IEC Component - control of blindness in India

I look forward to seeing my grandchild

Danida aims at information in project for the control of blindness in India

By Poul Struve Nielsen

I look forward to seeing my grandchild properly for the first time. I can see her dimly if she is held up close to me, otherwise it is very difficult. Is it certain that I will get to see her properly?

65 year-old Lakshmamma is a little doubtful as she sits cross-legged on the hospital bed dressed in her finest sari. She is from the village of Tanagatta in the Kolar district situated in the South Eastern corner of the Indian constituent state Karnataka.

-You will get to see your grandchild very clearly, Dr. Kanappa says reassuringly. He is an eye surgeon at the Sri Narasimharaja Hospital to which Lakshmamma has been admitted. She is to be operated for cataract later that day. Cataract is an eye disease that some people get with the advance of old age and which leads to loss of sight.

Vision can be saved and re-established with a relatively simple operation and with subsequent use of glasses.

Over the last year Laksmamma's vision has steadily deteriorated. At present she only has a dim vision on one eye which is why she has not really seen her youngest grandchild, a little girl of one month.

On this Thursday, November 18, 1999, 25 patients are waiting to be operated by the eye surgeons. There are only 20 beds at the eye department of the hospital, however there is no difficulty in finding extra beds for the rest of the patients. 15 persons are to be operated for cataract. The patients arrived Wednesday and on Friday they will return to their homes. Most of them are elderly people from the villages of the district.

-Sometimes villagers find it a bit difficult to understand our instructions. Therefore it is important that we keep them here. It gives us time to tell them to remember to wash their hands, take the medicine, etc., Dr. Kanappa says.

For several years the constituent state of Karnataka has constituted the framework of a Danida supported pilot project for the control of blindness in India. Patients with cataract make up the most important target group of the project. However, among other things, the project also works to ensure that schoolchildren with reduced faculty of vision receive glasses at an earlier stage.

In rich countries cataract does not pose a problem. However, in developing countries the disease can have serious consequences. In the World Development Report (the World Bank, 1993) blindness is categorised as one of the most serious health problems of the developing countries.

In India no technical obstacles prevent the performing of operations on cataract patients. There are enough doctors and hospitals. Nevertheless many elderly people just sit around in the villages accepting that their faculty of vision steadily deteriorates. These people are, in any case, not able to read books or newspapers because they are illiterate.

Since they are poor and cannot afford to drive a car or a motorcycle, they are of no danger for anybody else than themselves if they venture into traffic.

Nevertheless, loosing faculty of vision due to cataract is still a serious matter to the elderly and their families because the blind also lose their working capacity, and this means that otherwise financially active people have to stop working. This is a serious problem even for large families. The people belonging to India's group of poor do not have very much to begin with. Half the population of India earns less than one US dollar a day, which means that they live below the poverty line.

Information about cataracts

Many elderly people do not get proper information about the possibilities of treatment. This is the reason why improved communication about cataract and the possibilities of treatment and offers is an essential part of the third and final phase of Danida's programme for the control of blindness.

-We know that many people that have lost their sight due to cataract do not come forward and join the programme. As a result we have sent out anthropologists who interview people on the basis of age, sex, geography and income. It is of course important that we bring the right messages to the right receivers. The goal is to develop effective tools for the collection of qualitative facts, says Claes Broms who is chief adviser of Danida's share in the national programme for control of blindness.

-How do we provide the needed service? How do we reach out our hands to people? Qualitative facts have not been collected and used before. As providers of a service we have some ideas as to what is needed. However, now we would also like to hear what the people in the villages want, he continues.

-Communication has not been structured before. Some people visit the villages with microphones, loudspeakers and drums. Naturally some information has been spread this way, but a lot of people have not received sufficient information. Furthermore the providers of the service within the health service have not known where to find the patients, says anthropologist and sociologist Arbind Sinha, who is co-ordinator of information on the project.

As a matter of fact Lakshmamma is among the fortunate patients. Her vision has only deteriorated steadily over approximately one year. At this time the uncomplicated operation has been performed and, if everything has gone well, she has received glasses. For the first time she can take a good look at her new grandchild, at the rest of her family and at her everyday life for that matter.

Poojari Venkata from the village of Uppakunte, also located in the Kolar district, has been less fortunate. The 70 year-old man's vision started to deteriorate steadily ten years ago. For several years now he has only been able to see the persons and objects held up close to his eyes dimly.

However when drinking tea with his friends at the village “Hotel”, in India this is often just the name of an eatery or a café, he has heard about cataract and about the fact that treatment of the disease is accessible.

He has several explanations as to why he has not had the simple operation performed long ago: -I have had nobody to take me to the hospital. Transportation is too expensive. My family has not done enough for me. We have not been able to afford the operation, he says, among other things.

