Eye care delivery for VISION 2020

BackgroundThe burden of disease of hearing disorders among adults is high, but a significant part goes undetected. Screening programs in combination with the delivery of hearing aids can alleviate this situation, but the economic attractiveness of such programs is unknown. This study aims to evaluate the population-level costs, effects and cost-effectiveness of alternative delivering hearing aids models in Tamil Nadu, IndiaMethodsIn an observational study design, we estimated total costs and effects of two active screening programs in the community in combination with the provision of hearing aids at secondary care level, and the costs and effects of the provision of hearing aids at tertiary care level. Screening and hearing aid delivery costs were estimated on the basis of program records and an empirical assessment of health personnel time input. Household costs for seeking and undergoing hearing health care were collected with a questionnaire (see Additional file 2). Health effects were estimated on the basis of compliance with the hearing aid, and associated changes in disability, and were expressed in disability-adjusted life years (DALYs) averted.ResultsActive screening and provision of hearing aids at the secondary care level costs around Rs.7,000 (US$152) per patient, whereas provision of hearing aids at the tertiary care level costs Rs 5,693 (US$122) per patient. The cost per DALY averted was around RS 42,200 (US$900) at secondary care level and Rs 33,900 (US$720) at tertiary care level. The majority of people did consult other providers before being screened in the community. Costs of food and transport ranged between Rs. 2 (US$0,04) and Rs. 39 (US$0,83).ConclusionActive screening and provision of hearing aids at the secondary care level is slightly more costly than passive screening and fitting of hearing aids at the tertiary care level, but seems also able to reach a higher coverage of hearing aids services. Although crude estimates indicate that both passive and active screening programs can be cautiously considered as cost-effective according to international thresholds, important questions remain regarding the implementation of the latter.

To identify level of job satisfaction among physicians at secondary and tertiary care levels. Random sample of 450 secondary and 523 tertiary care physicians filled in structured questionnaire about job satisfaction. Among secondary care physicians, 37.4% had extra work compared with 16.1% of tertiary care workers. More than 87% of both groups reported exposure to work-related violence. Physicians reported somewhat satisfaction for general work condition, promotion and financial aspects, work activities, and total satisfaction score with significant differences between studied groups. Significantly higher tertiary care physicians reported satisfaction with relationship in work and supervision at work compared with secondary care workers. Job satisfaction was significantly affected by age in years, number of shifts per month, years of experience, gender, being single or ever married, and having extra work. There is moderate level of satisfaction with significant differences in relation to level of care.

BackgroundRegular measurement of the availability and use of key medicines for non-communicable diseases allows the tracking of progress to achieve equitable access to medicines. Using a country-level public sector monitoring system for medicine supply, we aim to evaluate the availability and use of losartan 50 mg tablets and metformin 850 mg tablets between 2015 and 2020 investigating the impact of different policy changes and the COVID-19 pandemic.MethodsData from the Peruvian National System of Medicine Supply were analyzed using an interrupted time series analysis with known and unknown structural breaks. The outcomes assessed were medicine use (monthly doses dispensed at facilities over time) and medicine availability (proportion of facilities that reported having the medicine available).ResultsThe use of losartan and metformin at the primary level of care had a linear increasing trend over the period of analysis. In secondary and tertiary levels of care, there were no increases but some significant level and trend changes of doses dispensed at different times between 2017 to 2019, but none were related to the change of procurement procedures. At all levels of care, the COVID-19 onset in April 2020 caused an abrupt drop in doses dispensed especially at the primary level. Regarding availability, we found an increasing linear trend in the primary level of care for both medicines. In secondary and tertiary levels of care, the availability fluctuated between 40 and 95%. The onset of the COVID-19 pandemic did not significantly impact medicine availability, except for losartan in the tertiary level of care.ConclusionThe availability and proper dispensing of first-line medicines for hypertension and diabetes is an essential factor for sustainable and equitable treatment. Health care systems need to be prepared for forecasting the increasing demand of medicines for chronic diseases, but also to maintain effective medicine supply chains during humanitarian crisis like pandemics.

