Prior to the implementation of the project, refractive error services were offered at only a few public health institutions in KwaZulu-Natal – primarily due to the fact that there were only 6 full time optometrists working within the KZN DoH at the inception of the project. Furthermore the majority of PHC nurses were not delivering primary eye care, but merely referring all “eye cases” along the referral pathway, needlessly creating a backlog at the District and Regional Level.
Training of ONs in the province was discontinued by the KZN DoH in 2002 [Zimu N. 2002, personal communication]. To compound the situation, many ONs were deployed to other areas of clinical care as well as into clinic and hospital management roles. At the time of the project inception there were only 46 active ONs working in KZN. As this cadre had already received training in the delivery of refractive error services (as part of their ON training), a skills audit was conducted to identify areas in which the nurses felt they required further training. The results indicated a need for further training in basic refraction and the diagnosis of posterior segment diseases. As such, a post evaluation needs to be conducted at a later stage to determine the impact of the project’s training on the quality of eye care delivered by ONs.
Despite the development of tools and systems for data collection from all cadres trained, data collection remained a challenge. Extensive telephonic contact with trainees yielded varying levels of success in acquiring data. Optometrists and ONs reports were received fairly regularly; however reporting from PHC clinics was limited and very sporadic. As such, attempts were made to add eye care indicators into the DHIS, an existing data Management System utilized by the KZN DoH. This initiative proved successful.
The need for continuous advocacy for eye care services within the KZN DoH beyond the project lifecycle is critical to the maintenance and continued development of refractive error services established through this project. To this end, provincial forums for ONs and Optometrists have been established. An enabling factor in this regard was the existence of a policy for the formation of forums in the KZN DoH. These forums have been successfully launched, and the KZN optometry forum has also affiliated itself with the National Public Sector Optometry Forum in South Africa.
The role of community based cadres, particularly community Health workers and Traditional healers was not developed extensively in the project. The Community Health Worker (CHW) program is not uniformly developed in the province and this cadre was therefore not included in the capacity development initiative. However, a role in health promotion and case finding has been identified for these cadres and presents an opportunity for further development of eye care and refractive error services.
The increase in the percentage of patients seen at PHC level and the corresponding decrease in percentage of patients seen at District and Regional Level is of importance and is likely due to the presence of the newly trained PHC nurse within the eye care referral system. Previously patients would have needed to travel to the district and regional institutions to access the closest eye care service which was provided by ophthalmic nurses or an optometrist. These patients often needed treatment for simple bacterial or allergic conjunctivitis, which can now be managed by the PHC nurse at their local clinic resulting in a reduction in the percentage of patients reporting at secondary and tertiary level respectively. This allows for the more efficient use of the skills of personnel at different levels of the DHS.
A limitation of the analysis is a lack of information to determine the quality of service being provided by the different cadres. We were also unable to track the numbers that did not present after referrals and the non-compliance associated with this. Some patients were counted both at the primary and secondary referral sites as we were not able to determine from the data who were referred and who were not.
It will also be useful to determine the patients’ perception of the service. Furthermore an assessment of the quality of training rendered needs to be conducted.