Status of Ophthalmic Education and the Eye HealthWorkforce in South Asian Association for Regional

Cooperation CountriesHaroon Awan, MD,* Mohammad Daud Khan, MD,Þ William Felch, BA,þ Bruce Spivey, MD,þ

Hugh Taylor, MD,þ Serge Resnikoff, MD,þ and Tina-Marie Gauthier, BAþ

Purpose: This study aimed to assess the capacity for ophthalmic ed-ucation in the 8 South Asian Association for Regional Cooperation(SAARC) countries and to determine the need and future projections ofeye health professionals in the region.Design: This was a retrospective study and comprised desk review andWeb-based questionnaire.Methods: Developed in the Asia Pacific region, the Capacity Assess-ment Tool for SAARC Eye Care Education, a Web-based survey mecha-nism derived from a 12-point framework, was used to collect data on thenumber of ophthalmologists and other eye care personnel, training in-stitutions, and capacity for training in each SAARC country.Results: There are an estimated 17,568 practicing ophthalmologists and4086 ophthalmic subspecialists in the SAARC region. The population perophthalmologist is approximately 92,270. Allied eye health professionalsconstitute an important element of the eye health workforce and have apopulation per allied eye health professional of approximately 99,852; theophthalmologist to doctor (physician) ratio is 1:61. There are more than510 centers providing ophthalmology training and more than 32 centersproviding subspecialty training; ophthalmic subspecialty training variesfrom a 3-month observership to a 12-month hands-on training.Conclusions: In the SAARC region, the challenge is to sustain and in-crease the eye health workforce to meet the needs of a growing and agingpopulation. The demographic transitions, improved child survival and lifeexpectancy rates, and emerging noncommunicable disease trends requiretraining of ophthalmic subspecialists and supporting eye care teams tomeet the service delivery demands of changing eye health paradigms.

Key Words: ophthalmology, training, education, subspecialty, SAARC

(Asia-Pac J Ophthalmol 2014;3: 74Y82)

The South Asian Association for Regional Cooperation(SAARC) region is composed of 8 countriesVAfghanistan,

Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and

Sri Lanka. The region is home to a total population of 1621 mil-lion, which includes more than 100 million people who are vi-sually impaired.1 India alone has approximately 53,000 peoplevisually impaired per million population.

Although vision loss due to cataract comes under increasingcontrol with development of district eye care services and thetraining of general ophthalmologists and eye care teams, the needfor subspecialists to manage other eye conditions becomes evengreater. For example, childhood survival rates are improving inthe region, but changing lifestyles and poor nutritional awarenesshave led to increasing obesity and a surge in diabetes. High-quality vitreoretinal services will be needed in all SAARCcountries to meet the growing demand of ocular complicationsfrom diabetes. Glaucoma too remains a persistent challenge toprevention and control programs given its need for highly spe-cialized diagnostic facilities and surgical management.

Global prevention of blindness is high on the agenda ofVISION 2020: The Right to Sight. This worldwide initiative toeliminate avoidable blindness by the year 2020 is a joint pro-gram of the World Health Organization (WHO), the Interna-tional Agency for the Prevention of Blindness, and internationalnongovernmental organizations. The goal of global blindnessprevention, however, cannot be achieved without superior eyecare delivery at all levels, which to large extent is dependent onhigh-quality training of ophthalmologists and allied eye healthprofessionals (AEHPs).

Although there is an immediate need for subspecialistservices in the SAARC region along with training of moreAEHPs, the number of subspecialty training programs is mini-mal. The WHO’s World Health Report 2006, Working Togetherfor Health,2 identified the following SAARC regional countriesas ‘‘human resources for health’’ crisis countries: EasternMediterranean, Afghanistan, Pakistan, Southeast Asia, Bangladesh,Bhutan, India, Nepal. There has been a gradual increase in percapita spending on health in the SAARC region, with a corre-sponding increase in life expectancy. Global data, however, indi-cate that Southeast Asia has approximately 28% of the globalburden of disease but with only approximately 12% of the globalhealth workforce.2 The 2007 report, Everybody’s Business,presented theWHO’s framework for strengthening health systemsto improve health outcomes. The report identified an effectivehealth workforce as a critical component of the health care sys-tem.3 The WHO’s Task Force for Scaling Up Education andTraining for Health Workers 2008 report, Scaling Up, SavingLives, built on this point and emphasized the need for qualityassurance systems and quality standards for training, service, andmonitoring.4