In 2016, the prevalence of chronic obstructive pulmonary disease (COPD) and asthma in India was 4.2% and 2.9%, respectively.[1] The leading risk factors were ambient and household air pollution, tobacco use, and occupational exposure. The control and management of both these chronic respiratory diseases requires a strict adherence to medications and follow-up guidelines. Recent evidence suggests that Vitamin D can play a role in the control of exacerbations of COPD and asthma. In India, recent decades show an epidemic of Vitamin D deficiency from community-based studies, with the prevalence ranging from 50% to 90%.[2] Vitamin D and its metabolites have a significant clinical role because of their interrelationship with calcium homeostasis and bone metabolism. Vitamin D may also regulate many other cellular functions such as muscle and bone strength and immune and cardiovascular system. The primary source of Vitamin D is sunlight, and all other dietary sources provide <10% of the daily requirement.[3] Should Vitamin D levels be routinely measured in all patients of COPD and asthma? What role does the supplementation of Vitamin D play in reducing the exacerbation of COPD and asthma? How does the genetic polymorphism in Vitamin D metabolic pathway affect the control of asthma? The current issue of the journal carries two original articles which address these questions.[45] Mishra et al. in a hospital-based case–control study among persons >40 years old demonstrated a positive linear relation between serum concentration of Vitamin D and lung function (forced vital capacity and forced expiratory volume in 1 s), after controlling for confounders such as age, sex, body mass index, and smoking-matched participants. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines do not support the supplementation of Vitamin D for the prevention of exacerbations of COPD in unselected patients.[6] A systematic review and meta-analysis of individual participant data from three randomized controlled trials by Jolliffe et al. concluded that Vitamin D supplementation safely and substantially reduced the rate of moderate-to-severe COPD exacerbations in patients with baseline 25-hydroxyvitamin D levels <20 nmol/L but not in those with higher levels.[7] These three randomized controlled trials were conducted among European participants at the secondary care level using a GOLD spirometry grading system.[8910] They differed in the dosage and schedule of Vitamin D supplementation. The study findings support routine testing of 25-hydroxyvitamin D among COPD patients who experience exacerbations. It also supports giving Vitamin D supplementation to those COPD patients with 25-hydroxyvitamin D levels <25 nmol/L. Rajaram et al. in their hospital-based study among 18–50-year-old South Indian patients with bronchial asthma demonstrated the effects of genetic polymorphisms in Vitamin D metabolic pathway on Vitamin D level and asthma control.[5] They concluded that Vitamin D receptor polymorphism (rs2228570) was found to be protective against asthma exacerbations. There were poor correlations and insignificant associations of single-nucleotide polymorphisms and serum 25-hydroxyvitamin D levels among asthma patients and healthy controls. The Global Initiative for Asthma guidelines do not support the supplementation of Vitamin D for the prevention of exacerbation of asthma.[11] A systematic review and meta-analysis of individual participant data from seven randomized controlled trials by Jolliffe et al. studied the pooled estimate of the protective effects of Vitamin D against asthma exacerbations requiring treatment with systemic corticosteroids.[12] It also investigated the effect of Vitamin D supplementation on risk of asthma exacerbation according to baseline 25-hydroxyvitamin D concentrations. All these seven randomized controlled trials were conducted at secondary and tertiary care levels, among children and adults. The Vitamin D supplementation dosage and schedule varied among the studies. All the studies gave oral Vitamin D3 supplementation to participants in the intervention arm. Minimum dose given was 500 IU/day to a maximum of 4000 IU/day. Three of the randomized controlled trials also gave a bolus dose of Vitamin D3 ranging from 100000 IU to 120000 IU.[131415] The authors concluded that Vitamin D supplementation reduced asthma exacerbations treated with oral corticosteroids when compared with placebo. Nevertheless, differences across subgroups, including baseline 25-hydroxyvitamin D status, did not reach statistical significance. Therefore, which group of patients will have preventive effects of Vitamin D supplementation is still not known. The Indian Chest Society and National College of Chest Physicians, along with the Postgraduate Institute of Medical Education and Research, Chandigarh, framed guidelines for the diagnosis and management of COPD and bronchial asthma.[1617] These guidelines were made to bridge the gaps in recognition and management of COPD and asthma in India due to the differences in availability and affordability of health-care facilities across the country. None of these guidelines recommends the role of Vitamin D supplementation for the prevention of exacerbations in COPD and asthma patients. These guidelines require an update based on recent evidence from India. The patients with COPD had an increased risk for Vitamin D deficiency when compared to their controls.[18] The prevalence of Vitamin D deficiency increases as the severity of COPD increases.[19] COPD can also lead to osteoporosis and osteopenia.[20] These evidence were from cross-sectional and case–control studies. The casual association of COPD leading to Vitamin D deficiency has not been established. A systematic review and meta-analysis of observational studies by Jat and Khairwa studied the association of Vitamin D and asthma in children.[21] It concluded that asthmatic children had lower Vitamin D levels than nonasthmatic children. With the available data from India, the evidence is equivocal on the usefulness of routine measurement of Vitamin D levels among patients with COPD or asthma. However, patients with exacerbations can be followed up with measurement of 25-hydroxyvitamin D levels. This would provide an evidence base for initiating Vitamin D supplementation to them, as well as assist in planning future course of action. The Indian Council of Medical Research guidelines on recommended dietary allowance for Vitamin D are set at 400 IU/day. With the recent epidemic of Vitamin D deficiency among all age groups and the supplementation of Vitamin D being inexpensive, supplementation programs may be beneficial for reducing exacerbations in COPD and asthma patients. As correctly stated by Mishra et al. in their article in this issue of the journal, it is not clear whether abnormal level of Vitamin D is a consequence of COPD or a contributor to COPD.[4] Even if it is a consequence of COPD, its supplementation in the Vitamin D-deficient individual would have a positive effect on other systems of the body as well. India is a country of diversity with different ethnicity and origin. The genetic polymorphisms that lead to changes in the Vitamin D metabolic pathway need to be researched. Further genetic sequencing studies are required to understand the role of genetic polymorphisms in understanding the metabolism of Vitamin D and its effect on bronchial asthma. Randomized controlled trials and cohort studies in the Indian settings are required to understand the role of Vitamin D supplementation in the prevention of exacerbation among COPD and asthma patients.

