Vision 2020 Australia Submission to the

inquiry into the delivery and

effectiveness of Australia’s bilateral

aid program in Papua New Guinea

The Senate Standing Committee on Foreign Affairs, Defence and Trade

March 2015

About Vision 2020 AustraliaVision 2020 Australia is the peak body for the eye health and vision care sector in Australia. Members work in partnership and collaboratively with governments, local health services and civil society organisations towards the goal of the elimination of avoidable blindness and improving the quality of life for people who are vision impaired. Partnerships and collaboration provide the opportunity to pool member resources and competencies to deliver better aid outcomes on the ground. Members also work together to harmonise efforts and align with partner government priorities. This ensures local community ownership and creates mutual accountability for strong results. Working in partnership and collaboratively allows for better results for those most in need.Vision 2020 Australia has a Global Committee which is made up of members who have an interest in or which work directly in international development and is focussed on policy and advocacy activities. The Vision 2020 Australia Global Consortium is a partnership of six leading eye health and rehabilitation non-government organisations (NGOs), working collaboratively with the International Agency for the Prevention of Blindness (IAPB). Members work in countries across the Indo-Pacific Region, including Papua New Guinea (PNG), to strengthen eye health and vision care capacity and systems and thereby reduce rates of blindness and vision impairment.

ContactsJennifer GersbeckChief Executive OfficerEmail: jgersbeck@vision2020australia.org.au

Brandon Ah TongDirector of Policy and AdvocacyEmail: bahtong@vision2020australia.org.au

Vision 2020 AustraliaLevel 2, 174 Queen StreetMelbourne Victoria 3000Telephone: +61 3 9656 2020

1 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea

Introduction PNG ranks 157 out of 187 countries on the United Nations Human Development Index, which represents a decrease from 148th in 2009 and 128th in 1994.1 PNG has a higher level of poverty than neighbouring countries.2 Approximately eighty-five per cent of the mainly rural population is poor and an estimated eighteen per cent of people are extremely poor and living in isolated island or mountain regions. Many lack access to basic services or transport.3

There is a high prevalence of blindness and vision impairment in PNG. A 2006 blindness survey found that thirty-two per cent of people over the age of fifty are vision impaired, and of these people eight per cent are blind.4 Reducing rates of avoidable blindness and vision impairment in Papua New Guinea is a vital step which will improve health outcomes, increase access to education and employment, and facilitate community and economic participation.Since 1990, the prevalence of vision impairment has decreased from 7.7 per cent to 5.8 per cent. This indicates the capacity for further investment to achieve a twenty-five per cent reduction in avoidable blindness and vision impairment in Papua New Guinea by 2019. There remain 198,506 people affected by vision impairment and blindness in PNG.Eye health and vision care programs are effective and produce tangible results. At a program level, outcomes from cataract surgery, provision of spectacles and other interventions can easily be measured and reported. For example, the potential lost productivity resulting from the global burden of uncorrected refractive error is over US$225 billion annually. For individuals, productivity gains are immediately realised once sight is restored.As Australia’s closest neighbour, the Australian Government has a unique responsibility to ensure that PNG is supported towards sustained economic growth and reducing poverty through an effective bilateral aid program. Preventing avoidable blindness and supporting people who are blind or vision impaired to participate in the economic and social life of their communities, is achievable for PNG with the right political and policy levers in place and the right interaction between government, non-government and private sectors. Vision 2020 Australia therefore welcomes the Senate Standing Committee on Foreign Affairs, Defence and Trade’s inquiry into the delivery and effectiveness of Australia’s bilateral aid in PNG and herein responds to selected Terms of Reference.

1 United Nations Development Programme (2014) ‘Human Development Reports’, accessed at http://hdr.undp.org/en/data

2 United Nations Children’s Fund, ‘Papua New Guinea: United Nations Development Assistance Framework’, accessed at http://www.unicef.org/about/execboard/files/Papua_New_Guinea_-_PNG_UNDAF_2012-2015.pdf

3 Ibid4 Garap, J.N., et al., ‘Blindness and vision impairment in the elderly of Papua New Guinea’. Clinical and Experimental Ophthalmology,

2006. 34(4): p. 335-341.

