Cataract surgery units in SNNPR have reasonable resources (equipment and consumables), largely provided through NGO support. However, units and personnel were unevenly distributed. Many zones and almost half of the population had no access to services. The non-physician cataract surgeon training program was developed to help overcome the shortfall in ophthalmologists and to improve the coverage of services . Although SNNPR has achieved half of its planned surgeon deployment and Vision 2020 human resource development targets, as set out by the National Vision 2020 Plan, there remains a very uneven distribution of surgeons [10, 15]. This is largely attributable to the uneven distribution of eye unit locations and the unpopularity of working in more remote areas [18, 19].
The reasons for the uneven distribution of staff across SNNPR are complex. Selecting the right people for training is key . In Ethiopia, NPCS training is a significant career development and there is a general expectation among health workers that higher-level training leads to better placements and living condition. It is probably unrealistic to expect someone with many years experience, based in a larger town, to relocate to a rural eye unit following training. Willingness and ability to serve in district eye units should be considered in the selection process. Earlier studies have found that health workers with rural exposure or backgrounds show greater willingness to work in rural settings [19, 20]. We have previously found that working and living conditions in Ethiopia are significant determinants of staff retention in a trichiasis surgery program . A mechanism that rewards those who are working in rural eye units could be considered . To compensate for the current inequality of service provision, regular outreach programs are needed in areas where there is little or no access to services .
In 2010 the CSR for SNNPR was far below the target set in the National Vision 2020 Plan [9, 15]. For individual units or surgeons, availability of equipment and consumables did not appear to be limiting factors; however, productivity was often low. The reasons for this are multiple and may include under-utilization of the service by the population and personnel management challenges (distribution, motivation and support).
No units reported a “waiting list” of patients, suggesting that either the need has been met or the community is not utilizing the service . Under-utilization of this service by the community may have multiple causes: limited awareness, geographical inaccessibility, direct or indirect costs, low confidence in the service due to reported poor surgical outcomes [8, 13, 23]. Strategies that bridge the gap between patients and service providers need to be implemented and scaled-up in the region. A few units conducted activities designed to help bridge the gap, such as an awareness creation program, community based screening and outreach cataract surgery. These activities were associated with higher productivity in SNNPR. Moreover, other studies suggest that community-orientated approaches are needed to deliver high quality high volume cataract surgery services in low resource settings [12, 22, 24]. Increased support will be needed from the regional government and NGOs, as overcoming barriers to access and encouraging service utilization will require additional resources in terms of staff and logistics.
The average cataract surgeon’s productivity in SNNPR (280 cases/surgeon/year) was comparable with a report of their counterparts in four East African countries (243 cases/surgeon/year) . However, there was a significant difference in output between surgeons in SNNPR. Although the data is insufficient to model, univariate analysis suggests that ophthalmologists received more financial and logistic support from NGO to conduct outreach surgery, had more experience and were more satisfied with their work environment than the NPCS. These factors were associated with higher productivity in this and other studies [12, 24–26]. NPCS felt insufficiently recognized and supported by ophthalmologists and program managers. This was consistent with the findings from a recent situational analysis in SSA countries, where lack of adequate support and acceptance is leading to under-utilization of NPCS as reported by both the NPCS and their trainers . In our study, some program managers also indicated that NPCSs have unmet expectations which could affect their performance. Strengthened management systems and providing training to eye care mangers of all levels, including ophthalmologists, may help to build a supportive work environment. Consistent with other studies, NPCS who received supervision tended to have greater productivity [12, 25, 26]. However, unfortunately most cataract surgeons in SSA do not receive regular supervision from an ophthalmologist . Efforts need to be made to value the work that the NPCS are doing and provide them with equitable support if they are to succeed in addressing the cataract surgery service need in Ethiopia. Developing a system where decisions and information are shared, accountability mechanisms are strengthened and supportive supervision is provided could be transformational .
The aim of cataract surgery is to restore vision to an acceptable level . Therefore the quality and outcomes of surgery are of central importance. Currently, outcome-monitoring mechanisms are not built into the cataract surgery program in SNNPR. Monitoring outcomes through regular audit of results is essential for quality assurance and improvement; this should be built into all cataract surgery programs .
The average unit cost for cataract surgery in SNNPR varied widely between health facilities. The cost of cataract surgery services in Africa is probably somewhat higher than that reported from India . This is in part due to lower volumes of surgery being performed in African units and higher costs for surgical consumables [8, 9]. The major determinant of the provider unit cost is the number of surgeries per year, due to numerous facility-level fixed costs [8, 9, 28]. Newer health facilities incurred the highest fixed equipment cost. Consistent with the literature, we found variations in the source, type, cost and procurement practices of consumables, including IOLs, and the amount of support provided by the NGOs (such as incentives) were major reasons for large variations in variable costs between eye units [9, 29]. No published data are available on cataract surgery unit cost in Ethiopia.
In our study the actual cost of providing surgery was about 5 times higher than the charge to the patient in government eye units. In addition, the support from the regional government was limited to salaries and training with other resources provided by NGOs. This raises questions about the sustainability of the service in its current form . In addition to increasing output, cost containment and recovery mechanisms will be needed if the service is to become more self-reliant [8, 9, 30].
One of the significant themes that arose from interviews with the eye care managers and surgeons is the limited government support and attention to eye care as factor limiting both productivity and service sustainability. This might be due to other competing heath care priorities, poor awareness of the extent of the problem or even the considerable NGO support to eye care [31, 32]. The significant NGO support is a necessary response to the government’s limited investment in eye care. Anecdotal data shows that parts of the country without any NGO support are extremely underserved. If the Vision 2020 targets are to be achieved, cataract surgery services will need to be a health care priority for the government [30, 32]. Advocacy is needed within the government for a strengthened eye care service, integrated into the health system [30–32]. The development of an integrated primary eye care program within the existing Health Extension program would help to identify and refer people needing services, boosting demand and bringing down costs [9, 13, 30].
This study has some limitations. An assessment of surgical outcomes in SNNPR was beyond the scope of the resources available for this study. As highlighted above, surgical outcome monitoring is a crucial component of any cataract surgery program. Cataract surgery service output is measured by the CSR; data on the number of surgeries performed on blind cases and second eyes were not collected, as this was unavailable across all eye units. This limits our study’s ability to assess the impact of the program on reducing cataract blindness. Although all parts SNNPR where cataract surgery services are provided were visited and all surgeons in the region were interviewed; the number of personnel is relatively small, limiting the scope of the analysis. Finally, the provider cost does not include building costs.