Collaborative EffortAt a 2011 meeting in Bangladesh, the council of the SAARC

Academy of Ophthalmology (SAO) discussed the high prevalenceof avoidable blindness and visual impairment in the SAARC

ORIGINAL CLINICAL STUDY

74 www.apjo.org Asia-Pacific Journal of Ophthalmology & Volume 3, Number 2, March/April 2014

From the *Avicenna Consulting Pvt Ltd, Islamabad; †Comprehensive Health andEducation Foundation International, University Town, Peshawar, Pakistan;and ‡International Council of Ophthalmology, San Francisco, CA.

Received for publication August 5, 2013; accepted December 20, 2013.Supported by The Fred Hollows Foundation.The authors declare grant funding for research but no other competing

interest. All authors have completed the Unified Competing Interest format www.icmje.org/coi_disclosure.pdf (available on request from thecorresponding author) and declare the following: only Haroon Awan hadfinancial support from the International Council of Ophthalmology asconsultancy for the submitted work; there were no financial relationshipswith any organizations that might have an interest in the submitted work inthe previous 3 years; and there were no other relationships or activities thatcould seem to have influenced the submitted work.

Reprints: Haroon Awan, MD, Avicenna Consulting Pvt Ltd, 18-BKaghan Rd F-8/4, Islamabad 44000, Pakistan.E-mail: hawan@avicennaconsulting.biz.

Copyright * 2014 by Asia Pacific Academy of OphthalmologyISSN: 2162-0989DOI: 10.1097/APO.0000000000000037

Copyright © 2014 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.

region and its interconnection to the difficulty in obtaining qualityeye care in the area. The council specifically identified the lack ofwell-trained and motivated eye care personnel as critically im-peding access to quality eye care.

Determined to enhance ophthalmic postgraduate educationand improve the quality of ophthalmic care in the SAARC region,the SAO council made 2 important decisions; these are as follows:first, to establish the SAARC Foundation whose mandate is toimprove the standard of eye health education and ophthalmic re-search; and second, to collaborate with equally committed part-ners to develop eye health human resources and improve thequality of ophthalmic care in the SAARC region.

As a primary step, the SAO contacted the InternationalCouncil of Ophthalmology (ICO) in recognition of the ICO’s mis-sion to work with ophthalmologic societies and others to enhanceophthalmic education and improve access to the highest quality eyecare. In its 2011 to 2015 strategic plan, the ICO assigns high priorityto developing teams of eye care professionals led by well-trainedophthalmologists and to strengthening and supporting systems toimprove ophthalmic education. In 2011, a delegation from the SAOmetwith the president of the ICO and his team in Sydney, Australia,where they agreed to partner together to enhance subspecialtytraining in the SAARC region.

The FredHollows Foundation (FHF), a leading nongovernmentalorganization working in eye care in Australia, the Pacific, SouthAsia, Southeast Asia, and Africa, joined the collaboration shortlythereafter. With subspecialty development as one of their priorities,the FHF brought technical and generous financial support to theteam. At a 2011 meeting in Kuala Lumpur, Malaysia, the SAO,ICO, and the FHF decided that the first steps in improving thequality of ophthalmic care in the SAARC region were as follows:& assess institutional capacity for ophthalmic education, espe-cially subspecialty training, in the SAARC countries;

& determine the need and future projections of key AEHP in theregion; and

& develop an assessment tool that could be used in other regionsand countries.

