Building a national eye-care service in post-conflict Timor-Leste

Abstract Problem Violent conflict left Timor-Leste with a dismantled health-care workforce and infrastructure after 2001. The absence of existing health and tertiary education sectors compounded the challenges of instituting a national eye-care system. Approach From 2001, the East Timor Eye Program coordinated donations and initially provided eye care through visiting teams. From 2005, the programme reoriented to undertake concerted workforce and infrastructure development. In 2008 full-time surgical services started in a purpose-built facility in the capital city. In 2014 we developed a clinical training pipeline for local medical graduates to become ophthalmic surgeons, comprising a local postgraduate diploma, with donor funding supporting master’s degree studies abroad. Local setting In the population of 1.26 million, an estimated 35 300 Timorese are blind and an additional 123 500 have moderate to severe visual impairment, overwhelmingly due to cataract and uncorrected refractive error. Relevant changes By April 2018, six Timorese doctors had completed the domestic postgraduate diploma, three of whom had enrolled in master’s degree programmes. Currently, one consultant ophthalmologist, seven ophthalmic registrars, two optometrists, three refractionists and four nursing staff form a tertiary resident ophthalmic workforce, supported by an international advisor ophthalmologist and secondary eye-care workers. A recorded 12 282 ophthalmic operations and 117 590 consultations have been completed since 2001. Lessons learnt International organizations played a pivotal role in supporting the Timorese eye health system, in an initially vulnerable setting. We highlight how transition to domestic funding can be achieved through the creation of a domestic training pipeline and integration with national institutions.


Introduction
Blindness and moderate-to-severe visual impairment were estimated to affect 36.0 million and 217 million people, respectively, worldwide in 2015. 1 Of these, about 90.0% of affected people were in developing countries alone. 2 Age-related cataract and uncorrected refractive error account for 20 million of 36 million (55.6%) cases of blindness (presenting visual acuity < 3/60 in the better eye) and 169 million of 217 million (77.9%) cases with moderate-to-severe visual impairment (presenting visual acuity > 3/60 and < 6/18 in the better eye) worldwide. 1 Estimates suggest that nearly 80.0% of visual impairment is preventable or treatable through appropriate interventions. 2

Local setting
Timor-Leste is a mountainous island nation with a population of 1.26 million 3 and is ranked 133rd globally on the 2016 Human Development Index. 4 Approximately twothirds of Timorese live rurally. 3 All-cause blindness affects 35 280 people nationwide, where cataract causes 79.4% (28 000) of cases. Moderate-to-severe visual impairment affects 122 220 people and 70.0% (85 554) cases and 26.9% cases (32 914) are due to cataract and uncorrected refractive error, respectively. These numbers indicate that at least 93.0% (146 468/157 500) of all disabling visual impairment in Timor-Leste is treatable. 5 Currently, there is one national referral hospital in the capital city, Díli, and five secondary referral hospitals with inpatient capability, in addition to 91 peripheral centres. 6 The health-care system is provided free of charge to all citizens. Overall health-care expenditure, however, remains among the lowest reported worldwide at 1.5% of the 4 billion United States dollars (US$) gross domestic product in 2014. 3 Violent conflict in Timor-Leste from 1999 to 2001 left a dismantled health-care workforce and infrastructure. 3,[7][8][9] In response to this humanitarian crisis, and at the request of World Health Organization (WHO) representatives, the East Timor Eye Program was established in July 2000. Early involvement of the Royal Australasian College of Surgeons provided organizational capacity to the programme. The sole aim of the programme from inception until 2005 was to deliver surgical interventions through visiting teams, addressing the overwhelming burden of ocular trauma and, later, the backlog of untreated cataract and refractive error.

Approach
In 2005, the eye programme reoriented to undertake concerted workforce and infrastructure development (Fig. 1). WHO assisted by identifying international partners for the development of training pathways for medical, nursing and allied health-care staff. A rapid assessment of cataract surgical services survey was undertaken in 2005, 10 informing the 2006 national eye-health strategy. 11 From 2005 to 2016, the Fred Hollows Foundation New Zealand provided a crucial labour force, technical expertise and a robust funding stream. 12 Vi-sion2020 through Australian Aid provided support for a longterm advisor, and international training of graduates and staff. Before these arrangements the programme had been reliant on generous ad hoc funding from external donors.
From 2005 onwards, visiting specialist teams focused on vocational training of local tertiary surgical staff and collaborative development of models of care appropriate to the Timorese Lessons from the field National eye-care service in Timor-Leste Kristof Wing et al.
setting. Between visits, ophthalmology services were maintained by one Timorese doctor, who, with funding from international partners, completed an international master's degree of medicine in ophthalmology from the University of Sydney, Australia in 2008. From then on full-time ophthalmic surgical services became available at the national referral hospital in the capital city, Díli (Fig. 1). The programme concurrently funded an experienced expatriate ophthalmologist, acting as a long-term advisor to oversee ongoing training and service development (Table 1). In July 2011 a self-contained ophthalmology centre, the National Eye Centre, was opened in the grounds of the national referral hospital. Programme partners were responsible for its construction and equipping, with the centre being wholly owned by the health ministry.
From 2007, the Fred Hollows Foundation New Zealand facilitated the training of dedicated primary eye-care workers, yielding a current workforce of 20 mid-level eye-care workers and five refractionists. Expanding this specialized workforce, however, has proved challenging. 12 Since 2010, around 1000 Cuban-trained primary-care physicians have graduated to work in communities throughout the country. This initiative provides an opportunity for the development of a cost-effective workforce for the primary assessment and referral of ocular disease. In response, since 2013 the Royal Australasian College of Surgeons has delivered family medicine training, incorporating 4-to 6-week rotations at the department of ophthalmology. 8 In 2014 the postgraduate diploma of ophthalmology was established in collaboration with Timor-Leste's national university. Instituting a training programme was dependent on stable clinical caseload and clinical protocols appropriate to local needs. Nine registrars have undertaken attachments at international centres to provide for taskspecific intensive postgraduate training (Table 1). Donors additionally provide funding for postgraduate diploma graduates to undertake a master's degree of medicine in ophthalmology, at a cost of US$ 120 000 per trainee.

