By collaborating with child eye health relevant sectors including health, education, and disabled people’s federation (DPF), SiB V Shanxi CHEER (Children’s Healthy Eyes bring Educational Rewards) Project integrated child eye health into the health system at primary-, secondary- and tertiary-level in Shanxi China. Comprehensive eye care services for prevention, treatment, rehabilitation and early education were provided to children through the integration. Good outcomes were produced from the integration, e.g. improved capacity of eye care professionals, well-maintained equipment and facilities, improved the access, quality and efficiency of child eye health services. A new national policy was formulated for myopia prevention and control by the end of the project. Child eye health have been integrated into all aspects of local health system in the project. We are focusing more on learning from Leadership & Governance, Service Delivery, and Health workforce.
The child eye health network was established through the project by integrating into the governance of the general health network and expanded to the network of education sector and DPF at all levels. The senior governor and leader of these sectors were invited to the official launch and annual meetings of the project to understand and oversee eye health work as a part of their managerial work of the general health care. The governance of primary eye health also integrated into primary health care system from the county city to townships to villages, including school health. The integration paced with new policies issued by State Council, National Health Commission or Ministry of Education. For example, the project hospitals at county-/prefecture-/provincial- level jointed the Medical Care Consortium or Ophthalmic Specialist Alliance led by the tertiary hospital in the project. The networks focus on the two-way referral network, technical support, and quality assurance to institutions at lower level. This integrated and maximized the utilization of the available healthcare resources. Eye health also aligned with Ministry of Education’s policy of “Integrate Medicine & Education, Work with Family and Community” for children with visual or multiple disabilities in the project. These integration in leadership and governance of the health system was undertaken through multiform advocacy activities to motivate and inspire local stakeholders.
- Health workforce
The workforce of child eye health was integrated into the child health system by making use of the existing health workers, e.g. village doctors/community rehabilitation workers or teachers/school health workers for screening, nurses for optical service, administration staff for project management and so on. Task shifting, staff redeploying, or allowing multiple tasks were applied to substitute the shortage of eye care workforce. Training were provided to develop the competence or upgrade the skills of child eye care. With the same strategy of the management of general health workforce, eye care professionals were dispatched from the lead tertiary hospital in the Ophthalmic Specialist Alliance to counties to provide hands-on technical mentoring or to conduct the post-training follow-up through WeChat groups (social network app.) to ensure the quality of training. The joint reward certificates were co-issued by multiple sectors and INGOs to motivate those outstanding institutions or individuals. The integration of health workforce improved the capacity and availability of child eye care services at county-level, facilitated the application of the national policy about the tiered diagnosis & treatment, and in turn, further strengthened the health system.
- Service Delivery
The service delivery on child eye health was horizontally and vertically integrated into three-level health care system within the health sector and cross-sectors. The vertical integration included the referral & tiered service pathway from primary to tertiary, e.g. screening & referral and health education in schools & villages integrated into primary health workers’ general health practices at the primary-level; optical service, treat simple eye condition and referral complex cases at the county-level; managing complex cases, technical support to counties at the tertiary-level. Horizontal integration of service delivery created between the ophthalmic department and other specialties like maternal & child health department for children at 0-6 year-old, e.g. ROP screening in aligned with national health policy. Good collaboration between the ophthalmologist and the neurologist or other subspecialists treated more complicated eye diseases in children and raised awareness of the importance of treating a child patient as a whole person rather than solely focusing on the affected eye. Cross-sectoral service integration included service referral between the health care department and the educational sector or the PDF. Child eye health professionals and children both benefited from the integration. The eye health services were the needs-based and child-centered, which was in accordance with what has been promoted by National Health Commission (NHC)/MOH through the health care networks, e.g. Medical Care Consortium or Specialist Alliance. The integration improved the access & coverage, quality & safety, efficiency & satisfaction of the eye care system.
- Information & Research
Training and sharing information or progress of the project were integrated into local cross-sectors’ routine agenda of the general health system, e.g. monthly meetings or annual continuous medical education for village doctors. Evidence from small researches conducted in the project informed actions for improving service provision such as screening & referral, ROP awareness raising, and early educational intervention to pre-school children with visual or multiple disabilities through the medical-educational model.
- Health Care financing
Advocacy for integrating certain child eye care into the health insurance successfully achieved at tertiary-level and some of prefectural-level in Shanxi Province, e.g. to cover strabismus/ptosis surgery.
- Medical products & technologies
Advocacy was also conducted for integrating newly established low vision service into the health system, e.g. to be included in the list of medical services. Sources of the rehabilitation devices for functional vision assessment was identified for sustaining low vision service after the close-out of the project.
We overcame some challenges during integrating child eye health into the health system. For example, village doctors or teachers misunderstood screening as making diagnosis on eye disease as eye doctors did in the early stage of the project, so they were reluctant to do screening. Further training in theory and hands-on were provided to them then they fully understood that they were expected to conduct only primarily screening about the suspicious ocular or vision abnormality. Another case was about the collaboration and integration of medical and educational models. Medical and educational personnel had served children with visual impairment and blindness in silo. The project provided training on why and how to collaborate through home-visit to children with visual or multiple disabilities as a team. They observed and learned how to perform the functional vision assessments and recommend rehabilitative and/or educational strategies to the family through home visits. They were inspired by striking changes happened on children who benefited from the medical-educational model.
By integrating child eye health into the health system in above aspects, the following impact were generated in the project:
- the accessibility, demand and utilization of child eye health services improved in project areas.
- the capacity of child eye health services improved, e.g. screening & referral, treatment including optical services, low vision rehabilitation and early educational interventions.
- the quality of life of children with visual and/or multiple disabilities improved.
- the availability of the service provision of child eye health at project counties generated economic impact such as from the decreased refractive errors.
- catalyzed the national policies for myopia prevention and control among children, which was issued at the end of project in August 2018.
Senior Program Manager
Orbis International, North Asia