2 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea

1 Summary of RecommendationsRecommendation 1Vision 2020 Australia recommends that the Australian Government supports capacity building for training at all levels in eye health and vision care services in PNG.

Recommendation 2Vision 2020 Australia recommends that the Australian Government provides financial support to train eye health personnel, provide continuing professional development and expand service delivery through system strengthening.

Recommendation 3Vision 2020 Australia recommends that the Australian Government encourages an enabling environment for businesses to be involved in eye health and vision care in PNG including grants, seed funding, concessional loans and additional taxation incentives.

Recommendation 4Vision 2020 Australia recommends that the Australian Government supports the inclusion of Cataract Surgery Coverage as a Universal Health Coverage indicator in the Sustainable Development Goals.

Recommendation 5Vision 2020 Australia recommends that the Australian Government ensures all development activities in PNG facilitate the inclusion of people who are blind or vision impaired and people with disability more generally in PNG.

Recommendation 6Vision 2020 Australia recommends that the Australian Government continues efforts to improve gender equality including addressing barriers to access to eye health for women and girls in PNG.

Recommendation 7Vision 2020 Australia recommends that the Australian Government encourages the adoption of effective electronic data collection systems for eye health and vision care services in PNG.

Recommendation 8Vision 2020 Australia recommends that the Australian Government supports the recognition of the Pacific Eye Care Society as a professional body by the PNG Government.

Recommendation 9Vision 2020 Australia recommends that the Australian Government encourages the expansion of diabetic retinopathy training at the Pacific Eye Institute.

Recommendation 10Vision 2020 Australia recommends that the Australian Government considers Non-

3 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea

Communicable Disease Hubs as an effective option to strengthen eye health and vision care services in PNG.

4 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea

2 Responding to Terms of Reference

2.1 The political, economic and social objectives of Australia‘s aid.

Australia, as the largest bilateral aid donor to Papua New Guinea, plays a lead role in assisting PNG to make progress towards sustainable development outcomes. 5 An important outcome of aid is to strengthen PNG’s economic performance and to establish useful trade partnerships. Before this can be achieved, suitable conditions for economic growth must be established, including social and cultural conditions that support the participation of disadvantaged populations. Women, ethnic minorities and people with a disability may have limited legal rights, limited opportunities to access education and training, and limited access to productive resources such as land and credit.6 For PNG to achieve economic growth people need to be empowered to participate in the economy as workers and as consumers. Vision impairment is both a cause and consequence of poverty. There are direct links between vision impairment and lack of access to opportunities (such as education, employment, and social inclusion) and to basic needs (such as health services, good nutrition, safe housing and clean water and sanitation).7 Globally, the prevalence of vision impairment is five-fold higher in developing countries than in developed countries8, and eye health and vision care are important factors in working towards poverty alleviation. Research shows that people with vision impairment are more likely to be poor and that the removal of cataracts alleviates poverty.9 There is also a link between a country's economic development status and the prevalence of blindness, with research indicating that rates of blindness are higher in developing countries with lower per capita income.10 The relationship between poverty and vision impairment can be understood as involving mutual causality: that is, vision impairment presents barriers to poverty-reducing factors such as education and employment, and poverty makes it harder for people to access to eye health and vision care services.

Interventions for eye health and vision care in developing countries represent excellent value for money. The economic report commissioned by The Fred Hollows Foundation (FHF) and prepared by PricewaterhouseCoopers, Investing in Vision, indicates that eye health and vision care programs are among the most cost effective public health interventions available, providing an economic return of $4 for every $1 invested.11 5 Australian Government Department of Foreign Affairs and Trade, ‘Overview of Australia’s Aid Program to Papua New

Guinea’, accessed at http://www.dfat.gov.au/geo/papua-new-guinea/development-assistance/Pages/papua-new-guinea.aspx

6 AusAID (2012)‘Sustainable economic development – Private sector development’7 Gooding, K. (2006) ‘Poverty and Blindness: A survey of the literature’, Sight Savers International8 Resnikoff S, Pascolini D, Etyaále D, Kocur I, Pararajasegaram R. (2004) ‘Global Data on Vision Impairment for the Year

2002’, Bulletin of the World Health Organisation 82, 844-8519 Kuper H, Polack S, Mathenge W, Eusebio C, Wadud Z, et al. (2010) ‘Does Cataract Surgery Alleviate Poverty? Evidence

from a Multi-Centre Intervention Study Conducted in Kenya, the Philippines and Bangladesh.’ PLoS ONE 5(11): e15431. doi:10.1371/journal.pone.0015431

10 Ho, V.H. and Schwab, I.R. (2001) ‘Social economic development in the prevention of global blindness.’ British Journal of Ophthalmology, 85:653-657.

