Abstract
BackgroundVisual impairment is a global public health problem, with an estimated 285 million affected globally, of which 43% are due to refractive error. A lack of specialist eye care in low and middle-income countries indicates a new model of care would support a task-shifting model and address this urgent need. We describe the features and results of the process evaluation of a national primary eye care (PEC) programme in Rwanda.MethodsWe used the Medical Research Council process evaluation framework to examine the implementation of the PEC programme, and to determine enablers and challenges to implementation. The process evaluation uses a mixed methods approach, drawing on results from several sources including a survey of 574 attendees at 50 PEC clinics, structured clinical observations of 30 PEC nurses, in-depth interviews with 19 key stakeholders, documentary review and a participatory process evaluation workshop with key stakeholders to review collated evidence and contextualize the results.ResultsStructured clinical assessment indicated that the PEC provided is consistent with the PEC curriculum, with over 90% of the clinical examination processes conducted correctly. In 4 years, programme monitoring data showed that nearly a million PEC eye examinations had been conducted in every health centre in Rwanda, with 2707 nurses trained. The development of the eye health system was an important enabler in the implementation of PEC, where political support allowed key developments such as inclusion of eye-drops on the essential medicines list, the inclusion of PEC on insurance benefits, the integration of PEC indicators on the health management information systems and integration of the PEC curriculum into the general nursing school curriculum. Challenges included high turnover of primary care nurses, lack of clarity and communication on the future funding of the programme, competing priorities for the health sector and sustained supervision to assure quality of care.ConclusionsA model of a national primary eye care programme is presented, with service delivery to all areas in Rwanda. Key learning from this evaluation is the importance of strengthening the eye health care system, together with a strong focus on training primary care nurses using a PEC curriculum.
Highlights
Visual impairment is a global public health problem, with an estimated 285 million affected globally, of which 43% are due to refractive error
The health system in Rwanda is organized around local health centres, each serving a population of between 4000 and 10,000 people formed a basis for the delivery of primary eye care (PEC)
PEC examination included in community health insurance coverage External funding raised to support PEC and outreach activities
Summary
Visual impairment is a global public health problem, with an estimated 285 million affected globally, of which 43% are due to refractive error. Task-shifting, a process of delegation where clinical tasks are shifted to less specialized health workers where appropriate, has been used successfully to improve access to HIV services in low income countries [3] Adaptions of this strategy for cataract and trichiasis surgery have had limited impact [4, 5]. Training primary healthcare workers to deliver primary eye care (PEC) offers a pragmatic approach to address the eye health workforce shortages through improving access and reducing demand for specialist care. This strategy aligns to WHO’s framework on integrated, people-centred health services, which re-orientates service delivery to patients and communities, that is accessible and of high quality [6]. There is limited evidence of the effectiveness of PEC [7]
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