It is difficult to state what the real reason is. The only certain thing is that the health service has failed. Poojari Venkata has only recently learned of the following things; the operation is safe and quickly done, he will get his vision back immediately if he also, subsequent to the operation, wears glasses with the right power. All of it, including operation and transportation, is free of charge.

Mr Venkata only realised all this three months ago when a health worker knocked on his door, and told him that he could get transportation to the hospital, an operation and glasses completely free of charge.

In the district an investigation has been conducted by health workers who simply knocked on every door in order to survey the number of cataract patients and their addresses. Subsequently a closer selection will be made of who is ready for an operation, and, finally, these patients will be taken to the hospital and operated.

New Indian strategy

This is historic progress for the control of cataract. Never before has it been known where the patients were. The investigation coincides with a new strategy by the Indian government.

Up until recently the cataract operations were performed by doctors and the necessary health staff, who travelled around to different villages and installed temporary operating rooms, resembling field hospitals. At these operating rooms patients from the closest villages signed up, and the operations were performed on as many of them as time allowed.

Today operating rooms have been established in certain locations with good facilities. The patients are then transported to these places and operated there; among these locations is the hospital in Sri Narasimharaja,. With the list of patients in his hand the health worker plans transportation in such a way that all patients from the same village are transported to the operating rooms at the same time.

-However I fear one thing in connection with this project. We have the infrastructure in place, the doctors, hospitals and health workers are ready, but where are the patients?, Arbind Sinha says.

In Karnataka, home of 50 million people, 172.000 eye operations were performed last year by a 1000 surgeons. The Indian government aims at having each surgeon perform a future average of 700 operations a year. On a national level the doctors now each operate an average of 200 patients a year. This means that, even though the infrastructure is well-developed, far too few patients are getting an operation.

There are approximately ten million blind people in India and each year another two to three million are added to his number. Most of them lose their sight because of cataract. Three million eye operations are performed in India, but this does not necessarily bring the number down. Some of the operations are performed on patients who are not included in the statistics because they are only blind on one eye. All in all the doctors do not succeed in handling all the new cases, and they continue with being behind with the ten million people who are already blind.

The majority of Karnataka's eye surgeons are situated in the constituent state capital, Bangalore. One of India's most modern cities due to, among other things, the flourishing of a number of software companies. In this city there is a lot of money to be earned by doctors. If a computer employee's parents get cataract, it would be easy for them to have the operation performed. The operation can be done for an amount of money that is relatively modest in the eyes of the newly rich middleclass that marks the Bangalore city life. The chances for a doctor's wife to get a job and proper education for their children are also higher in Bangalore. In contrast it is not very attractive to work in the rural districts, and, as in almost every other condition of life, women and the poor suffer from this.

They are the ones that lose their sight if they get cataracts. In compliance with Danida's year 2000-strategy the project focuses especially on women and on patients from the poorest areas.

Cataracts is a problem for poor people. This is the reason why they are the ones it is most important to communicate with.

If their situations are to be improved, it is important that they get proper information about their own situation and about their rights. An essential part of the reason why doctors are in arrears with the operations compared to the objectives of the government is, exactly, that the poorest people of the population do not know their rights or do not have the necessary self-confidence to make demands to society. In some cases doctors take advantage of the situation and pass on information to patients that is outright wrong.

-In reality nothing is free of charge at the public hospitals, even though, it should be. This is why doctors try to avoid passing on this kind of information, Arbind Sinha says. He has divided the target group into four categories:

• People with no information
• People with some, but incomplete information
• People with wrong information
• People with several pieces of contradictory information
  

-In villages close to cities the number of people with contradictory information is especially high because it is against the interests of doctors to inform about the free operations, Mr Sinha explains.

The personal contact

The communication work in itself is about understanding the situation at the grass-roots level – i.e. in the villages. Subsequently an information strategy should be developed. This strategy should be discussed with the health authorities, who are carrying out the programme. It is particularly important to convince them that even cleverly planned and effective campaigns in the mass media only has a limited result.

-The mass media, radio, TV and newspapers, reach the population in the cities. Naturally this is also important because we should also influence the decision-makers and the people carrying out the practical work with the patients, Arbind Sinha says.

Roughly divided, work is done on three levels. On the national level the Indian government, in this case the Ministry of Health in the capital New Delhi, does the superior planning. However the health service in itself is the responsibility of the constituent state. In the local communities the individual health worker meets with patients and their friends and family. This is where mass media do not have a major impact.

To Arbind Sinha the solution is what he calls “Human Channel of Communication”. The term covers the concept that people should be convinced through conversations containing good arguments. That is not even enough. Communication plays an important role in the development of India's rural districts, but communication in itself does not lead to change. If development is to progress, direct human interference in local communities is necessary.