11 The Fred Hollows Foundation (2013) Investing in Vision – Comparing the costs and benefits of eliminating avoidable blindness and visual Impairment. Accessed at http://www.hollows.org.au/sites/default/files/pdfs/research/FHF_Summary_Investing_in_Vision_Report_130430b.pdf

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Investing in eye health and vision care leads to social as well as economic benefits. Reducing blindness and vision impairment improves quality of life not only for those whose sight is improved but for their carers, families and communities.

In PNG blindness and vision impairment impact significantly on individual lives, productivity and employment rates, health care costs and local and national economies.12 Approximately three quarters of the blindness and visual impairment in PNG is treatable or preventable, and eye health and vision care interventions are among the most straightforward and cost effective health care interventions. Despite significant rates of refractive error, cataract and diabetic retinopathy, eye health and vision care services in PNG remain under-resourced. More support is needed for training at the University of PNG for ophthalmologists. While CBM Australia is currently funding the Head of Ophthalmology Department position at the University of PNG, further funding may be required to sustain this position. Support is also needed for capacity building at primary eye care level in communities and remote locations.Vision 2020 Australia considers that building the local capacity of the eye health and vision care workforce in PNG would ensure progress towards the political, social and economic objectives of Australia’s bilateral aid. Building workforce capacity is essential to fostering sustainable eye health and vision care systems and reducing avoidable blindness, which is a known driver of poverty.

Recommendation 1Vision 2020 Australia recommends that the Australian Government supports capacity building for training at all levels in eye health and vision care services in PNG.

2.2 The role of multilateral and regional organisations, non-government organisations, Australian civil society and other donors.

Australian NGOs have a long history of tackling blindness and vision impairment in developing countries. Coupled with Australia’s leading development role and commitments to eye health and disability inclusion through the foreign aid program, the expertise of Australian NGOs in reducing blindness and vision impairment is vital in improving health outcomes and strengthening health systems. Donors and NGOs from Australia and New Zealand provide funding and programs for eye health in PNG, though funding from the PNG government is increasing and there are more local NGOs. Many areas are now benefiting from upgraded facilities and vision centres. A project developed by Vision 2020 Australia members in conjunction with Lions Clubs International Foundation (LCIF) will develop a National Resource Centre for Eye Health in PNG. Funded by a Lions Sight First grant awarded in January 2015, the project involves refurbishing and equipping the resource centre, supporting the PNG National Prevention of Blindness Committee (PBL) meetings and providing mentorship and eye health and vision care promotional activity.

Australian and New Zealand NGOs such as Brien Holden Vision Institute (BHVI) and The Fred Hollows Foundation New Zealand (FHF NZ) have made significant 12 MI Vision (2014) ‘Eye care facilities double in Papua New Guinea’, accessed at http://www.mivision.com.au/eye-care-

facilities-double-in-papua-new-guinea

6 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea

achievements in collaboration with PNG partners, including:• Establishment of PNG Eye Care Vision Centres (under the Avoidable Blindness

Initiative 2010-2013) to address the high uncorrected refractive error need and free up capacity of other eye clinics (including the Port Moresby General Hospital). This centre has serviced over fifteen thousand patients and has freed doctors to focus on cataract and trauma presentations.13 A significant proportion of Vision Centre patients have been serviced through outreach or as a result of awareness created by outreach. This is an example of a holistic approach to supporting sustainable eye care systems, demonstrating the need for NGOs to support established, and often overwhelmed, public infrastructure.

• Establishment of the National Spectacle Supply (NSS), using eye nurse networks across PNG. Distance and communication difficulties have presented major financial barriers to service delivery, which are somewhat mitigated by operating a bulk supply system. This model has also been replicated in Fiji, where a hub was established to supply spectacles to smaller Pacific island communities which do not have large scale buying power.