MATERIALS AND METHODSOn recommendation of the SAO, ICO, and FHF, a method-

ology was devised to determine the need and future projections ofkey AEHPs in the SAARC countries and to assess institutionalcapacity for ophthalmic education in the region. Desk research ofcurrently available capacity assessment tools and methods wasundertaken. Based on research results, a 12-point framework wasdeveloped from which a Capacity Assessment Tool for SAARCEye Care Education (CATSEYE) was designed.

The 12-point framework included the following:1. profileVpopulation of the country and number of cate-

gories of eye health professionals;2. publicVinstitute in public sector attached to a general or

eye hospital and sources of funding;3. privateVinstitute in private sector attached to a general or

eye hospital and sources of funding;4. program OVtypes of ophthalmology training programs

offered, duration, and subspecialty rotation;5. program AVtypes of AEHP training programs offered

and duration;6. peopleVnumber of faculty for ophthalmology and sub-

specialty training programs;7. processVselection criteria for enrollment of candidates to

ophthalmology and subspecialty training programs andwhether curriculum is approved by an accrediting body;

8. practiceVtype of training (eg, theoretical, practical,observational);

9. portfolioVtype of subspecialty services offered (eg,vitreoretina, pediatric ophthalmology, cornea);

10. proceduresVsubspecialty procedures available (eg, diag-nostic, surgical, therapeutic);

11. performanceVwhether subspecialty training assessmentincludes experience certificate, competency-based assess-ment, and/or performance appraisal examination; and

12. productVqualification offered and whether qualification isaccredited and registrable with a professional body orcouncil.

The Web-based application of CATSEYE used MySql,which is an open-source relational database management systemthat runs as a server providing multiuser access to a number ofdatabases. The CATSEYE was pretested and debugged and wasconfigured to work with the most commonly used Internetbrowsers and on Windows, Linux, and Apple operating systems.

Focal persons were requested to provide a list of SAARCtraining centers for ophthalmology, including subspecialty train-ing centers. A list of 81 training centers was obtained, whichserved as the basis for the survey.

Before data collection, an e-mail was sent to alert all listedtraining centers. This served 2 purposes; these are as follows: first,to establish a communication link, and second, to test whether thee-mail was functional. Several e-mail addresses were found to beeither nonfunctional or inappropriate; the e-mail addresses wereupdated, and the appropriate contact names were noted.

A second e-mail was then sent to the revised list of contactsproviding a brief background of the survey and requesting con-tacts to open aWeb link to the online questionnaire. A reminder e-mail was sent to those who had not completed the survey within10 days. The data were cleaned for duplicate entries, incompleteforms that were accidentally submitted, or incorrect submissions.

The questionnaire included questions on the followingareas:& participating institutionVtype of institution (government,private, or nongovernment) and its income source;

& type and duration of training program offered inophthalmologyVresidency or other;

& type of AEHP trained and type and duration of training pro-gram offered;

& number of teaching faculty and students;& type of selection process for postgraduate students and can-didates for subspecialty training;

& practice of trainingVtheory, observational, or practical;& type of subspecialty services offered at the institution;& areas in which subspecialty training is offered;& type of performance assessment for subspecialty training; and& accreditation status of the subspecialty training program.

The following categories of eye health professionals wereused for the survey:

& ophthalmologists;& ophthalmic subspecialists; and& the AEHPs, which included optometrists, orthoptists, oph-thalmic assistants, and ophthalmic nurses.

Fourteen subspecialty areas (corresponding to subspecialtyareas used by the ICO) were identified; these are the following:& cataract and lens;& community eye health;& contact lens;& cornea and external diseases;& glaucoma;

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& low-vision rehabilitation;& neuroophthalmology;& ocular oncology;& oculoplastic surgery and orbit;& ophthalmic pathology;& pediatric ophthalmology and strabismus;& refractive surgery;& uveitis and ocular inflammation; and& vitreoretinal diseases.