Background To understand barriers and promoters for accessing eye care by rural communities, we used a modified approach to Photovoice, a community-based participatory action research approach Methods Community members took photographs and wrote or spoke stories based upon a series of questions intended to facilitate deeper thinking. Fifteen rural paramedical team members who were affiliated with the rural network of L V Prasad Eye Institute, and 60 people from four villages reported barriers and promoters for eye care access for 20 villages Results Important barriers for accessing eye care included the following: no caretaker at home for grandchildren except for the grandparent(s), alcoholism, uncontrolled blood pressure, inadequate diabetes management, lack of escort for blind people and elders, affordability, and inadequate clinic staffing during summer season when farming villagers were available. Important promoters for seeking eye care included having a neighbor who had a good surgical outcome in one eye which resulted in the ability to resume work. The Photovoice project offered specific suggestions to hospital management for improving eye care access, including providing evening transportation, providing additional surgical staffing during busy summer season, and the creation of tool spectacle repair kits to be kept at the primary vision centers Conclusions This Photovoice project facilitated a deeper understanding of the important barriers and promoters for accessing eye care by villagers, and by the rural eye care team, offering specific suggestions to hospital management for improving eye care access and to communicate without any inhibiting factors like fear of hierarchy within the hospital administration.

The study examines the behavioral intention to use an AI doctor at the individual level at primary, secondary, and tertiary care levels. The research model has been designed according to the unified theory of acceptance and use of technology to understand the acceptance and use of an AI doctor at the individual level. The causal comparison screening approach, which is used to identify the causes and effects of people’s attitudes, behaviors, ideas, and beliefs, has been employed. This study utilized a hybrid analysis methodology combining two-phase analysis using partial least squares structural equation modeling and evolving artificial intelligence named deep learning (Artificial Neural Network) on 432 usable responses. The first step was using structural equation modeling to examine the hypotheses; then the nonlinear interactions between the variables have been examined using an artificial neural network. According to the analysis results, perceived task-technology fit, perceived privacy, performance expectancy, and social influence constructs affecting the intention to use an AI doctor in primary, secondary, and tertiary levels of care are the main constructs. A strong behavioral intention exists at all levels of healthcare, primary, secondary, and tertiary, to use an AI doctor for individual-level healthcare.

