Loopholes in the Indian Health System — Preventing Childhood Blindness

GS-II | Health | Government Policies and Interventions | Issues Related to Children

Why in News?

• World Sight Day (14 October 2021): As we observe World Sight Day, the question we need to ask today is not just how do we find more children. It is also how many children already exist in our health system that we are not seeing.

The Occurrence of Visual Impairment in Children

• World Scenario: WHO estimates about 19 million children are visually impaired and among them 1.4 million are blind.
• India: Bengaluru blames lack of professional eye care for 3 lakh children said to be blind here.
• Preventable and Treatable Cases: Half of them can either be prevented or treated successfully with timely treatment.
• Issue of Great Concern: Access to care continues to be a major barrier in India, but threats to vision of a child are not only about access to healthcare; they can also arise from missed opportunity for visual problems recognition within their already accessed healthcare systems.

What Happens in the System?

• Example of Anu: A couple came in with their 5-year-old daughter Anu to a clinic. She was noted to have dense bilateral cataracts with nystagmus (involuntary eye movement).
• Late Diagnosis: The presence of nystagmus meant that the visual defect would have been present since infancy. At the time, her parents believed they should wait until she was older to ‘behave herself’ for an eye test.
• Critical Period in Visual Development: One of the areas we target is early vision, since a newborn infant is born with a relatively immature visual system, and development depends on ongoing interaction between an eye that inputs the signals from our world to an articulating brain (Signal Processing).
• Amblyopia: If no clear images reach the brain during this time window, amblyopia or lazy eye can develop.
• Irreversible Loss: Once this phase of visual development is over, treatment cannot regain the lost potential vision. Anu had, however, lost the full option of restoring her vision (if she had surgery right now).

What Doesn’t Get Seen?

• Missed Opportunity: Anu’s failure to access care was a missed opportunity: she had been seen by health personnel seven times from birth to five and her vaccinations were up-to-date. However, despite all these visits, her severe visual impairment went completely undetected.
• Poor Integration of Vision Screening: Poor integration of vision screening with the vaccination schedule and general paediatric screening.
• Existing Healthcare Network: India has the most diverse frontline health workforce and other child health programmes.
• Rashtriya Bal Swasthya Karyakram (RBSK): Targets the identification and management of health conditions occurring in children from birth to 18 years.
• Screening Capacity: A vast number of school-aged children with vision problems can be screened using existing resources; the efficiency of screening programmes has been established. The tools we put in the hands of mobile health teams to detect developmental delays are some of our most powerful tools at the community level.

Gaps in Screening and Treatment

• Karnataka: As per the Annual Report 2023–24 from the Health & Family Welfare Department, the State screened 62,45,424 children (6–16 years) as part of School Health Programmes in government and government-aided schools.
• Low Spectacle Distribution: Only 1.2 lakh children received spectacles, and the distribution rate was low, i.e., 1.9%.
• Prevalence of Refractive Errors: In stark contrast to localised epidemiological studies in southern districts of Karnataka, which report actual prevalence of paediatric refractive errors as high as 8%.
• Operational Challenges: That pronounced gap may reflect operational challenges such as drop-outs in the multi-tier referral system or supply chain delays.
• Treatment Gap under RBSK: A study that evaluated the coverage gaps in child health screening conducted under RBSK found that only 47.4% of children were referred for follow-up care once a problem was detected, thereby suggesting a high treatment gap.
• Follow-Up Issues: Independent field evaluations in Tumkur show that the system is having issues with dealing with younger children and follow-up.
• Challenges for Implementation on the Ground: Lack of parental co-operation for follow-up, logistical challenges making it hard to train enough screening teams.

Gaps in the Training of Frontline Workers

• During the experience of the clinician, ASHA workers from Tumkur district can say they have no training to pick up eye diseases in children.
• If parents or caregivers reported problems with vision only, the ASHA workers referred them to a paediatrician who visited the taluk hospital once weekly.
• This highlights a huge training aspect that needs to be covered by frontline workers.

Way Forward

• Higher Efficiency of Existing Systems: You do not need a complete new system. We need to leverage the system that already exists better.
• Common Red Reflex Examination: A simple red reflex exam using a direct ophthalmoscope is one of them.
• Discovering Major Eye Problems: The test is a rapid, under-30-second, non-verbal, child-friendly screening able to detect serious sight- and life-threatening problems such as cataract, retinoblastoma (eye cancer) and high refractive errors.
• Training of Healthcare Personnel: RBSK mobile health teams, primary health centre nurses and paediatric residents should be trained to carry out this test.
• Must-Do: This simple check must be integrated with the immunisation schedule so it is never missed, similar to a child’s weight measurement.
• To Train ASHA Workers: We should train ASHA workers in simple methods to assess visual behaviour in infants and other non-readers, who cannot read a chart or respond appropriately to traditional tests of visual acuity.
• The Basic Observation: Can the baby track light and objects? Is there visual engagement? Does the corneal light reflex look abnormal or indicate a squint? These are not sophisticated examinations. These are observations that can detect children who require an eye examination with proper training and referral pathways.
• Clear Referral Pathways: A child detected with a potential eye condition needs to be referred to the appropriate facility where treatment is available. Referral mechanisms should be clear, functional and monitored.
• Digital Integration: Frontline screening may also connect to digital systems with appointments at district or tertiary eye-care level systems wherever possible.
• Tele-Ophthalmology: By establishing linkages between peripheral health workers and specialists, tele-ophthalmology could help alleviate some of the logistical barriers contributing to loss-to-follow-up among families.

Conclusion

India already has a large infrastructure of frontline health workers, immunisation services, RBSK teams, school health programmes and primary and tertiary healthcare facilities. It remains to be connected.

This means that just having a higher number of children screened should not be the goal. It should be to create a system where every interaction with a child is an opportunity to safeguard vision, every abnormal finding activates an unequivocal referral and each referral leads through to intervention.

It is not just losing vision—it is losing the chance of an education, independence and who knows what all else a child could do!

UPSC Mains Practice Question

Q. A multitude of healthcare services exist in India, but childhood visual impairment often goes unnoticed. Assess your knowledge of the screening and referral process and identify ways to fill in those gaps.

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