Relevant changes
By April 2018, the resident ophthalmic workforce in Timor-Leste comprised one consultant ophthalmologist, seven ophthalmic registrars, two optometrists, three refractionists and four nursing staff, supported by the international advisor ophthalmologist. Six candidates have completed the postgraduate diploma of ophthalmology, three of whom are studying for a master's degree of medicine in ophthalmology in Nepal or Fiji and are expected to graduate in late 2019. The remaining three graduates make up the domestic workforce as senior registrars, benefiting from both domestic and international vocational clinical teaching (Table 1).
A total of 12 282 ophthalmic operations and 117 590 consultations have been completed since 2001 (Fig. 2). A sharp drop in consultations and operations in 2012 corresponded to the opening of the National Eye Centre, when the work of the ophthalmology department had to be diverted to achieve this. A strong relationship with the national referral hospital and the health ministry lessened the impact of the withdrawal of Fred Hollows Foundation New Zealand in late 2016, with no change in annual caseload. However, focusing on maintenance of caseload during withdrawal of international partners resulted in the decline of several systems, including electronic medical record and stock management systems, which have proved difficult to reintroduce due to a lack of endogenous expertise.

Lessons learnt
Although the Timorese post-conflict setting is unique, we believe lessons learnt are broadly applicable to other settings. Starting with a high-volume intermittent service delivery approach facilitates the development of local, context-appropriate protocols and training of allied staff (Box 1). Initial focus on local capacity-building in preference to infrastructure provision ensures that donated goods are not underutilized. Establishing, in initial phases, that transition to local ownership is the end goal is crucial. Integrating into local health-care facilities through the guidance of a long-term advisor facilitates development of a full-time clinical service, permitting the specialist training of local medical graduates. Training a mixture of both cataract surgeons and general ophthalmologists balances the cost of advanced training against having a context-appropriate service. Elements of this model have been applied to Sumba, Indonesia, 13 and to a new eye care programme in the Federated States of Micronesia. 14 Improving surgical coverage of cataract and refractive error in Timor-Leste is an ongoing challenge. Over 45% of people with unoperated cataract and severe visual impairment identify access as the main barrier to care. 5 Most Timorese still seek medical services by foot, with many walking over two hours to reach health outposts. 6 For those with poor vision or impaired mobility this may not be possible. One-fifth of Timorese (23 of 121 surveyed) with disabling cataract did not feel the need for treatment, despite knowledge of availability and acceptability of treatment services; 5 this could in part be due to the perception that poor vision is a normal part of ageing. Since 2005,  Lessons from the field National eye-care service in Timor-Leste Kristof Wing et al.
monthly outreach trips from the capital city to regional districts have provided in situ management of refractive errors and operative management of cataract to overcome barriers to care. In 2017, outreach accounted for 442 of 1394 (31.7%) of the ophthalmology department's surgical caseload, which suggests this is an effective mechanism that could be strengthened through funding and health promotion. Strengthening nonspecialist primary eye care and establishing regional surgical centres would further address this barrier.
Presently there is one ophthalmologist in Timor-Leste, contrasting with the Vision2020 workforce recommendation of at least 25 in-country ophthalmologists. 15 For a nation of Timor-Leste's size, Vision2020 recommends 25 mid-level eye-care personnel and 13 refractionists. The ophthalmology department will inform the development of a 30-year plan for eye care in Timor-Leste as part of a system-wide undertaking to ensure service longevity and equality of access. The aim is to establish five cataract surgical centres staffed by future ophthalmology graduates and additional secondary non-surgical referral locations staffed by specialist mid-level eye-care workers, and supported by referrals from community-based primary medical practitioners.
Threats to sustainability of the programme include maintenance of the training pipeline and management of conditions typically reserved for subspecialist ophthalmologists. The sustainability of the current postgraduate diploma is assured by the presence of a long-term advisor acting as an instructor. Once the international master's degree graduates return to Timor-Leste, it is anticipated they will assume similar teaching roles. Sustainability of the international master's degree component presents a threat to the current Lessons from the field National eye-care service in Timor-Leste Kristof Wing et al.