Why do we do what we do?
The negative impact of uncorrected refractive error on children is well-documented: limited academic achievement (1,2), a risk to mental health (3), distress (4), and reduced quality of life (5). However, its correction could improve academic (6,7) and mental health outcomes (8). In 2017, Vision Aid Overseas (VAO) [ now Vision Action] piloted a school-based eye health programme (SBEHP) in Kafue district, Zambia. After screening 18713 children, 3.33% had vision-impairing uncorrected refractive errors, and 17% had non-refractive eye conditions. These findings have two implications. Firstly, there are critical unmet eye health needs among Zambian children. Secondly, these findings are critical for future planning since there were no reliable national estimates on vision impairment among children. In other words, we can now plan for the future on the basis that an estimated 20% of Zambian school children have unmet eye health needs.
The SBEHP aligns with the Zambian National Health Strategic Plan 2017–2021 and the National Eye Health Strategic Plan 2017–2021. The National School Screening Programme Protocol 2020 was also developed through the pilot. All the learning from the Kafue Pilot Programme points us to the need for upscaling the programme interventions in Zambia. The question is, how can it be done systematically to ensure its effectiveness and sustainability?
What is next?
At the conclusion of the Pilot Programme, VAO conducted a robust upscaling assessment (9) using the WHO-ExpandNet framework to determine the potential to upscale the SBEHP, the scope of SBEHP, partner organisations’ roles, responsibilities and capacities, the resources needed to operationalise SBEHP and the facilitators and inhibitors for scaling up.
What did we find?
Key information: Zambia has a population of 20 million in 2022, divided into 10 provinces and 105 districts. It has 99 first-level hospitals, 1839 health centres and 953 health posts. The per capita health expenditure was $67.75. The enrolment rates in primary school education (7 to 13 years old) and secondary schools (14 to 18 years) stand at 83% and 75%, respectively. The district is responsible for implementing health promotion, preventive, curative, and rehabilitative services. Administratively, the district health office is responsible for coordinating service delivery at that level. Each district has a district hospital, which provides first-level referral services. Below the district, there are health centres which provide both static and outreach activities. These are staffed by a clinical officer, midwife, nurse, and environmental officer. The main activities at the health centre level are health promotion and disease prevention. Some limited curative services are also provided, with complicated cases referred to first-level district hospitals. Each health centre is responsible for running key health programmes, which include maternal, newborn and child health, communicable and non-communicable diseases, environmental, water and sanitation, school health and nutrition, and epidemic preparedness (NHSP, 2012).
The Innovation: The pilot SBEHP comprehensively covered all aspects of child eye health. The SBEHP addressed the shortage of ophthalmic health workers by training schoolteachers as screeners and bringing services closer to the community using the Mobile Eye Health Clinics. There is a need to strengthen community and local leaders’ sensitisation to secure commitment and support.
User Organisations: All three user organisations – VAO, MOH, and MoGE – agreed to upscale the comprehensive SBEHP. The roles and responsibilities are clear: MoGE will be the main implementer in Zambia, supported by the Ministry of Health and Vision Aid Overseas. There is also a great need to involve other potential partners working in child and eye health to scale up the SBEHP.
Resource Team: The local team implementing the pilot project will be employed for future upscaling because they understand the political, social, and cultural environments and can plan and implement the upscaling effectively. They have also built strong relationships with relevant stakeholders. Nevertheless, capacities such as monitoring, evaluating, and advocating for formalising the programme must be strengthened further.
Environment: The schools and communities showed no objections to the SBEHP. Enabling environments such as supporting teachers with training, small incentives and meals, and transportation reimbursement might lead to schoolteachers’ dedication to the programme. The identified inhibiting factors include the shortage of funding and the limited supply chain, the risk of discontinuation of advocacy efforts if there are changes in government administration and uncertainty about the timeline for the inclusion of SBEHP into the existing School Health and Nutrition Programme.
Horizontal Scaling-up: It would be more realistic to gradually expand the SBEHP to a new district rather than a province without compromising the essential components of the programme. The pilot project evidenced this – 154 schoolteachers were trained to screen 18,713 schoolchildren in 73 schools over 6 months, based on the needs and existing financial and human resources available within the user organisations. The cost to screen and/or treat a child (with eye drops/spectacles) was estimated to be £3.35. The success of scaling up will depend on the accuracy of key data and our ability to convert this into a budget.
Future considerations and opportunities:
Two issues remain. One, the Mobile Eye Clinic approach may be effective in reaching the community in the short term, but we will need to address its sustainability issue in the long run. Two, there is still a large number of out-of-school children who are not reached through the SBEHP. Both issues highlighted the need to invest in Zambia’s primary eye care and vision centres, the two key components of a successful school eye health programme. A reliable supply of eye drops for conjunctivitis is to be prescribed and supplied by the nearest Heath Centre/Health Posts. A supply of spectacles from the nearest Vision Centre is to obviate the need for outreach.
Despite school eye health being included in the Zambian National Health Strategic Plan and National Eye Health Strategic Plan, concrete action was not highlighted or emphasised. Integration of the comprehensive SEHP into the existing School Health and Nutrition Programme is crucial, and this formal institutionalisation secures government funding, and therefore programme sustainability can be ascertained. An implementation study in Zanzibar also showed that an integrated school eye health programme is more cost-effective and performs better than a standalone programme (10). Continued efforts such as constant engagement with the government and working closely with strong advocates within the government departments will contribute to the integration’s success.
Shashidhar S, Rao C, Hegde R. Factors affecting scholastic performances of adolescents. Indian J Pediatr. 2009;76(5):495-499.
Shankar GS, Sujakhu D, Joshi P. Refractive error among school children in Jhapa, Nepal. J Optom. 2011;4(2):49-55.
Li D, Chan V, Virgili G, et al. Impact of vision impairment and ocular morbidity and their treatment on depression and anxiety in children: A systematic review. Ophthalmology. 2022.
Fai V, Id C, Singer S, Naidoo KS. Disability-related-distress in primary school learners with vision impairment due to uncorrected refractive error in KwaZulu-Natal Province, South Africa – a qualitative study. 2020:1-16.
Chadha R, Subramanian A. The effect of visual impairment on quality of life of children aged 3-16 years. Br J Ophthalmol. 2011;95(5):642-645.
Ma X, Zhou Z, Yi H, et al. Effect of providing free glasses on children’s educational outcomes in China: cluster randomised controlled trial. BMJ. 2014;349:g5740. doi:10.1136/bmj.g5740
Glewwe P, Kristine LW, Jongwook L. The Impact of Providing Vision Screening and Free Eyeglasses on Academic Outcomes: Evidence from a Randomised Trial in Title I Elementary Schools in Florida. J Policy Anal Manag PMC. 2018;176(1):100–106.
Guan H, Wang H, Du K, Zhao J, Boswell M, Shi Y, Qian Y. The effect of providing free eyeglasses on children’s mental health outcomes in china: a cluster-randomized controlled trial. International Journal of Environmental Research and Public Health. 2018 Dec;15(12):2749.
Yong AC, Buglass A, Mwelwa G, Abdallah I, Chan VF. Can we scale up a comprehensive school-based eye health programme in Zambia? BMC Health Serv Res. 2022;22:945.
Chan VF, Omar F, Yard E, et al. Is an integrated model of school eye health delivery more cost-effective than a vertical model? An implementation research in Zanzibar. BMJ Open Ophthalmol. 2021;6(1).