Analysis of Eye Care Services in Yemen

Purpose: The objective of this study was to undertake an analysis of the eye care services situation in Yemen and to assess ophthalmic human resources, eye units’ ownership and ophthalmic equipments. Methods: Eye care providers were surveyed by a standardized questionnaire which was sent to the 184 eye units in governmental, university, military, private and charity clinics and hospitals in Yemen and covered the period between 01 January to 31 December 2012. The questionnaire determined location, human resources and eye units’ ownership and ophthalmic equipments. Results: The response rate to the questionnaire was 80.7%. During 2012, 184 eye units involved in providing eye care services in Yemen. 25% of eye units represent public sector, 72.3% represent private sector and 2.7% belong to non-governmental charity organizations. 682 people worked in eye care services of which 268 are ophthalmic doctors that is equivalent to 1.06 per 100,000 populations. Human resources and eye care equipments were below vision 2020 targets. There is significant unequal distribution of eye care services provision between urban and rural areas in Yemen. Original Research Article Al-Akily et al.; OR, 7(1): 1-7, 2017; Article no.OR.33295 2 Conclusion: Deficiency, maldistribution and inadequate training of ophthalmic doctors in addition to poor financial resources to establish and provide eye care units with good infrastructure. All these factors are regarded as major factors that cause underperformance in the Yemeni eye health system. We recommend equal distribution of trained ophthalmic doctors and personnel with good financial support for eye care services in rural areas of Yemen.


INTRODUCTION
Yemen is one of the WHO Eastern Mediterranean Region countries, the estimated prevalence of blindness in this region is 0.97 [1,2] and Yemen is regarded as one of the countries with high prevalence rate of blindness [3,4]. Republic of Yemen is located in the south west part of the Arab peninsula with an area of 555,000 square kilometers. Yemen population is around 25. 3 Million distributed in 21 governorates in addition to the capital city of Sana'a [5]. About 68.2 percent of the Yemeni population lives in rural areas [6].
Apart from the ophthalmic situation analysis survey that was done in 2003 [7,8] there is still need to update the information describing eye health care services in Yemen. The affordability, accessibility and availability of eye health care services are affected by various changes strongly related to the socio-economic situation of Yemen.
The aim of this study which was done in 2012 is to undertake analysis of the eye care services situation and to assess ophthalmic human resources and eye units' ownerships and equipments through Yemen. The outcome of this study is going to help decision makers in the Ministry of Health and Population and other eye care providers in updating short and long term strategies for the reduction and prevention of blindness in the framework of the global initiative "Vision 2020 -the right to sight" [9].

PATIENTS AND METHODS
Eye care providers were surveyed by a standardized questionnaire adapted from the Vision 2020 form B [9] which was sent to the 184 eye units in governmental, university, military, private and charity clinics and hospitals in Yemen and covered the period between 01 January to 31 December 2012.
The questionnaire determined location, human resources, and eye units' ownership and ophthalmic equipment.
Member of the data collection team visited each eye unit after a preliminary telephone call and collected the data by face-to-face interviews with the personnel responsible for eye unit and the data were filled in the questionnaire form.
Ethical approval from Nebras Health Society was obtained.

RESULTS
The response rate to the questionnaire was 80.7%. To increase the accuracy and quality of data, the collected information were obtained from clinic and hospital administration data. In 2012, there were 184 eye units providing ophthalmic care in Yemen ( The majority (76.0%) of eye units are localized in Sana'a (city) (32.6%) and in the governorates of Aden (21.7%), Taiz (13.0%) and Hadramout (8.7%).
There are no eye units in the governorates of Mareb, Al-Jawf, Al-Mahara, and Reima. There is a deficiency of eye units in the governorates of Amran, Sana'a, Shabwa, Al-Beidah, Al-Mahweet, and Hajja ( Fig. 1).
Overall, there are 1.06 ophthalmic practitioners per 100,000 population, but they are not evenly distributed throughout the country. Sana'a (city) and the governorates of Aden, Taiz, and Hadramout have more than three quarters (79.5%) of the practicing ophthalmologists. The highest concentration of ophthalmologists is in the governorate of Aden, where there are 5.67 ophthalmologists per 100,000 population. Of 21 governorates, 11 have fewer than 0.50 ophthalmologists per 100,000 population. There are no ophthalmologists in the governorates of Mareb, Al-Jawf, Al-Mahara and Raima.
The numbers of dedicated eye beds and ophthalmic nurses are summarized in Table 5.
Overall, there are1.81 ophthalmic beds and 1.30 ophthalmic nurses per 100,000 population. The highest concentration of ophthalmic nurses is in Sana'a (city) and the governorates of Taiz, Aden and Hadramout. A similar high concentration of ophthalmic beds is also present in Sana'a (city) and these 3 governorates.
The distribution of major ophthalmic instruments in Yemen is summarized in Table 6. There are 142 ophthalmic operating microscopes, of which 105 (74.0%) are concentrated in the governorates of Sana'a (city) (56), Taiz (25), Hadramout (12), and Aden (12). Equipment for phacoemulsification, as well as YAG and argon lasers, are present only in these 9 governorates.

Fig. 1. Distribution of eye care services in Yemeni governorates
There was a shortage of skilled ophthalmologists in some ophthalmic surgical techniques namely phacoemulsification and vitreoretinal surgery. In 2003 the number of phaco machines in Yemen were 12 [7] and this number increased four folds (46 phaco machines) in 2012. The increase in phacoemulsification machines in recent years in Yemen reflected as an increase in number of phacoemulsification procedures for cataract surgery from 0.8% in 2003 to 17.9% in 2012 [7,11]. During the 12-month period, a total of 62,577 cataract surgeries were performed by 268 ophthalmology specialists. The majority of cataract surgeries (61.54%) were performed in the private sector facilities. The cataract surgical rate was 2,473 operations per million inhabitants per year. Intraocular lens implantation was performed on 98.02% of the cases [11].
Despite availability of operating ophthalmic microscopes in the majority of governorates, modern equipments (ie, YAG laser, Argon lasers and phacoemulsification machines) are only present in the five main governorates.
Based on our findings, we make the following recommendations: The number of cataract surgery in Yemen is still lower that the incidence of cataract in the population, this is attributed to low number of trained ophthalmic surgeons, inadequate eye units all over the governorates of Yemen and socio-economic factors mainly low education and poverty.
Our study faced a number of limitations firstly; our questionnaire could have been subject to bias due to selective under-reporting as, due to practical constraints, some of our respondents were emailed the questionnaire for selfcompletion while others responded face-to-face. We tried to minimize bias by contacting all facilities via telephone before emailing the questionnaire, to ensure that the same information was provided to all respondents and potential questions were answered.

CONCLUSION
The factors that are regarded as major obstacles that cause underperformance of the Yemeni eye health system include: deficiency, maldistribution and inadequate training of ophthalmic doctors in addition to poor financial resources to establish and provide eye care units with good infrastructure.

CONSENT
It is not applicable.

ETHICAL APPROVAL
As per international standard or university standard, written approval of Ethics committee has been collected and preserved by the authors.