Effective scale up of refractive error and primary eye care service within a District Health System: Results of the Seeing is Believing Program in the.

Effective scale up of refractive error and primary eye care service within a District Health System: Results of the Seeing is Believing Program in

the province of KwaZulu-Natal, South Africa

Kovin S Naidoo1, 2, 3, Kesi Naidoo1,2, Yashika Maharaj2, Prasidh Ramson,2, Diane Wallace,2,3 and Reshma Dabideen,2

1International Centre for Eyecare Education, Durban, South Africa2African Vision Research Institute (AVRI), 3University of KwaZulu-Natal

Giving Sight to Africa• Standard Chartered Bank - Seeing is

Believing

• KwaZulu-Natal DOH

• 1.28 Million USD

• July 2007 to June 2011

Giving Sight to Africa

July 2007 to June 2011

Population: 10 Million

11 Health Districts

OBJECTIVES

• Development of guidelines for Eye care within District Health System

• Guiding principle: Sustainability through integration

Suburb 2

Municipality 1

Municipality 2

THE DISTRICT HEALTH SYSTEM• Building blocks of the national health system – South Africa = 53

health districts• Structure of the District health system

Health District

CHC

CHC

CHC

Clinic

Suburb 1 Clinic

Clinic

Suburb 3 Clinic

Clinic

Clinic

Suburb 4 Clinic

Clinic

DH

DH

RH

HRD

PEC ON Optom

Professional Nurses

National Guideline

4 day training

TOT approach

Nurse Educators

Skills Audit

In – service program

CHALLENGE

Training

BECN

Recruitment

SLA

-Project supported-DOH commitment to take over funding secured upfront

Develop skills in line with scope of practiseUtilise existing cadres’

Referral protocol and policy

Define service available at different levels

CO

NS

ULTA

TIO

N

To ensure efficient utilisation of scarce human resources and effective management of patients

Define referral criteria

Define referral pathway

Clinic

CHC

DH

RH

Infrastructure Development

Advocate for space

Equipment donation process

Define Physical space needed at institutions

Define Equipment needs for cadres

Provide equipment to cadres

Data

Parallel Data Collection Process

Direct reporting to project

Worked well for optometrists - direct contact

Poor reporting from PHC

Resource intensive

DHIS

New indicators developedImproved reportingSustainable

Training – overviewCadre Trained Key Competencies Developed Duration of Training

Primary Health Care Nurses Part 1 Measurement of Visual acuity Identification of basic eye

pathological conditions5 days

Primary Health Care Nurses Part 2

(Advanced Training offered to

a percentage of those that completed Part 1)

Ophthalmoscopy Identification of basic posterior

segment diseases5 days

Ophthalmic Nurses Basic Refraction Diagnosis & Management of Ocular

Disease5 days

Optometrists Low Vision Assessments

5 days Treatment of Binocular Vision

Anomalies Posterior Segment Pathology

2 days

Numbers TrainedLevel Cadre 07/08 08/09 09/10 Total

Trained

PHC Primary Health Care

Nurses - Part 1

92 540 292 924

Primary Health Care

Nurses - Part 2

    75 75

CHC; District; Regional

and Tertiary

Ophthalmic Nurses     42 42

Optometrists   38   38

Total Trained 1004

RESULTS

Primary Eye Care service

PHC – Reporting from clinics

YEAR Number of PHC Clinics reporting

Percentage of reports received

Percentage of patients treated by PHC nurse

2007 22 67 58

2008 107 39 59

2009 643 50 66

2010 702 76 80

2011 731 53 84

PHC – Patients examined

Jul - Dec 07 Jan - Jun 08 Jul - Dec 08 Jan - Jun 09 Jul - Dec 09 Jan - Jun 10 Jul - Dec 10 Jan - Jun 110

20000

40000

60000

80000

100000

120000

44178736

20373

51820

63291

84346

71153

99422

PHC

PHC

Optometry Service

Optometrists

• 0nly 6 in the public sector at inception in July 2007

• Supported recruitment through initial employment of optometrists • Negotiated with institutions in advance to secure

future employment• Marketed opportunities to graduating classes

• 38 optometrists in the public sector at June 2011

Optometry – Reporting from clinics

YEAR

Year

Number of Clinics

reporting

Percentage of reports received

Average number of

patients per report

2007 50 82 37

2008 61 130 23

2009 84 276 18

2010 116 293 14

2011 124 274 13

Optometry – Patients examined

Jul - Dec 07 Jan - Jun 08 Jul - Dec 08 Jan - Jun 09 Jul - Dec 09 Jan - Jun 10 Jul - Dec 10 Jan - Jun 110

5000

10000

15000

20000

25000

30000

35000

40000

4393

6527 6570

15774

18466

23648

1482815973

28061689

46175961

7011

9821

6001

8241

1715 2143667

1616 1681 2051 1727 2333

891410359

11854

23351

27158

35520

22556

26547

District

Regional

Tertiary

Total

Optometry service percentage by level

Jul - Dec 07 Jan - Jun 08 Jul - Dec 08 Jan - Jun 09 Jul - Dec 09 Jan - Jun 10 Jul - Dec 10 Jan - Jun 110%

10%

20%

30%

40%

50%

60%

70%

80%

49%

63%

55%

68% 68%67% 66%

60%

31%

16%

39%

26% 26%28% 27%

31%

19%21%

6% 7% 6% 6%8% 9%

District

Regional

Tertiary

Assistive Device’s dispensed

Jul to Dec 2007 Jan to Jun 2008 Jul to Dec 2008 Jan to Jun 2009 Jul to Dec 2009 Jan to Jun 2010 Jul to Dec 2010 Jan to Jun 20110

1000

2000

3000

4000

5000

6000

7000

8000

9000

4622

5288

4439

7579

6148

7916

6196

7813

Overview by service level

% age of patients examined by level

Jul - Dec 07 Jan - Jun 08 Jul - Dec 08 Jan - Jun 09 Jul - Dec 09 Jan - Jun 10 Jul - Dec 10 Jan - Jun 110%

10%

20%

30%

40%

50%

60%

70%

6%8%

17%

34%

44%

49%

54%

57%

65%

56%

48%

40% 40%39%

31% 30%

17%

28%

31%

25%

11%8% 9%

8%

11%

8%

3%1%

5% 4%5% 5%

PHC

District

Regional

Tertiary

Conclusion

Working within the DHS provides the opportunity for developing sustainable service delivery systems that are

able to address the needs of large populations

This is most effectively achieved through institutionalisation of program components

Sufficient time for Advocacy and program development consultation is essential to ensure success

THANK YOUKesi Naidoo

Sub Regional Manager: Southern Africa

Brien Holden Vision Institute

[email protected]