• Establishment of a one year Postgraduate Diploma in Eye Care (now the ‘Advanced Diploma in Eye Care’) in partnership with Divine Word University (DWU), Madang in 2005. The Advanced Diploma in Eye Care (ADEC) enables students to provide effective and comprehensive eye care services, encouraging holistic practice to effectively reduce the burden of blindness in PNG. Fifty-four nurses and ten community health workers have graduated with a Certificate in Eye Care. Six of the graduate nurses are studying towards a Masters in Community Eye Care (MCEC). Despite the success of the training program, the size and growth rate of the PNG population means the current number of graduates does not meet the country’s ongoing needs.

The importance of PNG’s PBL cannot be overstated. The PBL meets regularly to discuss issues such as training gaps for mid-level eye workers, and is becoming an effective forum for coordination and advocacy. Members of the PBL are representatives of local NGOs, international NGOs (including Vision 2020 Australia members and the IAPB) and private organisations such as Youth With A Mission.

Vision 2020 Australia considers that support for the work of the PBL and advocacy through the PBL should be encouraged by all stakeholders. This includes assisting the PBL to advocate for the ratification of the National Eye Plan (NEP) by the National Executive Council (NEC). Although the NEP is fully operational, ratification by the NEC will provide more advocacy opportunities for the advancement of eye health in PNG. This in turn will increase the effectiveness of aid delivery.

Towards Universal Eye Health: A Regional Action Plan for the Western Pacific (2014–2019) has been endorsed by the World Health Organization (WHO) Regional Committee for the Western Pacific. The endorsement of the Regional Action Plan represents great progress among member states in recognising the importance of addressing eye health

13 Brien Holden Vision Institute, ‘Local access to eye care doubles in PNG in one year’, accessed at http://www.brienholdenvision.org/media-centre/latest-news/652-local-access-to-eye-care-doubles-in-png-in-1-year.html

7 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea

and vision care in the region, and the important and influential role of multilateral organisations in development. The Vision 2020 Australia Global Committee has used the Regional Action Plan to inform the development of the Vision 2020 Australia Regional Strategy to guide the work of Australian NGOs in the region. This approach ensures that eye health and vision care development in the Indo-Pacific region is consistent with global approaches and best practice standards.

Vision 2020 Australia considers that multilateral, regional and non-government organisations and civil society play an important role in contributing expertise, funding and resources to development work in PNG. The most effective and efficient way of developing eye health and vision care systems and workforce capacity in PNG is through using the local knowledge, international experience, resources and networks of these stakeholders.

Recommendation 2Vision 2020 Australia recommends that the Australian Government provides financial support to train eye health personnel, provide continuing professional development and expand service delivery through system strengthening.

2.3 Scope for increasing private sector involvement in sustainable economic growth and reducing poverty.

Health services in PNG commonly involve partnership approaches. Faith-based organisations provide approximately fifty per cent of the health services in PNG, and in recent years there has been increasing support from and involvement of the private sector in health service provision. The PNG National Department of Health (NDOH) support for public-private partnerships (PPPs) is demonstrated in the National Health Sector Partnership Policy (2013). Private sector involvement in particular in the response to HIV/AIDS in PNG provides some foundation for working together to expand services and improve community health outcomes.

In the provision of health services, the private sector has always had an important role to play through research, the provision and sale of medicines, private hospitals, practitioners in private practice, social enterprise and innovative financing through loans and bonds. Globally there are many useful models of public-private partnerships in eye health. In many countries (including Australia), optometric services are provided primarily in the private sector, and many profitable businesses have been developed to provide health care. Eye health and vision care provide opportunities for private sector partnerships through research, innovation and enterprises, and results are tangible and simple to measure. The “social enterprise” model, otherwise known as “inclusive business”, demonstrates the key role that private businesses can play in international development. Social enterprises providing eye health services and training have demonstrated their effectiveness as business models that provide quality, inclusive services. PNG Eye Care is one such model, providing fee based services on a sliding scale depending on the client’s ability to pay and reinvesting income to subsidise service operations. Research indicates that people in PNG are

8 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea

willing to pay for eye health services, however some services, including cataract surgery, are still considered outside of what people are willing to pay.14

Further innovation in medical technology and supporting new and innovative sources of finance can play a similarly positive role. There remains an acute need for portable, low-cost equipment as well as more effective electronic data collection and transmission. A potential market therefore exists for Australian entrepreneurs willing to develop new products that suit the needs of low-resource settings. The Australian Government could encourage an enabling environment for businesses interested in tapping these markets, including grants, seed funding, concessional loans and additional taxation incentives. Actions to encourage this environment include:

• Integrating health initiatives for employees with community health outreach and referral.