The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), originated in Wuhan, China, and spread across the globe. As of 5th June 2020, it has infected nearly 6.5 million individuals and killed more than 400,000 individuals.[1] The route of transmission includes mainly droplets, fomites, and also aerosol particles.[2] There is evidence that SARS-Cov-2 can also cause intestinal infection and present in faeces, however there are no reports on the faecal-oral transmission.[2] The most common symptoms reported are fever and cough.[34] Ocular involvement in the form of conjunctivitis can sometimes be the first symptom.[35] Advisory measures include social distancing, working from home and safe hygiene practice. Legal measures include travel restrictions, reduction or postponement of elective procedures, lockdown, and curfews.[6] Health care professionals are at an increased risk of infection, including ophthalmologists, 000 other allied health personnel, as most of the ophthalmic procedures bring them in close contact with the patients.[357] There are also reports of SARS-CoV-2 identified in tears and conjunctival swabs, thus putting clinical eye care professionals at risk of acquiring the infection.[5891011] Different guidelines have been developed for ophthalmologists by the American Academy of Ophthalmology (AAO),[12] International Council of Ophthalmology (ICO)[13] as well as national societies such as All India Ophthalmological Society (AIOS).[1415] Similarly, the American Optometry Association has developed guidelines for optometry.[16] However, there are limited guidelines available for primary eye care (PEC) facilities in India. In India, the government sector offers PEC through its Vision Centres (VC) located within the primary health centres (PHC). The non-governmental organizations (NGO) offer care through a stand-alone Vision Centre (VC) model.[1718] In this article, we describe the guidelines followed in our PEC network, i.e., VC network of L V Prasad Eye Institute (LVPEI), India.[19] LVPEI response to COVID-19 at primary level can be divided into the following steps: Safeguarding infrastructure and equipment Primary eye care personnel protection Patient triaging and Clinical protocols (including optical dispensing) Administrative control and monitoring The protocols can also be viewed at: https://youtu.be/zVcSiHfFojk 1. Protection of infrastructure and equipment: A PEC facility is typically set up in a space of approximately a 500 square feet area. The existing structure has been modified and re-arranged to suit the current COVID-19 situation. This includes seating arrangement to ensure that social distance (3 feet distance) is maintained. Cleaning and disinfection protocols have been developed [Table 1]. Sanitizers are also placed at the entrance of the examination room as well as the optical dispensing counter and used after each examination. As described in other guidelines, breath barriers have been installed on slit lamp biomicroscopes.[12131415] Additional breath barriers have been created for retinoscopes, autorefractors, and for fundus imaging equipment. The cleaning and disinfection protocols of the PEC facility are shown in Table 1.Table 1: Cleaning and disinfecting protocol for the primary eye care facility2. Primary eye care personnel protection: Personal protective equipment has been provided as described in other guidelines [Table 2].[1314151620] The procedure for donning PPE (putting on) and doffing PPE (taking off) is detailed in [Fig. 1]. Along with PPE, the importance of social distancing and hand hygiene practice has been reinforced. They are also advised to avoid social gatherings and visitors, as well as family holidays. All pregnant women and high risk persons are given leave.[21] For education, the use of online platform is encouraged and being used.Table 2: Personal protective equipment for primary eye care personnelFigure 1: Donning and doffing of personal protective equipment by primary eye care personnel3. Patient triaging and clinical protocols (including optical dispensing): The PEC facilities are stand-alone units managed by a single person (in most cases). The core functions include refraction and dispensing of spectacles, diagnosis of common eye conditions, and appropriate referrals for further intervention. Hence, the clinical protocols are developed with a focus on these functions as well as other guidelines.