local competence in eye health care and for other purposes that may be necessary. The development and dissemination of clinical practice guidelines for eye health shall form part of the research agenda of the program.

The program shall support researches/studies in the clinical behavior (KAP) and epidemiological (trends) areas. It also aims to acquire information that is utilized for continuing public health information and education, policy formulation, planning and implementation. DTAaCE

G. Service Delivery

Service delivery for the Prevention of Blindness Program shall be covered by the principle of best practices. In collaboration with the local government units and stakeholders, the program shall develop systems and procedures for the integration and provision of services at the community level. This means primary prevention concentrating on health education, advocacy and primary eye interventions; Secondary prevention; screening/early detection/basic management/counseling, referral and/or definitive care and tertiary prevention: management of complications, continuing care and follow up including rehabilitation. The following areas will be the priority areas for services to be provided by the National Prevention of Blindness Program:

1. Cataract Surgeries

2. Errors of Refraction

3. Childhood Blindness

4. Other eye diseases emerging as a public health concern (e.g., diabetic retinopathy, age-related macular degeneration)

In addition, minor eye diseases will be addressed in the context of strengthened primary eye care in Barangay Health Stations and Rural Health Units, while other major eye conditions and other cases requiring specialized care will be addressed within functional referral systems which will be established as part of the comprehensive eye care program and integration with existing health programs (e.g., for the elderly, diabetes control, etc.), utilizing government health facilities, with links as required with private health facilities and hospitals.

Activities for the Vitamin A Deficiency Disorder, for practical purposes, shall be led by the Family Health Office also of the NCDPC.

A Referral System shall form part of services delivered by the program. This is to ensure that all patients receive quality eye health care at appropriate levels of health care delivery system. All rural health units should be linked to an eye care referral center. DIETcH

VIII. Roles and Responsibilities

1. Department of Health — Central Office shall develop systems, policies and guidelines that will facilitate the implementation of the Prevention of Blindness Program at the local level.

As such, the following offices shall have the following responsibilities:

a. The National Center for Disease Prevention and Control (NCDPC) shall:

1) Develop the system for the implementation of the National Prevention of Blindness Program;

2) Provide technical assistance and conduct monitoring and evaluation of program operation, through a focal coordinating unit;

3) Lead in the formulation of the health intervention and rehabilitation programs and strategies that will reduce the burden and consequences of eye diseases and disabilities and promote visual health; and

4) Ensure the participation of other DOH offices in program activities where needed.

5) Ensure optimal use of allocated resources and support establishment of strategic public-private partnerships for program implementation.

b. The National Center for Health Promotion shall assist the NCDPC in the formulation of standards and development of information, education and communication (IEC) and advocacy strategies for the prevention of blindness program to ensure the promotion of a health and less stressful lifestyle for the Filipinos, as well as to help in ensuring that the public has knowledge of services being offered as part of the program. DCAHcT

c. The National Epidemiology Center and the Information Management Service shall assist NCDPC in the development of a national reporting and surveillance system as well as the development of methodologies for the generation, collection and distribution of information and knowledge on the possible establishment of the national registry for blind persons.

d. The Health Policy Development and Planning Bureau shall:

1) Assist in the proper and effective implementation, monitoring and evaluation of the National Prevention of Blindness Policy;

2) Ensure its formulation into a national program plan of action;

3) Assist in developing a health financing scheme/protocol for eye health care services together with the Philippine Health Insurance Corporation; and

4) Ensure inclusion of prevention of blindness in the priorities for the health research agenda.

e. The Health Human Resource Development Bureau shall assist in the:

1) Development of standards in the curriculum and the training of all types of health professionals, practitioners, and care providers who are responsive, sensitive, which should be consistent with the national and local human development goals and culture;

2) Adequate and equitable distribution of health manpower through provision and protection of plantilla positions in the health care delivery system at the national and regional levels; and aIEDAC

3) Provision of a good incentive and benefit program to attract health caregivers in the unserved and underserved areas.

f. The Bureau of International Health Cooperation shall ensure that the program has strong network linkages with international health institutions, agencies, units that will continually ensure the inclusion, participation, cooperation and collaboration of the Philippines in the global scene for the prevention of blindness.

g. The Bureau of Local Health Development shall assist in the integration of quality eye care into local health system development.

h. The National Center for Health Facilities Development shall ensure that the capacity of government hospitals (DOH and local government hospitals) shall be upgraded and enhanced to provide adequate quality eye care services, to be undertaken through capacity needs assessment, capacity enhancement investment, and capacity utilization monitoring. For local government hospitals, guidance documents issued for local government hospitals to undertake a parallel process at local level.

i. The Centers for Health Development shall facilitate the implementation of procedure/guidelines in the LGU pilot areas for the Prevention of Blindness Program from ground working and situational analysis to finalizing the commitment of the key player (DOH, LGU, PHIC, private sector, NGOs, etc.) provide technical assistance to LGUs in selecting program strategies and assist the LGUs in coordinating the actual implementation of the chosen program strategies and activities.

j. DOH hospitals and medical centers shall ensure the availability of quality eye care services to its clients through the establishment of appropriate capabilities and competencies in their respective units. HaTAEc

2. Local Government Units — should organize themselves into inter-local Health zones that will manage the implementation of Prevention of Blindness Program strategies and activities. LGUs shall pass the necessary local legislation (ordinances, resolutions) to implement program strategies. Provide counterpart funds for implementing their investment plan.