• Supporting the expansion of social enterprises for eye health using PNG Eye Care as an example.

• Promoting social enterprise initiatives and models amongst the existing eye health private sector to help increase accessibility for the poor and vulnerable in the community.

• Mobilising private sector funds.• Developing cost-sharing or saving initiatives by working in partnership with

companies working in remote and rural areas.• Supporting locally developed innovation, research and development for the PNG eye

health sector.

In PNG the private sector provides an ongoing conduit for outreach to the urban working poor. For example, major companies such as OilSearch and Telikom provide time during working hours for their employees to receive free eye tests. This is beneficial in raising awareness of eye health services and providing key referral opportunities for staff. Such opportunities could be expanded to other villages to ensure more people gain access to eye health and vision care services. Partnerships between the major companies and local health organisations could improve the

14 Willingness to pay (WTP) was investigated, and participants reported that they are willing to pay an average of 57.55 Kina (US$ 26.5) for testing and spectacles/treatment. Public hospitals require a minimum payment of 2 Kina (US$ 0.90) for testing, while spectacles through non-government agencies start from 9 Kina (US$ 4.00). For common treatments such as cataract removal, public hospitals charge an estimated 120 Kina (US$ 55, for cataract intra-ocular lenses). As the current price of spectacles from public hospitals falls below the average WTP (even for those with less education) current public hospital pricing may be acceptable.  However the current cost of cataract treatment remains much higher than what people are anecdotally willing to pay; hence recommendations for cataract treatments to be subsidized further by the National Department of Health. It’s possible that PNG’s unique ‘wantok’ system - where community members have a social obligation to assist one another financially when required - may have confounded willingness to pay reporting. But it’s also important to note that WTP varies little between rural and urban communities – essentially due to the wantok system: there is always somebody from the village, living in the city, who is able to sponsor the patient to receive a pair of low cost spectacles.

9 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea

coverage of these programs.

Recommendation 3Vision 2020 Australia recommends that the Australian Government encourages an enabling environment for businesses to be involved in eye health and vision care in PNG including grants, seed funding, concessional loans and additional taxation incentives.

2.4 Improving PNG‘s progress towards internationally-recognised development goals.

Key indicators of development progress are strongly impacted by rates of blindness and vision impairment. There is a demonstrated correlation between vision impairment and poverty, with blind and vision impaired people facing barriers to participation in education and employment.15

The WHO’s Regional Action Plan for the Western Pacific notes the importance of understanding the magnitude and causes of visual impairment to inform resource allocation and planning.16 Refractive error is the most frequent cause of vision impairment in PNG (forty-seven per cent)17.

The recommendations of the Open Working Group on the Sustainable Development Goals include an important sub goal of Universal Health Coverage (UHC), which says that there should be 80 per cent coverage of essential health services for everyone by 2030, and that no-one should be excluded from health service access on financial grounds.18 The indicators for UHC are not yet finalised, but the WHO and World Bank have proposed using core ‘tracer’ indicators.19 Cataract Surgery Coverage (CSC) fits all the criteria for an ideal Universal Health Coverage (UHC) and is an important inclusion, as cataract surgery provides a strong base for developing wider eye health systems. Having eye health measures in the SDG indicators will incline governments to demonstrate progress against these measures.20 The Cataract Surgery Rate (CSR) in PNG is 700. According to IAPB, the ideal rate is between 1,500 and 2,000. The low CSR means that an extra 6,000 people per year are being added to the backlog of cataract surgeries.15 Jaggernath, J. et al. (2014) ‘Poverty and Eye Health.’ Health, 6, pp1849-1860.16 World Health Organisation (2014) Towards Universal Eye Health: A Regional Action Plan for the Western Pacific (2014 –

2019). Accessed at http://iapbwesternpacific.org/download/advocacy-material/Towards_Universal_Eye_Health%20Western%20Pacific.pdf.