[13141516] Fig. 2 shows the clinical workflow at a PEC facility in our network. All patients are instructed to wear a mask or cover their nose and mouth with cloth/scarf. The patient is greeted (non-contact method). For patient triaging, a COVID-19 questionnaire is administered and temperature is recorded. Anyone with high temperature is referred to the nearest government facility. Before examination, the patient is asked to sign a COVID-19 consent form.Figure 2: Clinical workflow in a primary eye care clinicRecording personal history and demographic information: The standard protocol with social distancing is followed to obtain personal and demographic information. Aadhar card (personal identification card issued by government) and mobile numbers (of patient and next of kin) are mandatory as these details would be required at a later date, if any positive cases are reported among the patients examined in the centre. Attendants are discouraged unless the patient is a child or physically disabled. Visual acuity assessment: Visual acuity for the distance is assessed using standard illuminated Snellen's visual acuity chart. However L-Occluder is not used. Instead, the patient is instructed to close the non-testing eye with his/her hand (not fingers). The near vision chart is held by the examiner at a distance of 35-40 cm, and at least one-meter distance from the patient is maintained while assessing visual acuity. Objective and Subjective Refraction: Objective and subjective refraction is performed on all patients. The trial frame is cleaned with an alcohol wipe before placing it on the patient for refraction. Touching the forehead of the patient to measure working distance is avoided. All the lenses used for neutralization are placed on the desk. After completing a subjective examination, each lens and occluder is cleaned with alcohol wipes before replacing in the trial box. The trial frame is also cleaned each time. Retinoscopy barrier is used while doing retinoscopy, similar to the slit lamp barrier as shown in Fig. 3. Wherever possible, spherical equivalent lenses are prescribed and dispensed, so that movement of lenses and frames can be minimized.Figure 3: A barrier for performing retinoscopySlit-lamp examination and applanation tonometry: Slit-lamp examination is performed on all patients and the same protocols described in other guidelines are followed.[13141516] This includes avoiding all non-essential examination as well as 'no talking' policy during the examination. Patients with conjunctivitis are not examined on slit-lamp, and referred directly to higher centres. Aerosol generating procedures like non-contact tonometry are avoided.[22] Wherever possible intraocular pressure (IOP) measurement is avoided. This includes patients who are less than 30 years of age, those with redness in the last 2 weeks, those likely to be referred to higher centres, and those with Best Corrected Visual Acuity (BCVA) 6/6 and N6 for near. Procedures like direct ophthalmoscopy is also avoided. Lensometry: If the patient is using spectacles, preferably hand neutralization technique is used to assess lens power and the spectacles are cleaned with hydrogen peroxide before returning to the patient. Fundus camera: A breath barrier is installed with the help of the manufacturer and imaging is restricted to those who require the service. These include patients with a history of diabetes; intraocular pressure more than 20 mm of mercury; and those with shallow anterior chamber. It is also indicated if the vision is not improving with refraction beyond 6/12; and if there is a relative afferent pupillary defect (RAPD). Spectacle dispensing: Patients are advised to clean hands with sterillium at the entrance of the optical outlet. During frame selection, social distancing is maintained. All frames tried by the patient is kept in a separate tray (Ex: Red colour tray). After trial, the frames are cleaned using 0.5% hydrogen peroxide spray, especially the nose pad and nose bridge before replacing them. 4. Administrative control and monitoring: The PEC centres are a part of a larger eye care network, and are monitored by a higher level center through frequent phone calls and physical checks where possible. A monitoring checklist is developed and implemented. The checklist includes indicators to assess the adherence to protocols such as one attendant policy, awareness of health messages, compliance with PPE and cleaning protocols. One-to-one meetings are also held with the PEC personnel. The aim is to reduce anxieties, obtain feedback, provide guidance for implementation, monitoring, and compliance. The PEC personnel is also instructed to submit Incident Reports on any serious event. To summarize, these guidelines are based on the best possible evidence and also align with other recent guidelines in India.[1415] While these guidelines are developed based on our experience at our higher centres, these can be easily adopted by the PEC facilities in the developing countries of our region. The guidelines are subject to change based on the generation of new evidence as well as changes in national policies. In conclusion, a good triaging system at multiple levels and following the best-preferred practices would significantly mitigate the risk of COVID-19 at the PEC facility. Disclaimer The guidelines are based on the best available evidence as of today as well as experience in our network of more than 100 centres. Despite adherence, they may not mitigate the risk to 100%, however, they would aid in reducing the risk at multiple points. These guidelines will be updated as and when new evidence is generated. Anyone interested in following the updates and the protocols, we would recommend that they get in touch with our Hospital Infection Control Committee. Acknowledgements We would like to acknowledge Ms Sreedevi Penmetcha, Management Consultant at L V Prasad Eye Institute for language editing of the manuscript.