3. The National Committee for Sight Preservation (NCSP), a coalition of GOs, NGOs and professional associations, committed to the preservation of sight through partnership building, sharing of technical expertise, and contributing to program development, as well as to serving as an advisory group to the Department of Health's National Prevention of Blindness Program, will be the lead technical partner agency of the DOH in helping to ensure that the PBP is implemented nationwide, in strong collaboration with local government units, non-government organizations, and other concerned organizations and government agencies.

4. National professional organizations for eye health care (recognized by the Philippine Professional Regulation Commission, Philippine Medical Association and Securities Exchange Commission) which includes the Philippine Academy of Ophthalmology and the different Optometric organizations, shall collaborate with and support the Department of Health in helping to ensure that competent, efficient, gender-sensitive and public health-/community work-oriented eye health care professionals are available to support activities and initiatives of the Department of Health, CHDs, and local government units in the implementation of the National Prevention of Blindness Program.

5. Civil Societies — shall 1) assist the Local Government Units in achieving their health objectives 2) shall identify the health needs of the people and bring to the attention of the inter-local health zones 3) enhance accountability and transparency of inter-local health zone management.

6. Donor and Technical Partner Agencies — shall provide funding and/or technical assistance according to the investment plan developed for the Prevention of Blindness Program, as well as in accordance with partnerships entered into with local government units and other stakeholders. The objectives, initiatives and planned activities of prospective donor and technical partner agencies in prevention of blindness must be in accordance with the strategic directions and objectives of the National Prevention of Blindness Program, with proper coordination mechanisms to be established and implemented.

IX. Implementing Mechanisms

A. Program Administration

The Prevention of Blindness Program shall be one of the programs of the Degenerative Disease Office, National Center for Disease Prevention and Control. cAHIST

Program administration shall focus on the following guiding principles 1) leadership of the Department of Health, Center for Health Development and stakeholders 2) inter-sectoral coordination and collaboration 3) flexibility and adaptability to situations 4) strengthening linkages and networking 5) cost sharing initiatives.

B. Coordination with Other NCDPC Program and DOH Offices

To ensure a comprehensive approach to blindness prevention, coordination with the other programs and other DOH Offices such as the National Center for Health Facility Development and the Bureau of Health Facilities and Services shall be instituted.

C. The Program Management Committee (PMC)

For the years 2012-2016, a Program Management Committee (PMC) shall be organized to ensure the implementation of the National Sight Plan. The Program Management Committee shall be chaired by the Director of the National Center for Disease Prevention and Control. The composition, other roles and responsibilities of this PMC shall be spelled out in a Department Order that will be issued for this purpose. The Assistant Secretary for Health responsible for the technical cluster which includes the NCDPC and the National PBP shall have overall supervision of the program.

The Program Management Committee (PMC) shall be the main coordinating body for the program. Its members shall include:

1. The Division Chief of the Degenerative Disease Office in charge of this program (DOH-NCDPC)

2. The national focal person for this program (DOH-NCDPC)

3. One representative from the Philippine Academy of Ophthalmology

4. Representative from the Optometry group

5. One representative from National Committee for Sight Preservation cTECHI

6. One representative from Department of Education

7. One representative from Department of Social Welfare and Development

8. One representative from Department of the Interior and Local Government

9. One representative from Philippine Health Insurance Corporation

Members who represent their organizations in this committee shall be those nominated by their respective organizations, which may be renewed or replaced annually.

The Program Management Committee (PMC) shall have the following responsibilities:

1. Recommends to the Secretary of Health activities and plans

2. Monitoring of implementation of program activities

3. Others as may be identified and approved by the Secretary of Health

X. Funding

The Department of Health and the Centers for Health Development shall provide funds for technical assistance, monitoring and advocacy campaigns (IEC materials). The Department of Health encourages, and shall also actively pursue opportunities for, public-private partnerships to secure support in terms of financial considerations, donation of equipment and facilities, provision of capability building programs, provision of logistics, etc., in support of the implementation of the National Prevention of Blindness Program. Furthermore, the local government units, non-government organizations and other stakeholders shall be encouraged to contribute counterpart support funds to help ensure the implementation of the National Prevention of Blindness Program.

XI. Repealing Clause

This Administrative Order repeals AO No. 179 s. 2004 and other previous issuances that are inconsistent with the provisions of this order.

XII. Effectivity

This Order shall take effect immediately.

(SGD.) ENRIQUE T. ONA, MDSecretary of Health

Published in The Philippine Star on March 24, 2013.