The following subspecialty levels were used:& Level 1Vgeneral ophthalmologist who has an interest in thatsubspecialty and spends 50% or more time working in it butdoes not have a formal subspecialty qualification in it;

& Level 2Vgeneral ophthalmologist who has been trained in asubspecialty training center for less than 12 months; and

& Level 3Vgeneral ophthalmologist who has been trained in asubspecialty training center for at least 12 months or more.

RESULTSThere was an 84% response rate of contacts completing the

online survey.1 The data receivedwere then analyzed and tabulated.Although variations exist among the regional countries,

SAARC as a region has 1 ophthalmologist for approximately92,000 population (Table 1).5Y24 India and Pakistan have pop-ulation per ophthalmologist of less than 90,000. Table 1 sum-marizes the key findings of the SAARC countries.

The survey indicted similar ratios of AEHPs and ophthal-mologists to total population. Bhutan and Sri Lanka have 9 or moreAEHPs to every ophthalmologist. Sri Lanka and Afghanistan,however, have much fewer ophthalmologists (Table 1).

Optometry training is gradually increasing in the SAARCregion. In India, there are at least 30 schools and colleges of op-tometry affiliated with the Association of Schools and Collegesof Optometry in India (further details can be obtained fromwww.asco-india.org). For India, the numbers of optometrists andorthoptists need to be interpreted as a combined workforce becausemost orthoptist training is part of the optometry training program.

The status of subspecialists in the SAARC region variesfrom country to country. The highest number is seen in India,where approximately 4000 ophthalmologists practice as sub-specialists. Other than India, which has 300,000 populationper subspecialist, all other SAARC countries have more than1.5 million population or more per subspecialist.

The type and duration of subspecialty training vary withinthe SAARC region. This may range from a 3-month observershipto a 12-month hands-on training course. Countries such as India,Nepal, Pakistan, and Sri Lanka have nationally approved cur-ricula for subspecialty training. India has nationally approvedcurricula for 13 of the 14 ICO-defined subspecialties, whereasNepal, Pakistan, and Sri Lanka have only 3 to 4 of the 14 ICO-defined subspecialties.

In Bangladesh, for example, there are well-trained subspe-cialty fellows with 12 months of training who are practicing in theirchosen area of expertise. There is, however, no nationally accredited

TABLE 1. Status of the Eye Health Workforce in SAARC Countries

AFG BGD BTN IND MDV NPL PAK SLK SAARC

Population in million 30 160 0.7 1200 0.3 30 180 20 1621Doctors 7250 57,143 179 840,000 600 1765 157,000 10,000 1,073,937Ophthal* 128 950 6 14,000 8 175 2200 101 17,568Subspecs† 3 30 0 4000 0 20 20 13 4086OP‡ 6 5 4 9000 4 45 300 320 9684OR§ 0 10 0 1000 0 10 20 3 1043OA|| 46 500 49 3000 0 350 450 0 4395ON¶ 65 250 3 100 4 20 70 600 1112Ophthal training centers 7 5 1 458 0 6 30 3 510Subpsec training centers 0 4 0 17 0 2 7 2 32Population per ophthal 234,375 168,421 116,667 85,714 37,500 171,429 81,818 198,020 92,270Ophthal per 75,000 population 0.32 0.45 0.64 0.88 2.00 0.44 0.92 0.38 0.81Ophthal per million population 4.27 5.94 8.57 11.67 26.67 5.83 12.22 5.05 10.84ODR# 57 60 30 60 75 10 71 99 61Population per AEHP** 256,410 209,150 12,500 91,603 37,500 70,588 214,286 21,668 99,852AEHP per 75,000 population 0.29 0.36 6.00 0.82 2.00 1.06 0.35 3.46 0.75AEHP per million population 3.90 4.78 80.00 10.92 26.67 14.17 4.67 46.15 10.01

Summary of key findings regarding the status of the eye health workforce in SAARC countries.

*Ophthalmologists.

†Ophthalmic subspecialists.

‡Optometrists.

§Orthoptists.

||Ophthalmic assistants.

¶Ophthalmic nurses.

#ODR.