The L V Prasad Eye Institute: A comprehensive case study of excellent and equitable eye care

Despite advances in diagnostic techniques and treatment, lung cancer is the leading cause of cancer death worldwide and in Cuba. Prompt initiation of cancer therapy depends on rapid diagnostic confirmation; however, most patients are diagnosed at an advanced stage. In the Cuban health system, primary, secondary and tertiary levels of care are interrelated; patients may seek care at any level or may be referred from one to another. Lung cancer diagnoses are confirmed at the tertiary level. Determine the length of diagnostic delay in patients diagnosed with non-small-cell lung cancer (NSCLC) at a tertiary care facility in Havana, Cuba, as well as mean diagnostic delay attributable to the patient and to the health system by level of care. A descriptive observational study of 96 patients with a cytologically and/or histologically confirmed diagnosis of non-small-cell lung cancer was conducted in 2005-2007. Patients initially sought care for disease symptoms at primary, secondary or tertiary levels in the Cuban public health system, but diagnosis of all patientas was confirmed at a specialized tertiary care facility. Total diagnostic delay was calculated as the time elapsed from onset of symptoms to confirmation of NSCLC diagnosis. Variables also included diagnostic delay attributable to the patient and diagnostic delay attributable to the health system by level of care. Data were arranged in tables and analyzed by absolute value, percentage, mean, and standard deviation. Of the 96 patients studied, 69% were male, and 54% were aged 50-69 years. Fifty-five percent of patients sought medical care within 15 days of onset of symptoms, 21% within 16-30 days, and 3% waited >90 days. Mean diagnostic delay attributable to the patient was 18.19 +/- 3.45 days while mean diagnostic delay attributable to the health system was 61.63 +/- 18.50 days, and overall diagnostic delay was 73.13 +/- 17.53 days. For the 71% of patients seen in primary care, mean diagnostic delay was 29.51 +/- 4.53 days; for the 45% seen exclusively or additionally at the secondary level, mean diagnostic delay was 24.45 +/- 7.31 days. Upon admission at the tertiary care level, mean diagnostic confirmation delay was 18.23 +/- 3.68 days. Diagnostic delay of lung cancer patients in this study was prolonged. Appropriate strategies are needed for reducing this delay.

SummaryBackgroundThe health burden of geriatric eye care is expected to rise, yet medical insurance uptake among the elderly population remains low. There is minimal evidence regarding insurance uptake for eye care among the elderly population in the Southeast Asia region. We explored insurance uptake and its impact on visual outcomes among the elderly population who visited an eye care system distributed across four Indian states.MethodsIn this retrospective cohort study, we used a browser-based proprietary, Hospital Information Management System (HIMSS) stage six, electronic medical record (EMR) system. Datasets were collected from new patients who visited the four tertiary centres with linked primary and secondary centres of our pyramidal health system (L V Prasad Eye Institute [India]) distributed in four Indian states, Andhra Pradesh, Odisha, Telangana, and Karnataka, between August 2011 and December 2022. The electronic medical records of 38,387 patients aged >70 years who underwent cataract surgery were included (45.5% were females [17,471]). Individuals treated with fully subsidised care were excluded. Data on age, health insurance uptake, type of health insurance (government or private), and mode of payment for cataract surgery were collected. Factors impacting insurance uptake and visual outcomes were studied using logistic regression analysis.FindingsInsurance uptake declined from 17.5% among people aged 70 years to less than 10% among those aged >85 years. Private insurance uptake declined from 13.3% among people aged 70 years to 4.7% among those aged 90 years, while publicly funded insurance remained between 3.3% and 4.2%. Insurance uptake increased during 2018–2022 compared to 2011–2017 (20.61% vs. 10.65%; p < 0.001). A higher proportion of males had insurance uptake compared to females. Median waiting times for surgery among patients with government versus private insurance were 18 and 11 days, respectively. Among patients aged >80 years, surgical outcomes for those without insurance were worse than for those with insurance.InterpretationInsurance uptake declined dramatically in patients aged above 80 years and was associated with poorer visual outcomes following cataract surgery, as the insurance uptake may impact the quality of eye care received. Policy changes are needed to increase insurance uptake for eye care in this population.Funding10.13039/501100009053DBT Wellcome Trust India Alliance, Clinical Research Centre Grant IA/CRC/19/1/610010; 10.13039/501100005809Hyderabad Eye Research Foundation (HERF).