17 Garap J.N., et al., ‘Blindness and vision impairment in the elderly of Papua New Guinea.’ Clinical and ExperimentalOphthalmology, 2006. 34(4): p. 335-34118 Open Working Group of the General Assembly on Sustainable Development Goals (2014) ‘Open Working Group

proposal for Sustainable Development Goals.’ Accessed at https://docs.google.com/gview?url=http://sustainabledevelopment.un.org/content/documents/1579SDGs%20Proposal.pdf&embedded=true

19 Ackland, P. (2015) ‘SDGs: what’s in it for eye health?’ Accessed at http://www.iapb.org/blog 20 Ibid.

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The WHO notes the importance of measuring the number of eye care personnel by cadre, to determine workforce availability, identify gaps and inform planning21. The number of ophthalmologists needed for comprehensive provision of eye care for the people of PNG is estimated at seventy; currently there are nine practicing ophthalmologists and four in training. The recommended number of mid-level personnel (nurses and technicians) according to the WHO is 144 for PNG. However, FHF NZ conducted a country specific programme assessment and developed a strategy to train one ophthalmic nurse per 25,000 people. This was considered more appropriate due to the geographical variation, feasibility of transportation and the spread of population throughout the country. According to this strategy, for the population of PNG (7,000,000+) 280 eye care workers are required. At present there are about sixty-three nurses or technicians providing eye care on a full or part time basis. If ten eye care nurses were trained a year, it would take at least twenty-five years to achieve this ratio, given attrition and retirement.

While funding is a major obstacle towards providing training positions, capacity building to improve the effectiveness of current programs would enable an improved return on investment. An eye nurse who is trained but has no ongoing workplace support will not be able to deliver programs as effectively as one who is constantly mentored and developed. PNG Eye Care sees the continuing professional development of its staff as a priority to enable their delivery of effective, sustainable outcomes – hence ongoing investment in workshops and mentoring through the relationship with BHVI.

Since the establishment of PNG Eye Care, BHVI have invested in the training and mentoring of seven spectacle technicians (spec-techs) and eight refractionists, employed by PNG Eye Care, and trained over thirty eye nurses in activities as diverse as refraction upskill, dispensing and stock management. BHVI has further acknowledged the need for training by developing a Pacific spec-tech trainer position, based in Honiara, Solomon Islands and has trained a regional Spectacle Supply Manager for the Pacific Supply hub in Fiji. This Supply Manager is a local entrepreneur, and this demonstrates the potential of private-public partnership in the region.

One of the greatest barriers to health is the difficulty people have in accessing health services. Research in PNG and Fiji22, has found that even those people living within an hour of eye clinics are often unable to afford the bus fare or the time to travel to such a clinic. Those living further away, and those living on islands without eye clinics, have almost no access to eye care. WHO has long advocated that different categories of health workers are needed to work in and with communities to improve access to health care. This includes supporting capacity development at local community levels.

When CSC is sufficient, wider eye health systems can be developed to address issues that prevent progress towards development goals, such as the issues of geographic isolation and lack of trained staff that are discussed above. Vision 2020 Australia considers that because CSC is an important indicator of how well the existing eye health system is working, the Australian Government should support its inclusion as an indicator of Universal Health Coverage in the Sustainable Development Goals.

21 Op cit, World Health Organisation.22 Op cit, Garap et al, 2006.

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Recommendation 4Vision 2020 Australia recommends that the Australian Government supports the inclusion of Cataract Surgery Coverage as a Universal Health Coverage indicator in the Sustainable Development Goals.

2.5 Supporting inclusive development by investing in good governance, health and education, law and justice and women‘s empowerment.

