Supporting the Ministry of Health to include eye heath indicators in the HMIS
In line with one of the VISION 2020 target, ensuring availability and accessibility of eye health information system, the Seeing is Believing (SIB) Project has invested in integrating eye health Information and Research system. This investment was mainly through influencing the Ministry of Health to build up additional eye health indicators from 3 to 11 within the wider Health Information Management System (HMIS). In addition, the SIB project facilitated the implementation of the Rapid Assessment of Avoidable Blindness (RAAB) in Muchinga Province of Zambia during the implementation of Phase 5 project.
These two outputs were achieved within the life span of the SIB project. The current HMIS has been expanded from 3 to a total of 11 indicators, capturing indicators on cataract, Allergic Conjunctivitis, Refractive errors, Purulent Conjunctivitis, Trachoma, Leukocoria, Eye Injury, Cornea Ulcer, Cornea Scar, Conjunctival growth and other eye diseases. In 2018, the HMIS was operationalised and was rolled over to all the District Health Offices. The increase in additional eye health indicators will assist the Ministry of Health as well as other interested stakeholders capture quality, timely and disaggregated data that will build into the National Health Strategic Plan. This will ensure that eye health is adequately planned for within the wider health budget and subsequently lead to improved health service delivery and in setting national health priorities.
Using RAAB data to understand prevalence & causes of blindness
In order to demonstrate the magnitude of blindness in the SIB project areas, Sightsavers provided technical and financial support to undertake the RAAB. The results were profound in informing the government on the magnitude of blindness in Muchinga Province. A total number of 3,600 persons aged 50 years and above were sampled; among these 3,502 (97.3%) were examined. The age and sex-adjusted prevalence of bilateral blindness (presenting VA < 3/60) was 4.1% (95% Confidence Interval [CI], 3.4-4.9%), and age and sex-adjusted prevalence of bilateral severe VI (VA of <6/60-3/60) was 3.1% (95% CI, 2.4-3.8%). Avoidable causes of blindness (i.e. cataract, glaucoma and non-trachoma corneal scarring etc) were responsible for 89.8% of bilateral blindness and 86.1% of bilateral severe VI.
Cataract was the major cause of blindness (53.0%); similarly, it was a major cause of severe VI (63.5%). The cataract surgical coverage in blind people adjusted for age and sex was low at 36.8% with significant gender difference of 45.8% for men and 27.6% for women. The main barrier for cataract surgery was inaccessibility of the service (49.1%); this was followed by lack of awareness of the available service (32.7%).
The result of the RAAB were disseminated and has since been adopted by the Ministry of Health in the implementation of key activities in the Muchinga region.
Strategies used to ensure eye health indicators were integrated into the health system HMIS
Sightsavers working with other eye care supporting organisation such as Orbis, Operation Eye Sight Universal (OEU), Lion Aid Norway (now Lion Aid Zambia) and Vision Aid Overseas, lobbied the MOH Monitoring & Evaluation Department (key MOH department in reviewing the HMIS) to allow for the review of the eye health indicators from 3 to a number that could capture more information and/or eye diseases. At the point of engagement with the M&E Department, the review had reached the point of finalisation for rolling out.
The eye care supporting organisations working as a team, lobbied through the National Eye Care Coordinator to reach out to the Director M&E and the Permanent Secretary MOH to allow for the inclusion of additional Eye health indicators. As a result of the unified engagement with the MOH, the eye care supporting organisation working with a constituted eye care team contributed to the inclusion of the indicators from 3 to 11. These have since been incorporated and included in the HMIS
Challenges with integrating eye health into the health system and how they were overcome
Zambia is faced with inadequate Human Resource for Health (HRH) generally in all spheres, however, the Human Resource for Eye Health is highly inadequate. This resultant factor in HReH crisis, makes it difficult for Districts with non-ophthalmic staff to capture accurate data that will assist in planning for and reaching people that need eye care services. As long as the HReH gap remains wide, the quality of information will be is negatively affected.
Despite the existence of the National Eye Health Strategy 2017-2021, there is limited investment from the government in terms of budget support to the implementation of the strategy. One of the reasons for this could be that eye does not appear on the top 10 causes of deaths in the country and could be the reason why most of the District Health Offices don’t prioritise it. As a result, eye health is less prioritised and this affects that quality of the service as well as information collected.
In order to address some of the challenges, the project facilitated for the annual review meetings attended by District Health Directors and the Ophthalmic Staff. The aim is to influence the District Health Directors prioritise Eye Health in their District Plans. Some Districts have incorporated eye health activities with under five clinics (Growth Monitoring and Nutrition). The project further supported the training of Community Health Workers (CHWs) in Primary Eye Care. The training mainly focused on disease identification and referral system to the District Eye clinic. The involvement of the CHWs has been instrumental in increasing the number of people accessing eye health services.
Benefits of integrating eye health indicators into the HMIS
The HMIS system captures disaggregated data focusing on gender and age group. The sex disaggregated data has helped the project analyse the gender dimension in terms of access to eye health services. As a result of this information, the project undertook key decisions to package Information, Education and communication (IEC) materials with gender inclusion in the delivery of eye health services. In addition, during the annual review meetings attended by the District Health Directors as well as Ophthalmic staff, the pictorial presentation on who is benefiting more based on gender is shared. This equally positions the District partner to package their outreach/community sensitisation messages to reach out to more women.