**AEHPs.

AFG indicates Afghanistan; BGD, Bangladesh; BTN, Bhutan; IND, India; MDV, Maldives; NPL, Nepal; PAK, Pakistan; SLK, Sri Lanka.

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curriculum for subspecialty training, nor any formal training pro-gram. There is good potential to use the existing faculty forsubspecialty training programs in the various SAARC countries.

A detailed directory of the participating institutions and or-ganizations has been prepared and is available at www.icoph.org/SAARC-Ophthalmic-Education-Directory.pdf.

Other than India, subspecialty information was obtaineddirectly from each country’s subspecialty organizations. Infor-mation for India had to be obtained from multiple sources (eg,SAO secretariat in Delhi, the All India Ophthalmological So-ciety Web site, and the Medical Council of India Web siteand statistical reports). There are at least 458 or more centersoffering postgraduate training in ophthalmology in India. TheNational Board of Examination has 141 registered centersthat provide postgraduate training in ophthalmology (details atwww.natboard.edu.in). The Medical Council of India has107 registered centers that offer training for a diploma in oph-thalmology (details at www.mciindia.org). The Medical Councilof India has 210 registered centers that offer training for masters insurgery in ophthalmology (details at www.mciindia.org). The to-tal number of ophthalmologists obtained from the All IndiaOphthalmological Society may be an underestimate.

Supply and Need ProjectionsHuman resource planning for eye health usually tends to be

based on need. For instance, the need may be estimated by di-viding a given population by the number of ophthalmologists orAEHPs in that particular country.

This does not take into account; however, supply mecha-nisms (ie, how many ophthalmologists does that country pro-duce annually), pull factors such as creation of posts andattraction of further specialization, push factors such as oph-thalmologists retiring annually or those who leave a clinicalcareer for something else or who migrate to other countries nordoes it take into account urban and rural disparities. In the ab-sence of a more practical option or model to estimate the futuresupply and need, the use of an arbitrary indicator has provided auseful, if limited, planning formula.

Viewing the status of ophthalmologists per million popula-tion (Fig. 1)YYBhutan and the Maldives have been omitted fromFigure 1 owing to their small population sizeYYit can be observedthat there are 2 major benchmarks, 11.9 and 5.2. The benchmarkssuggest that India and Pakistan may need to aim in the short tomedium term to have 15 ophthalmologists per million population,whereas the remaining 4 countries need to effectively double oreven triple their current numbers of ophthalmologists.

In comparison with other developed countries, it shows thatthey (developed countries) have a much higher ophthalmologist-to-million population ratio with an average of 38.6 per million(Fig. 1).

The comparison of 1 ophthalmologist per total populationrates illustrates that developed countries have 3 times as manyophthalmologists compared with India and Pakistan and at least7 times more than some of the other SAARC countries (Fig. 2).

Ophthalmologist-to-Doctor PredictorUnlike dentists who start their training as dentists, a med-

ical student graduates as a general physician and then chooses a

specialty (eg, pediatrics, surgery, ophthalmology). The ‘‘marketpreference’’ for one medical specialty over another varies fromcountry to country. Using a case study from Pakistan, weattempted to ascertain the relationship between the number ofophthalmologists and doctors because ophthalmology residentscome from the pool of available doctors in that country.

The number of doctors (physicians) was determined fromthe Economic Survey of Pakistan and the Pakistan Medical andDental Council Web site.22 The projection of the number ofdoctors for 2025 was based on the trend of the compound an-nual growth rate (CAGR) for the series and retaining the samefor year 2035.

The actual and projected number of doctors up to the year2035 is illustrated in Figure 3, which also shows the decliningCAGR. Rate 1 shows a continuous declining CAGR based ondeclining rate, whereas rate 2 shows a steady state that is similarto 2025.

The number of ophthalmologists was determined fromofficial planning documents, including the National Eye HealthPlans (Ministry of Health, Government of Pakistan 1994Y1998,1999Y2003, and 2005Y2010).