By ensuring eye health and vision care work in PNG integrates consideration of the needs of people with disability into all activities, programs, initiatives and policy, no-one will be excluded or left behind.The PNG PBL includes Callen Services, a leading provider of education, health and community-based rehabilitation services for people living with disabilities in PNG. Callen Services plays an important role on the PBL in advocating for the prevention of blindness within their networks.In the BHVI low vision situation analysis conducted in 2012, the prevalence of low vision among those aged fifty and older was estimated to be approximately eleven per cent, after excluding fifty per cent of people with cataracts and all people with refractive errors. In the Rapid Assessment of Cataract Surgical Services, fifty per cent of people with cataracts were considered to have low vision because of the poor vision outcomes of cataract surgery.23 Using the population estimates from 2010 and hypothesising that twenty-five per cent of people aged fifty years and older with vision impairment may benefit from low vision services, it is estimated that three in one hundred adults (16,500 of 0.55 million) aged fifty years and older in PNG would require low vision services24. Low vision is not included in the current curriculum for ophthalmology, nursing, refraction or Postgraduate Diploma in Eye Care. BHVI has worked with its local partners in PNG Eye Care to develop referral pathways with both Callan Services and St John’s Blind Services who support rehabilitation in PNG. PNG Eye Care staff have been trained in the provision of Low Vision Aids and a PNG Eye Care orthoptist has undergone specialist Low Vision training from the Hong Kong School of the Blind in September 2014. PNG Eye Care Vision Centres are equipped with Low Vision Aids and are all accessible to people with disabilities.

Ongoing support for service delivery is crucial in continuing to break through the barriers to people accessing eye health services. Research suggests that gender-based issues are a significant barrier, as women and girls have substantially less access to health care and education services than males. IAPB workshops on Gender and Service Delivery in PNG, notes that women in highland rural areas lack access to money and information. Women in urban areas are more likely to have access to transport to access services and to have a higher level of education and to be engaged in work or sports, therefore having greater mobility and opportunity to

23Garap JN, Sheeladevi S, Brian G, Shamanna BR, Nirmalan PK and Williams C. ‘Cataract and its surgery in Papua New Guinea.’ Clinical and Experiment Ophthalmology 2006; 34:880-885.

24 Chiang PP, O'Connor PM, Le Mesurier RT, Keeffe JE. ‘A global survey of low vision service provision.’ Ophthalmic Epidemiology 2011;18:109-21.

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access information and services.

Rates of gender-based violence in PNG are amongst the highest in the world.25 Education has been a cornerstone of BHVI efforts to address gender-based violence through its work with PNG Eye Care. Workshops have been held in Port Moresby with both male and female staff, as well as involving key staff in cross-culture seminars in Australia that address these issues and their impact on society and development.

PNG Eye Care has specifically targeted organisations (such as UN Women) as partners in gender based programs to redress the gender specific access issues in PNG. PNG Eye Care recognizes that by providing free eye checks to the working poor and their families through business houses, a larger number of women can be reached proactively, rather than waiting for them to attend Vision Centres or Eye Clinics. As a result, females now account for approximately fifty-five per cent of those who get spectacles from PNG Eye Care, which is an increase of twenty-five per cent. At PNG Eye Care two out of three Head Office staff members are female, and the training of four female spectacle technicians is aimed at further empowerment in the workforce.

A reduction in blindness and vision impairment will contribute to a reduction in the gender gap by increasing economic opportunity through access to education and employment, and by facilitating access to services and participation in communities. The Australian Government can actively seek to redress the severe gender inequalities in PNG by integrating the needs of women into all development activities. Vision 2020 Australia applauds the significant effort that the Australian government is making in this regard with its Pacific Women Shaping Pacific Development Program.

Recommendation 5Vision 2020 Australia recommends that the Australian Government ensures all development activities in PNG facilitate the inclusion of people who are blind or vision impaired and people with disability more generally in PNG.

Recommendation 6Vision 2020 Australia recommends that the Australian Government continues efforts to improve gender equality including addressing barriers to access to eye health for women and girls in PNG.

2.6 Establishing realistic performance benchmarks to assess aid outcomes against set targets and to improve accountability.

In 2012, Brien Holden Vision Institute (BHVI) conducted a study of knowledge, awareness and practices related to eye health in PNG. There is very little academic evidence of barriers to eye health service access, despite anecdotal evidence that women and children are disadvantaged.Development of a consistent and user friendly data collection and management system would make considerable progress towards improving accountability of eye 25 Chandler, J. (2014) ‘Violence against women in PNG: How men are getting away with murder.’ The Lowy Institute for

Public Policy. Accessed at http://m.lowyinstitute.org/files/violence_against_women_in_png.pdf.