PurposeMany ocular conditions that lead to blindness or visual impairment are preventable or treatable with early diagnosis and timely access to eye care. However, individuals in low-income areas often encounter significant barriers. This study assessed eye care management strategies and facility availability for patients in the uMgungundlovu district.MethodsA cross-sectional, descriptive, quantitative, and retrospective study was conducted using an online questionnaire and record card reviews to assess management strategies in selected public eye care facilities in uMgungundlovu from January to December 2022. Cluster sampling across 27 facilities was employed. Data were analyzed with the Statistical Package for the Social Sciences (SPSS), with descriptive statistics presented in graphs and tables. Significant differences in optometrist prescribing patterns were identified, with a p-value of less than 0.05 considered statistically significant.ResultsA total of 1397 record cards were reviewed from seven facilities. Most patients received spectacles (n = 741, 53%), but 12.5% (n = 174) took six months or longer to receive them, and 12% (n = 167) did not receive them at all. Primary facilities occasionally supplied eye drops, requiring referrals to secondary hospitals for ongoing treatment. Statistically significant differences in optometrist prescribing patterns were found for spectacles (p = 0.039) and pharmaceutical treatments (p < 0.001) between primary and secondary care levels. Six out of seven representatives (85.7%) indicated that facilities lacked adequate ophthalmic equipment and qualified professionals. None of the facilities conducted data analysis, resulting in insufficient evidence-based information for planning.ConclusionThe district faces healthcare access and management gaps. With 84% of the population relying on public services, a comprehensive eye care model (CEC) is essential for equitable access.

This cross-sectional study assessed knowledge and utilization of the partograph among health care workers in southwestern Nigeria. Respondents were selected by multi-stage sampling method from primary, secondary and tertiary levels of care. 719 respondents comprising of CHEWS--110 (15.3%), Auxiliary Nurses--148 (20.60%), Nurse/Midwives--365 (50.6%), Physicians--96 (13.4%) were selected from primary (38.2%), secondary (39.1%) and tertiary levels (22.7%). Only 32.3% used the partograph to monitor women in labour. Partograph use was reported significantly more frequently by respondents in tertiary level compared with respondents from primary/secondary levels of care (82.4% vs. 19.3%; X2 = 214.6, p < 0.0001). Only 37.3% of respondents who were predominantly from the tertiary level of care could correctly mention at least one component of the partograph (X2 = 139.1, p < 0.0001). The partograph is utilized mainly in tertiary health facilities; knowledge about the partograph is poor. Though affordable, the partograph is commonly not used to monitor the Nigerian woman in labour.