The ratio of ophthalmologist to total doctors was com-pared, and it was found that during the 30-year period, the ratioremained constant at 1:70.

The ophthalmologist-to-doctor ratio (ODR) seems to be auseful and practical predictor of supply. Furthermore, althoughit was based on the number of doctors and the number of oph-thalmologists, the effect of those who are retiring or leavingservice would tend to cancel each other.

The need and supply of ophthalmologists in Pakistan areillustrated in Figure 4. ‘‘Required’’ (need) was estimated using1:75,000 ratio. The current ratio is 0.92 per 75,000 population(Table 1). The rationale was to determine the nearest multi-ple of 5000 population figure for 1 ophthalmologist. There-fore, 1 per 75,000 was taken as the nearest whole number toestimate need.

To estimate those who were working, actual figures availableare used up to 2012, and ODR is used for future projections.

The comparison of ODR of different regional and devel-oped countries was done.25Y36 The SAARC region has an av-erage of 61 ODR, whereas the United Kingdom has an ODR ofapproximately 115, indicating that the SAARC region has ap-proximately twice the proportion of ophthalmologists to doctorsthan the United Kingdom (Fig. 5).

Nepal has a very low ODR (or high percentage of doctorswho are ophthalmologists), suggesting a preference for thespecialty of ophthalmology among their doctors. Sri Lanka,Australia, and UK ODRs indicate that these countries probablyhave a shortage of ophthalmologists, or there are not enoughtraining positions in ophthalmology or that the specialty is notamong the top few preferred choices among doctors (Fig. 5).37

The findings indicate that there is a relative consistency inODR rates among various countries. The 3 SAARC countries,Bangladesh, India, and Pakistan, demonstrate fairly steadyODRs during the 20-year period, whereas the 4 developedcountries, Australia, Canada, United Kingdom, United States,indicate a nominal increase in ODRs. Taken individually, forexample, in Australia and the United Kingdom, the decadaltrend of ODR suggests fewer ophthalmologists in training com-pared with the pool of available physicians and overall popu-lation (Fig. 6).

The ODR trend in SAARC and developed countries islikely to have implications for changing disease patterns andaging populations, both of which require greater numbers ofophthalmologists and ophthalmic subspecialists.

The survey questionnaire was sent to 81 organizations and institutions, ofwhich 84% responded. Telephone follow-up was used to increase theresponse rate. The directory referred previously includes the names of theorganizations identified by National Focal Persons and shows where datawere made available and where there is still a need to add data.

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Figure 7 illustrates a schematic model to estimate ‘‘supply’’of ophthalmologists at a time in the future. The model has 5 keysteps; these are as follows:Step 1Vestimate the population in the future using the population

figure from official sources (eg, census departments) andapply a CAGR to make future projections for a time series;

Step 2Vestimate the number of doctors (general physicians) byusing actual figures from official sources (eg, medicalcouncils) and apply a CAGR to make future projectionsfor the time series used in Step 1;

Step 3Vestimate the ‘‘need’’ of ophthalmologists by applyingan appropriate ratio for the respective country (eg, weused 1 per 75,000 population as explained earlier; one canalso use other variations, such as number per millionpopulation; Table 1) for the time series used in Step 1;

Step 4Vusing the estimates from Steps 2 and 3, determine theODR for the past by dividing the number of doctors by thenumber of ophthalmologists for the past time series usedin Step 1. The ODR can then be used for Step 5; and

Step 5Vuse the estimates established in Step 2 for the number ofdoctors in a time series, divide the numbers of doctors by

the ODR to estimate future supply (or likely availability)of ophthalmologists. The difference between need (cal-culated in Step 3) and supply (calculated in Step 5) wouldhelp establish the gap that needs to be addressed.

DISCUSSIONThe list of training centers in the 8 SAARC countries was

provided by focal persons and may not represent a complete listof all training centers. Although there was an 84% responserate, not all of the listed training centers responded, so the per-centages obtained may underrepresent the situation in a partic-ular country. The time and limitation of resources did not permitan onsite validation of data for each center that responded to thequestionnaire. The survey also did not make any distinctionamong ophthalmologists who were practicing, retired, and sur-gically active because this information was considered difficultto obtain. Thus, the total numbers are estimates rather thanabsolute.