The local health workers play an important role. Most often, however, they are already suffering under a too heavy workload. Furthermore they are an extension to the same system as, for example, the doctors who might have an interest in failing to disclose that the operations are free of charge. As a result Arbind Sinha searches for voluntary idealists, who can help solve the extensive information task.

-Person-to-person communication is needed. You have to have people working in the villages passing on information. There is a need of 1.4 million advisers to India's 70.000 villages. We need volunteers who are willing to do a piece of work of public utility without getting paid for it.

Mass media are easiest to work with. An advertisement costs 85.000 rupees for ten seconds, so 40 seconds run into 0.35 million rupees. It would be no problem to shoot off ten million rupees in one week and write a fine report about it afterwards. However the mass media have no impact in the villages. Only 12 per cent of the population have TV, and they, generally speaking, exclusively watch entertainment programmes. This goes for radio listeners as well, Mr Sinha says.

In advance it had been planned to spend 20 per cent of the disposable funds on the TV medium, 20 per cent on the radio medium, 10 per cent on the printed media, 40 per cent on communication efforts in the villages and 10 per cent on co-ordination. However these percentages have been shifted. Now 50 per cent of the resources will be spend on the TV medium and only 20 per cent will go to communication efforts in the villages. These numbers demonstrate how difficult it is to get the communications strategy on the right track.

IEC committees

An important strategic tool is certain committees who are to work with Information, Education and Communication (IEC). These IEC committees are formed of representatives from the government and from the media, of communication experts and with representatives from the districts. Nevertheless, even after a long time of treading water, the committees have still not been formed. In addition to this communication is a tool that can only function if a lot of other aspects are in place.

-We have to hold back the information until the health service can deliver the promised goods. If we start talking about treatment, transportation, medication and glasses free of charge all this has to actually be provided at the hospitals. Otherwise we will lose contact with the people we want to reach when they find out we are not speaking the truth, Arbind Sinha concludes.

-It is assumed that the part providing the service is in place and now we just need to get the information out. However the service providers have not come that far. Obviously people still do not get proper treatment in the Indian health service, but things are progressing. Through the government's new strategy, we have, for the first time, drawn people to the operating theatres. Now I would like to see how many of the patients will get a regular follow-up including the right glasses and test of the vision etc. Furthermore I will make sure that also poor people and women get orderly treatment, Claes Broms says.

In India social differences cannot be counterbalanced without taking sexual differences and caste distinctions into consideration.

-For the first time we also look into what kind of treatment low-ranking castes, tribesmen and women get. I can see that the number of people identified as cataract patients corresponds, to a high degree, to the percentage share of low-ranking castes, women and tribesmen. This is the time to get a realistic picture of how many that get the operation and the necessary following treatment in reality, Danida chief adviser Claes Broms concludes.

Poul Struve Nielsen is a freelance journalist specialising in developing countries.

India's national blindness programme

Danida has supported India's national blindness programme since 1979. “Danish Assistance to the National Programme for Control of Blindness” (DANPCB) has entered the third and final phase of the project.

The final phase began in November 1997 and runs to November 2001.Danish support to a total of approximately 320 million Indian rupees (approximately DKK 55 million) has been granted. The Indian government contributes with between 100 million and 150 million rupees.

A particularly important part of the project is called Information, Education and Communication, (IEC).

By the conclusion of the project IEC strategies will have been developed and tested in the field in Karnataka and in selected tribesmen areas in the constituent states Maharashtra, Madhya Pradesh and Orissa. A selection of communications methods will have been used to reach different target groups.

Experiences will have been documented and publicised. Methods for the training of health workers will have been developed and will be practised in Karnataka:

The target groups are as follows:

• Patients and their families living in the project areas, especially, Karnataka and the selected tribesmen areas, Maharashtra, Madhya Pradesh and Orissa.
• Staff at the National Programme for the Control of Blindness and everybody who has been involved in the project on any level (national, state, district or local level).
• The population in general, after long-term improvements, on a national level, of the effectiveness of the National Programme for Control of Blindness.
  

Furthermore the project aims at showing special consideration for women's participation and to be aware of the specific needs women have as patients, citizens, health workers and leaders.

IEC is to benefit society in general through increased knowledge and consciousness of the control of blindness. The interests of cataract operated patients' family members will be considered through the fact that the operated patients will obtain increased independence and maybe become productive members of the families again.

Above document provided as background for The Drum Beat #57

DANIDA, the Danish International Development Agency, supports communication for development. There is currently a policy revision taking place. These articles and activities indicate pathways for future activities relatingto communication for development. Not all activities are supported by DANIDA.

Inge Estvad (journalist, est@image.dk), Finn Rasmussen (Communication Adviser, IBIS Ecuador, frasmussen@andinanet.net) and Thomas Tufte, Ph.D. (Professor, Roskilde University ttufte@ruc.dk) gathered the material that provides comprehensive insight into the policies and programmes selected.