Background:The organization of health care system on Cantonal level with the coordination from Federal level represents a real situation with the possibility of decentralization of health care system according to the experiences of developed countries.Objective.To make an overview of the situation at the primary and hospital health care level with the aim of assessing the existing human resources and capacity of health care institutions in FB&H, with which we entered in COVID-19 pandemic.Methods.This retrospective study presents the efficiency of health care in FB&H measured by number of medical doctors, and other medical staff during the time period of five years. Data of the Institute for Public Health FB&H were used. The Institute for Public Health FB&H is authorised by the law to conduct and implement statistical research in the field of health care in line with relevant laws and by-laws. The Institute is obliged to report on organisational structure, human resources and medical equipment.Results.Presented data include the number of health care employees in medical institutions in FB&H in the period 2015-2019 per 100,000 inhabitants and their numbers in primary health care, family medicine, secondary and tertiary level of health care in 2019. The study also presents the number of doctors of medicine, specialists and medical residents in FB&H, the number of nurses of all profiles and levels of education as well as medical staff and other employees in the public health care system in FB&H in 2019.Conclusions.The COVID-19 pandemic in FB&H has confirmed the fact that human resources in health care are insufficient, especially in the field of public health and epidemiology. The availability of these health facilities and human resource is not uniform throughout the FB&H, which may affect the capacity of the health system in some parts of the FB&H to meet the needs of providing services during COVID-19 pandemic.

Introduction: Aim of the study is to piloting nursing documentation to obtain comments based on the experience of nurses/medical technicians from the primary, secondary, and tertiary health care about the documentation before it is published and starts being used.Methods: A questionnaire was designed in the electronic form to be used for the evaluation and suggestions by nurses/medical technicians on the piloted form and content of nursing documentation for all levels of health care. A piloting sample was prepared to make 10% of nurses/medical technicians from health care institutions from the territory of the Federation of Bosnia and Herzegovina.Results: A total of 94.3% of examinees at the primary health care level and only 17.2% of the examinees in the secondary and tertiary health care fill out nursing documentation both manually and electronically. All examinees at all levels of health care understand the purpose and importance of nursing documentation. A total of 27.7% of the examinees at the primary and 40.9% of the examinees at the secondary and tertiary level of health care pointed out that filling out nursing documentation was too time-consuming.Conclusion: A total of 51.2% of the examinees at the primary and 64.2% at the secondary and tertiary level of health care agreed that submitted nursing documentation was adequate for use. It is suggested that after the adoption of nursing documentation at all levels of health care, piloting of its use should be conducted to evaluate the quality and quantity of all nursing documentation.

Introduction. The second stage of the reform in the domestic health care system, which concerns its secondary and tertiary levels, began in Ukraine on April 1, 2020 after fulfilment of some tasks of reforming medicine. The issues of modern peculiarities of the work of institutions of these levels are currently insufficiently worked out both on the theoretical and empirical level, which often leads to the lack of algorithms for solving problems that arise in this area. This requires research in the context of modernizing the organizational mechanism of operation of these health care facilities in today’s complex environment.The purpose of the study is to develop theoretical and methodological foundations of the enterprise’s organizational mechanism, its empirical assessment of the health care institution of the secondary (tertiary) level of medical care in the course of its transformation, and develop proposals for its modernization.Methods. The study used epistemological, comparative and systematic methodological approaches to study the object and subject of research, research methods: dialectical, linguistic, PEST analysis, ABC analysis, SWOT analysis, expert evaluations, program- target.Results. The author’s position on the interpretation of the content of the enterprise’s organizational mechanism and its main components is presented. The factors are determined and the objective necessity of modernization of the organizational mechanism of the health care institution is substantiated.The structural component-by-component analysis of the current organizational mechanism of functioning of the health care institution of the secondary (tertiary) level of medical care is carried out. “Bottlenecks” have been identified, and the most influential among them, such as unsatisfactory coordination of the working processes and problems of resource provision, have been distinguished.The expediency of developing a strategy for the development and operation of a medical institution for the future is substantiated. Strategic priorities in the formation of a modernized model of development and functioning of a medical institution are highlighted. Clear structuring and content of strategic and operational goals; strategy development in optimistic and pessimistic variants; development of additional strategies - image and resources have been proposed.Finally, the following steps have been proposed: a) improved organizational structure of management, through the addition of units of the current linear-functional structure and the creation of an additional adaptive structure as a temporary; b) the author’s solution of the problem of organizational design of the content of works, which is based on a differentiated approach to the typical work related to the treatment process and work (technology, types of services); c) organizational design of personnel activities.Prospects for further research concern the study of modernization of organizational design of medical staff and the problem of introducing innovative technologies in the organization of functional activities of hospitals.