This initial study was limited in its ability to collect de-tailed information about India, and the numbers obtained for

FIGURE 1. Ophthalmologists per 1 million population. Status of ophthalmologists per 1 million population (Bhutan and the Maldiveshave been omitted because of their small population size). Two major benchmarks, 11.9 and 5.2, suggest that India and Pakistan mayneed to aim in the short to medium term to have 15 ophthalmologist per million population, whereas the remaining 4 countries need toeffectively double or even triple their current numbers of ophthalmologists. In comparison with other developed countries, it showsthat they (developed countries) have a much higher ophthalmologist-to-million population ratio with an average of 38.6 per million.

FIGURE 2. Total population per ophthalmologist. Population per ophthalmologist (Bhutan and theMaldives have been omitted becauseof their small population size). Data fromdeveloped countries indicate that they have approximately 1 ophthalmologist for approximately26,473 population, whereas India and Pakistan have 1 ophthalmologist per 83,766 population, suggesting 3 times difference in therates. Afghanistan, Bangladesh, Nepal, and Sri Lanka with a 1 ophthalmologist per 193,061 population have a difference of at least7 times with the developed countries.

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India are likely an underestimate. Further analysis and a follow-upstudy in India are warranted.

Based on the data obtained by CATSEYE, the followinginformation was learned:& approximately 17,568 ophthalmologists and an estimated4086 ophthalmic subspecialists practice in the SAARCregion;

& the ophthalmologist to population ratio in SAARC countries isapproximately 1:92,270 and 10.84 per million population;

& the AEHPs constitute an important element of the region’s eyehealth workforce and have a population ratio of approximately1:99,852 and 10.01 per million population;

& the ODR (physician) is 1:61 in the region; and& more than 510 centers provide ophthalmology trainingand more than 32 centers provide subspecialty training acrossthe region.

An interesting finding of the survey was the similar ratiosof AEHPs and ophthalmologists to total population. In this re-gard, Bhutan and Sri Lanka have 9 or more AEHPs to everyophthalmologist. Sri Lanka and Afghanistan, however, havemuch fewer ophthalmologists (Table 1). This indicates that

ophthalmology training would be a priority in these countries,whereas Pakistan, for instance, might need to intensify effortsto train more AEHPs.

Countries with a shortage of ophthalmologists or fewerophthalmologists in training compared with the pool of avail-able physicians and overall population (Figs. 5, 6) support thenecessity to train eye care teams led by ophthalmologists tomeet the requirements of communities. This need is especiallycritical when considering the implications of changing diseasepatterns and aging populations.

In the SAARC region, the challenge is to sustain and in-crease the eye health workforce to meet the needs of a growingand aging population. The demographic transitions, improvedchild survival and life expectancy rates, and emerging non-communicable disease trends require training of ophthalmicsubspecialists and supporting eye care teams to meet the servicedelivery demands of changing eye health paradigms.

RecommendationsBased on a combination of desk research, telephone in-

terviews with the national coordinators for eye health and thefindings obtained by CATSEYE to access the capacity for

FIGURE 3. Projections for number of doctors in Pakistan. The actual and projected number of doctors to the year 2035 and the decliningCAGR. Rate 1 shows a continuous declining CAGR based on declining rate, whereas rate 2 shows a steady state that is similar to 2025.

FIGURE 4. Predicting the need and supply of ophthalmologists in Pakistan. The need and supply of ophthalmologists in Pakistanis illustrated. Required (need) is estimated using 1:75,000 ratio; ‘‘working’’ actuals are used up to 2012, and ODR is used forfuture projections.

