Primary Eye Care

PEEK VisionBy Rènée du Toit

Primary eye care is the eye health component of primary health care. The concept of primary health care (PHC) was proposed more than thirty years ago The Declaration of Alma-Ata as a way to improve fairness in access to health care and efficiency in the use of resources.

The eye health component of primary health care

In 2008, the WHO called for the revitalization of PHC in the World Health Report, “Primary health care – now more than ever“. Thus to enable access to quality eye health for all, the Universal eye health: a global action plan 2014–2019 (GAP) was designed to support “the integration of eye care into the health care system” and specifically, “the inclusion of “primary eye care” (PEC) into primary health care”. Such a health sector-wide approach can be especially effective when addressing conditions such as diabetes mellitus and vitamin A deficiency.

Recommended practises for the integration of eye health

The GAP recommends that the WHO secretariat “… provide Member States with tools and technical advice on primary eye care, and evidence on good leadership and governance practices in developing, implementing, monitoring and evaluating comprehensive and integrated eye care services.This poses a challenge in that little documentation1 or evidence exists about models for the effective integration and health system support required for the eye health component of PHC2.  Some lessons may be learned from other fields of health3.  For example, a Cochrane review concluded that although evidence is inadequate, non-specialist health workers and teachers have shown promising benefits in improving some mental health outcomes4.

Developing the capacity to provide eye health

The GAP further calls for “Support local capacity building for provision of eye care services, including rehabilitation services in line with policies, plans and programmes through national coordination mechanisms”. Ideally, all primary health care or frontline health facility workers, such as nurses or midwives, non-physician clinicians or general physicians should have the capacity to provide some curative, promotive and preventive eye health care, as part of their general health care duties. They should be able to detect and refer the eye problems that are beyond their scope of practice to allied ophthalmic personnel, ophthalmologists, and other specialists within eye care or in general practice. They should also receive referrals from community health workers, and provide links to other health and social services, inclusive education and rehabilitative services. For an approach such as this, integration at various levels5, effective referral mechanisms and well functioning referral sites are obviously required.

Limited evidence of the effective provision of eye health as component of primary health care

In Rwanda,6 the need for eye care at health centres was indicated by the increase in numbers of people who sought eye care after eye health training was provided to primary health care workers. Pilot projects in Zanzibar7 demonstrated that primary health care centres could successfully distribute presbyopic corrections, and in Dar-es-Salam8 that training could improve child eye health practices, but the effect seems to diminish over time.
 
In general, however, there is little evidence that eye health care is currently effectively provided by primary health care providers9. For example, the eye health knowledge and skills of samples of primary health care workers in Kenya, Malawi and Tanzania were found to be low10.  Also studies have reported that general practitioners in various high-income countries have inadequate training in and /or knowledge of ophthalmology11.

Work in progress

The IAPB Africa Human Resources for Eye Health Working Groups have developed sets of competencies for the eye health team; for primary/frontline health care workers, community health workers, allied ophthalmic personnel, optometrists, ophthalmologists. After validation in collaboration with WHO-AFRO, these will be available to countries to select competencies appropriate to their situation.
 
Decision-making in eye health care may be assisted with the use of new technology, PEEK,  apps, and aids such as algorithms, guidelines or protocols, which may be used in conjunction with m- or e-health12. The development and implementation of these and alternative, innovative strategies13 for the delivery of eye care within primary health care should be evidence based and thoroughly evaluated14.

Suggestions for further research

Additional evidence about how to effectively provide universal access to an eye health component of PHC is clearly required. Qualitative methods such as interviews, positive deviance and case studies may be useful to identify behaviour/practices, processes and systems that contribute to, primary/frontline health care workers effectively providing eye health care15.
 
Links

1. http://www.iapbafrica.co.za/resource/resourceitem/459/1 An Overview of Primary Eye Care in Sub-Saharan Africa 2006-2012 A retrospective survey of primary eye care activities in Sub- Saharan African countries, and accompanying challenges and recommendations, compiled from the reports from a series of workshops on primary eye care held in East, West, Southern and Central Africa between 2006 and 2012.

2. du Toit R, Faal HB, Etya’ale D, Wiafe B, Mason I, Graham R, Bush S, MathengeW, Courtright P. Evidence for integrating eye health into primary health care in Africa: a health systems strengthening approach. BMC Health Serv Res. 2013 Mar 18;13:

3. Joska JA, Sorsdahl KR. Integrating mental health into general health care: lessons from HIV. Afr J Psychiatry (Johannesbg). 2012 Nov;15(6):420-3.

