Strengthening primary eye care in South Africa: An assessment of services and prospective evaluation of a health systems support package

Abstract

Visual impairment is a significant public health concern, particularly in low- and middle-income countries where eye care is predominantly provided at the primary healthcare (PHC) level, known as primary eye care. This study aimed to perform an evaluation of primary eye care services in three districts of South Africa and to assess whether an ophthalmic health system strengthening (HSS) package could improve these services. Baseline surveys were conducted in Cape Winelands District, Johannesburg Health District and Mopani District at 14, 25 and 36 PHC facilities, respectively. Thereafter, the HSS package, comprising group training, individual mentoring, stakeholder engagement and resource provision, was implemented in 20 intervention sites in Mopani District, with the remaining 16 Mopani facilities serving as control sites. At baseline, less than half the facilities in Johannesburg and Mopani had dedicated eye care personnel or sufficient space to measure visual acuity. Although visual acuity charts were available in most facilities, <50% assessed patients at the correct distance. Median score for availability of nine essential drugs was <70%. Referral criteria knowledge was highest in Cape Winelands and Johannesburg, with poor clinical knowledge across all districts. Several HSS interventions produced successful outcomes: compared to control sites there was a significant increase in the proportion of intervention sites with eye care personnel and resources such as visual acuity charts (p = 0.02 and <0.01, respectively). However, engaging with district pharmacists did not improve availability of essential drugs (p = 0.47). Referral criteria knowledge improved significantly in intervention sites (p<0.01) but there was no improvement in clinical knowledge (p = 0.76). Primary eye care in South Africa faces multiple challenges with regard to organisation of care, resource availability and clinical competence. The HSS package successfully improved some aspects of this care, but further development is warranted together with debate regarding the positioning of eye services at PHC level.

Peer-support to increase uptake of screening for diabetic retinopathy: process evaluation of the DURE cluster randomized trial

“…This was foreseeable, given the structure of the hospital. These individual, social, and organizational level barriers are consistent with those in the literature [12,[21][22][23]. Some hospitals are testing the effectiveness of conducting DR screening at the diabetes clinic to overcome this challenge [24].…”

“…We therefore conclude that health system strengthening such as the development and implementation of clinical guidelines was a facilitator for the implementation of the intervention as well as adoption of screening behaviour by the participants. Several studies have found that health system strengthening gives traction to heath care interventions [18][19][20][21].…”

Prevalence and associated factors of vision loss in the South African National Health and Nutrition Examination Survey (SANHANES-1)

“…Most eye care providers (ophthalmologists and optometrists) in South Africa are with the private sector in the urban areas of the provinces, leaving minimal numbers in the public sector to cater for the majority of the populace [ 67 ]. Hence, with a considerable proportion of the people in poverty living in rural areas [ 68 ], coupled with the differences in the distribution of healthcare personnel, and the unavailability of eye care service providers in the rural areas as compared to the urban communities, make access to health care services extremely challenging and thus, may lead to increased prevalence of vision loss in the rural areas [ 69 – 72 ]. Furthermore, blurred vision and difficulty reading were the main contributors to vision loss in our study.…”

“…Further, a prospective study by Lilian et al, which assessed the primary eye care services in three South African districts, showed the need for introducing health system strengthening (HSS) package in primary eye care delivery. The study revealed that HSS enhanced organizational care and clinical practice [ 77 ]. Therefore, to curb the increasing occurrence of people going needlessly blind or having visual impairments, it is imperative that policymakers institute measures that aim to integrate ocular health promotional activities in the primary health care system.…”

Eye care utilization pattern in South Africa: results from SANHANES-1

“…Eye health promotion requires a holistic approach that empowers both individuals and communities [17] to take action for their eye health as well as strengthening sectoral partnerships at the district and national level. A prospective study [18] which evaluated primary eyecare services in three South African districts revealed that introducing a health system strengthening (HSS) package strengthened primary eyecare through improvement in organizational care and clinical practice. Therefore, assessing the patterns of eye care utilization is essential for appraising current eye health promotion systems [6,14].…”