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ophthalmic training in the 8 SAARC countries, the ICO, SAO,and the FHF suggest the following policy recommendations forthe SAARC region:& facilitate a high-level meeting of heads and specialty co-ordinators of ophthalmic professional bodies in SAARCcountries to develop a regional policy/strategy on ophthalmiceducation (including subspecialty training) and determinepriority areas for joint action;

& launch a regional forum or task force on human resourcesfor eye health, whose purview may include standardizationof definitions, to act as a catalyst in developing guidelinesfor roles and responsibilities of different professionals in theeye health workforce; recommend minimum service deliverystandards for human resources for eye health; develop an

essential subspecialty training curriculum and practical re-quirements for the subspecialties; design performance ap-praisal modalities, monitor quality, etc;

& mobilize a regional faculty to promote technical cooperationamong developing countries to participate in subspecialtytraining across countries;

& define standards for subspecialty training centers by analyzinggaps and initially strengthening centers that have the capabilityand capacity to provide subspecialty training; and

& foster collaboration with international partners to activelypromote ophthalmic graduate and subspecialty training and tosupport the functioning of a regional forum, such as eye healthpartnership for professional advancement to accelerate effortsin this regard.

FIGURE 5. Selected countries and ODR. The comparison of ODR of different regional and developed countries was done. The SAARCregion has an average of 61 ODR, and the United Kingdom has an ODR of approximately 115, indicating that the SAARC region hasapproximately twice the proportion of ODR than the United Kingdom. Nepal has a very low ODR, suggesting a preference forophthalmology among their doctors. Sri Lanka, Australia, and UK ODRs indicate that these countries probably have a shortage ofophthalmologists, or there are not enough training positions in ophthalmology or that the specialty is not among the top few preferredchoices among doctors.

FIGURE 6. Selected countries and ODR decadal trends. Bangladesh, India, and Pakistan demonstrate fairly steady ODRs duringthe 20-year period, whereas Australia, Canada, United Kingdom, and United States indicate a nominal increase in ODRs. Takenindividually, for example, in Australia and the United Kingdom, the decadal trend of ODR suggests fewer ophthalmologists in trainingcompared with the pool of available physicians and overall population.

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To meet the goal of global blindness prevention in theSAARC countries and beyond, superior eye care delivery at alllevels is needed, and it is dependent to large extent on high-qualitytraining of ophthalmologists and AEHP workers.

ACKNOWLEDGMENTSWe wish to recognize with deep appreciation the contri-

butions of the following people: Profs Ava Hossain andRajvardhan Azad (SAO); Ms Lesley Podesta (The FHF); DrsMohammad Babar Qureshi and Irfan Baig (Advisors); DrAhmad Shah Salam (Afghanistan); Profs Deen MohammadNurul Huq and Enayet Hosein (Bangladesh); Prof Nor TsheringLepcha and Mr Chandra Kumar Chhetri (Bhutan); Profs AshokGrover and Namrata Sharma (India); Dr Abdullah Junaid(Maldives); Prof OK Malla and Mr Sunu Dulal (Nepal); ProfsAsad Aslam Khan, Mohammad Saleh Memon, and Nasir Saeedand Dr Riaz Baloch (Pakistan); and Drs Mangala Gamage,Saman Senanayake, and Sunil Fernando (Sri Lanka).

We are especially thankful to Mr Jabbar Bangash and histeam at CREOLOOM for developing the Web-based applica-tion, to our colleagues at Avicenna Consulting Pvt Ltd, and MrNiaz Ullah Khan and Mr Mohammad Bashir Khan for theirtechnical assistance.

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FIGURE 7. Five-step ODR supply predictor model. A 5-step ODR supply predictor model is proposed. The model uses CAGRto estimate the future projections of population and the numbers of doctors from past time series using data from official sources. It alsoestimates need of ophthalmologists by applying an appropriate ophthalmologist-to-population ratio. The ODR calculated from thismodel can be used to predict the future supply of ophthalmologists and thus assist in human resource planning.

Asia-Pacific Journal of Ophthalmology & Volume 3, Number 2, March/April 2014 SAARC Ophthalmic Education & Eye Health Workforce

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