A journey, not a destination: eye health integration in Pakistan

Twenty-five years ago, a community health workers programme was launched in Pakistan.

The National Programme for Family Planning and Primary Health Care (FP&PHC) aimed to fulfil the unmet health needs of people living in rural areas by providing essential primary health services at community level. This was a significant step towards health services integration in Pakistan; since then it has grown to include more than 110,000 staff (known as Lady Health Workers), who cover the four provinces and two regions of the country to carry out monthly home visits. Each Lady Health Worker looks after about 1,000 people, addressing maternal, newborn and childcare needs, particularly for rural women. But until recently, primary eye care was not one of the areas they addressed.

To combat this, a phased approach has been adopted that has gradually built the skills, knowledge and outreach of Lady Health Workers, and from 2008-2013, efforts were made to increase the skills and knowledge of primary eye care in their training curriculum. Sightsavers and other international organisations worked closely with the national programme for the prevention and control of blindness (NPPCB) to:

• Develop and integrate a training module on primary eye care into the national training curriculum. NPPCB and FP&PHC took joint responsibility and ownership of the module.
• Increase the training of more than 80,000 LHWs, Lady Health Supervisors and managerial staff at district, provincial and federal level while developing a resource pool of master trainers within the system to make it sustainable. Sightsavers invested significant resources towards the training of LHWs on primary eye care and visual acuity screening, and provided them with the necessary screening materials.
• Develop a referral chain from community to the first level care facilities. LHWs are not trained eye health professionals, but they have now been provided with training to refer women, men and children with eye conditions to first level care facilities for examination and check up by a doctor.
• Strengthen the health management information system of FP&PHC by integrating eye health indicators into reporting tools of LHWs, to make this a regular feature of their reporting. This system strengthening helps ensure accuracy, accountability and informed planning.

The journey of integration was not without its challenges. These included:

• Gender-segregated data: The health management information system of FP&PHC captures data on eye patients screened and referred by LHWs. But attention was not given to having gender-segregated data, leading to an inaccurate assumption by officials of the LHWs programme that all patients referred by LHWs were women. Sightsavers has piloted collecting gender-segregated data in selected districts, and the results indicate that a third of the patients seen and referred by LHWs are men.  
• Compliance with referrals: LHWs are proactively referring a huge number of eye patients to health facilities. But the health management information system does not collect data on the number of patients referred, and the number of patients who comply with those referrals. The data from a different Sightsavers project confirmed that only a fifth of the people referred were complying with the referrals. Sightsavers has commissioned a research study to explore the reasons for the low compliance, and results of this study will help Sightsavers, other international organisations and the government to have more informed planning and decision-making processes.
• Lack of statistics on patients received at private health facilities: Another pressing challenge is that the health management information system of FP&PHC does not collect and reflect the data of charity hospitals and the private sector. This means we’re unable to know the number of people referred by LHWs and reported to private/charity hospitals.

The next steps…

In order to take this further, the government needs to join hands with all stakeholders, particularly international organisations. More resources are required to improve the quality of data, accountability and governance at all levels. Following simple steps can help decision-makers and donors to improve the system further, helping millions of people in need of eye care services in rural areas.

Here are three next steps that need taking:

1. Strengthening of the referral system: Sightsavers and other stakeholders should advocate with the government and invest resources to influence the Ministry of Health to scale up the data collection pilot. This will not only ensure accuracy and accountability, but will also improve governance and informed planning and decision-making.
2. Improved compliance: LHWs are screening and referring large numbers of eye patients in the community to secondary hospitals as eye care services are not available at first level health facilities in all provinces except Punjab. This causes some people who are referred to drop out because more time and money are required to reach secondary hospitals. There is a strong need to advocate with provincial governments, particularly ministries of health, to appoint eye care professionals (optometrists) at first level health facilities so that eye care services are available to millions at a local level.
3. Governance and accountability at a local level: Governance and accountability at the district level is important to strengthen eye health services. Sightsavers, in its current district comprehensive eye care project in four districts, has come up with a solution to this challenge by establishing district coordination committees (DCCs). These are headed by deputy commissioners, who are the administrative heads of the district. All the key stakeholders at district level are members of the DCCs, and they share their progress on a quarterly basis, as well as reviewing action plans from the previous quarter. This has proved to be effective in promoting eye care services, and improving accountability and governance at a district level. The idea of district coordination committees should be promoted in every district of the country.

The integration of eye care services is not a destination but a journey. These simple approaches will contribute towards the achievement of universal health coverage, while improving the access of people living in rural communities to primary eye care.

Itfaq Khaliq Khan
Itfaq is a Senior Programme Officer for Sightsavers, based in the Pakistan Country Office.