4. van Ginneken N, Tharyan P, Lewin S, Rao GN, Meera SM, Pian J, Chandrashekar S, Patel V. Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database Syst Rev. 2013 Nov 19;11:CD009149. 

5. Valentijn PP, Schepman SM, Opheij W, Bruijnzeels MA. Understanding integrated  care: a comprehensive conceptual framework based on the integrative functions of  primary care. Int J Integr Care. 2013 Mar 22;13:e010.

6. Courtright P, Murenzi J, Mathenge W, Munana J, Müller A. Reaching rural Africans with eye care services: findings from primary eye care approaches in Rubavu District, Rwanda. Trop Med Int Health. 2010 Jun;15(6):692-6

7. Laviers H, Burhan I, Omar F, Jecha H, Gilbert C. Evaluation of distribution of presbyopic correction through primary healthcare centres in Zanzibar, East Africa. Br J Ophthalmol. 2011 Jun;95(6):783-7. 

8. Mafwiri MM, Kisenge R, Gilbert CE. A pilot study to evaluate incorporating eye care for children into reproductive and child health services in Dar-es-Salaam, Tanzania: a historical comparison study. BMC Nurs. 2014 Jun 2;13:15

9. Courtright P, Seneadza A, Mathenge W, Eliah E, Lewallen S. Primary eye care in sub-Saharan African: do we have the evidence needed to scale up training and service delivery? Ann Trop Med Parasitol. 2010 Jul;104(5):361-7. 

10. Kalua K, Gichangi M, Barassa E, Eliah E, Lewallen S, Courtright P. Skills of general health workers in primary eye care in Kenya, Malawi and Tanzania. Hum Resour Health. 2014;12 Suppl 1:S2. doi: 10.1186/1478-4491-12-S1-S2.

      Kishiki E, Hogeweg M, Dieleman M, Lewallen S, Courtright P. Is the existing knowledge and skills of health workers regarding eye care in children sufficient to meet needs? Int Health. 2012 Dec;4(4):303-6

      Byamukama E, Courtright P. Knowledge, skills, and productivity in primary eye care among health workers in Tanzania: need for reassessment of expectations? Int Health. 2010 Dec;2(4):247-52. doi:

11. Gibson C, Roche E. A survey of general practitioners’ knowledge and perceived  confidence with clinical ophthalmology. Ir Med J. 2014 Jun;107(6):173-5.

       van Zyl, LM Primary health eye care knowledge among general practitioners working in the Cape Town metropole. S Afr Fam Pract 2011;53(1):52-55

12. Kiage D, Kherani IN, Gichuhi S, Damji KF, Nyenze M. The Muranga Teleophthalmology Study: Comparison of Virtual (Teleglaucoma) with in-Person Clinical Assessment to Diagnose Glaucoma. Middle East Afr J Ophthalmol. 2013 Apr-Jun;20(2):150-7

13. Collings S, Mathieson F, Dowell A, Stanley J, Hatcher S, Goodyear-Smith F, Lane B, Munsterman A. Clinical effectiveness of an ultra-brief intervention for common mental health syndromes in primary care: study protocol for a cluster randomized controlled trial. Trials. 2015 Jun 5;16:260

14. Andriamanjato H, Mathenge W, Kalua K, Courtright P, Lewallen S. Task shifting in primary eye care: how sensitive and specific are common signs and symptoms to predict conditions requiring referral to specialist eye personnel? Hum Resour Health. 2014;12 Suppl 1:S3. 

15. Courtright P, Seneadza A, Mathenge W, Eliah E, Lewallen S. Primary eye care in sub-Saharan African: do we have the evidence needed to scale up training and service delivery? Ann Trop Med Parasitol. 2010 Jul;104(5):361-7.

       Habtamu E, Heggen A, Haddad D, Courtright P. Using a case study approach to document ‘preferred practices’ in mass drug administration for trachoma.Community Eye Health. 2014;27(88):s01-2.

       Lawton, R., Taylor, N., Clay-Williams, R., & Braithwaite, J. (2014). Positive deviance: a different approach to achieving patient safety. BMJ Quality & Safety, 23(11), 880–883.

       Lorenzo T, van Pletzen E, Booyens M. Determining the competences of community based workers for disability-inclusive development in rural areas of South Africa, Botswana and Malawi. Rural Remote Health. 2015 Apr-Jun;15(2):2919