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health and vision care in PNG. Support for a simple monitoring and evaluation (M&E) system that is driven by and universal to all eye health stakeholders (including public, private sector, civil society and churches) would result in increased accountability across the sector and the ability of the sector to respond to evidence based demand. Currently, there is a lack of data consistency between PBL member organisations including continuing disagreement amongst NGOs regarding definitions for collection criteria (for example the age range for who constitutes a child is disputed).  Key areas that need to be addressed for improved accountability through strengthened data management and M&E systems include:• Data collection and M&E systems need to be universal, consistent and user friendly

at all levels from ophthalmologists right through to community health workers.• All stakeholders should have access to the data collected.• Data collection and M&E systems could build on the experience of civil society,

public and private sector and so on. For example PNG Eye Care collects basic data on patients seen, referred, supplied with specs and disaggregates by age and gender for services they provide directly. However PNG Eye Care also operates a bulk spectacle supply to eye nurses around PNG, but there is no public system data accountability requirements for nurses to supply or share basic data regarding their own services.

• Any new systems need to be integrated within existing Health Information Management systems.

• Strengthened Ministry of Health capacity to coordinate, manage and circulate data findings for service planning and management.

Recommendation 7Vision 2020 Australia recommends that the Australian Government encourages the adoption of effective electronic data collection systems for eye health and vision care services in PNG.

2.7 The extent to which development outcomes in PNG can be improved by learning from successful aid programs in other countries.

There are many regional models engaging with the private sector to strengthen eye care systems and services. Some of the key examples the Vision 2020 Australia Global Consortium has identified as having potential transferability to PNG are:

• Data collection: There is an electronic data collection system currently being used in eye health services in the Solomon Islands. The data informs government health budgets and programming. This is a simple online database which works in a low resource setting. In PNG this type of system could provide useful data for the National Eye Program.

14 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea

• Non-Communicable Disease Hubs: The Non-Communicable Disease program in Fiji includes screening for diabetic retinopathy at NCD hubs which are set up near vision clinics. This is a collaborative program which involves the Pacific Eye Institute, World Diabetes Foundation and other partners. The NCD model could be usefully replicated in PNG.

• PacEYES: It would be useful for PNG to become more active in the Pacific Eye Care Society (PacEYES). Support should be given to eye health and vision care professionals to be members of PacEYES, and advocacy should be conducted for the PNG government to recognize PacEYES as a professional body which is working towards getting accreditation for their Continuing Professional Development program in the region – this will benefit the eye health workforce in PNG.

• Diabetic retinopathy training: In Tonga they rely on visiting ophthalmology teams, but there is a trained diabetic retinopathy medical assistant who conducts screening and treatment of diabetic retinopathy patients using laser surgery. In other pacific islands, mid-level staff members receive training to manage diabetic retinopathy according to Pacific diabetic retinopathy guidelines. It is important to encourage diabetic training at the Pacific Eye Institute for mid-level ophthalmic staff, so that screening rates in PNG can be increase and local and visiting ophthalmologists can be supported.

Recommendation 8Vision 2020 Australia recommends that the Australian Government supports the recognition of the Pacific Eye Care Society as a professional body by the PNG Government.

Recommendation 9Vision 2020 Australia recommends that the Australian Government encourages diabetic retinopathy training at the Pacific Eye Institute.

Recommendation 10Vision 2020 Australia recommends that the Australian Government considers Non-Communicable Disease Hubs as an effective option to strengthen eye health and vision care services in PNG.

15 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea

3 ConclusionVision 2020 Australia contends that the Australian Government’s bilateral aid program is uniquely placed to support PNG to achieve sustainable economic growth and poverty reduction and urges support from the Senate Standing Committee on Foreign Affairs, Defence and Trade for the ten recommendations contained within this submission. Preventing avoidable blindness and supporting people who are blind or vision impaired to participate in the economic and social life of their communities, is achievable for PNG with the right political and policy levers in place and the right interaction between government, non-government and private sectors.

16 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea

17 Submission to the inquiry into the delivery and effectiveness of Australia’s bilateral aid program in Papua New Guinea