October 2003
Eleanor Cozens and Ronnie Graham
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October 2003
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Eleanor Cozens and Ronnie Graham |
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The Iringa CES project was established in 1998 with the aim to "integrate and improve the provision of eye care, rehabilitation, and education services to blind and visually impaired people of Iringa Region, such that avoidable blindness will be reduced by at least 30% and overall quality of life for the target population of all those with eye problems in the region noticeably improved by the year 2002".
The challenge for the NGO involved, Sight Savers International (SSI), and its Government of Tanzania (GoT) partners lay in forging links between the different government departments in order to provide a sustainable continuum of services for those suffering from eye conditions. This article reports the key findings of an evaluation of the project, done in November 2002 at the end of the funding phase. The evaluation team consisted of SSI staff and a Regional Health Officer for Iringa. |
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Iringa Region, lying in the southern central uplands of Tanzania, has a population of 1.6 million people in the 5 districts of the project. The population is therefore not much larger than the VISION 2020 model unit of intervention. Although by East African standards communications are relatively good, Iringa shares the characteristics of many African regions: the population, which mainly lives off the land, is dispersed over a vast area. All five VISION 2020 priority eye conditions are present in Iringa cataract, trachoma, onchocerciasis, childhood blindness, and uncorrected refractive error and low vision. Trachoma and onchocerciasis occur in pockets and control activities are managed by the International
Trachoma Initiative (ITI) and the African Programme for Onchocerciasis Control (APOC) programmes respectively. The CES project, and therefore the evaluation exercise, focused primarily on eye care activities other than trachoma and onchocerciasis and on the provision of services for blind and low vision adults and children.
Eye care Between 1997 and mid-2002, the Cataract Surgical Rate increased from 144 to 268, but is still low, given the deployment in 2001 of two newly trained cataract surgeons bringing the number to three, with two others in training. By the time the number deployed will have increased to five, a CSR of 1000 should be achievable and the evaluation recommended that this be considered when setting targets for Phase 2 of the project. Accessibility has greatly improved during the life of the project as cataract surgery became available in 16 sites in all 5 districts of Iringa. The cataract surgeons who had returned from training in Malawi were familiar with the cataract monitoring tool and reported that they were monitoring outcome for quality. While the practice of keeping most patients in hospital for about 5 days postsurgery enables immediate postoperative checks to be carried out effectively, and patients mostly returned a second time within one month, there was a very low return for assessment at a later date, so that the long-term outcome was impossible to measure. A key recommendation of the evaluation was to focus the project on increasing demand for services and on resolving some of the supply-side problems. The low demand appeared to be due to a number of factors including transport problems, cost of providing food for a 5-day stay in hospital, and local customs and beliefs. On the supply side, logistical and coordination issues needed to be addressed. The team suggested that a workshop for personnel involved in cataract service delivery could be convened to identify approaches for increasing patients' willingness and ability to come forward, and to ensure that the services provided were resourced and coordinated. |
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The evaluation recommended that the next phase of the project should focus on tackling refractive error and low vision, in addition to cataract, and on making provision for referrals of children suffering from serious eye conditions. A coordinated strategy was also needed for managing the activities of the various kinds of district-level workers who had received primary eye care (PEC) training, as they are an essential tool in increasing the numbers of cataract patients coming forward.
Human resource development There are no ophthalmologists resident in Iringa and the service relies heavily on cataract surgeons. Since the project began the numbers of fully trained ophthalmic personnel has doubled, and at the primary level 126 health care workers have been trained in PEC, whereas only 2 PEC workers were available pre-project. The target numbers of trained personnel were set before the VISION 2020 targets were well established and are now at variance with them. However they reflect political demands for an equal distribution of personnel per district. The evaluation team recommended that the next planning phase should align the human resource development targets to those of VISION 2020. If there are particular administrative or geographic reasons why this should not be the case, this should be clearly articulated. The bulk of the recommendations on HRD for Iringa CES concerned primary eye care. It was recommended that one worker per health centre should receive training in PEC and that courses should be extended to 3-4 days and include a practical component. The quality of service these workers provide is critical in increasing demand from the population and the simple system for monitoring and supervision of the PEC workers needs improvement. At community level the project has experimented with using volunteers to identify those people suffering from eye diseases and refer them to the PEC workers. This has contributed to a considerable increase in eye patients being seen at the primary and district level. The volunteers in question are called Community Based Eye Care and Rehabilitation Workers (CBERWs), and in addition to case identification they provide basic eye care education and rehabilitation training to people whose blindness is irreversible. However they are not a recognised cadre and therefore pose questions over sustainability and replicability. In two districts no CBERWs have been trained yet, and it was recommended that in those areas the recognised cadre of Village Health Workers receive PEC training and take on the identification and eye care education components. It was also recommended to investigate whether there were any existing grassroots or community networks which could take on a management role of the CBERWs, whose functions would then be confined to rehabilitation training and support. This approach could be compared to the concept of the CBERWs in place in the other two districts. The evaluation found that at the beginning of the project, facilities in Iringa for blind people whose condition could not be treated were very limited. The GoT has a policy of Universal Primary Education, and an annexe to Makalala primary school in one of the districts already served as a referral centre for 22 blind and low vision children. Since then a further 53 children have been identified and enrolled in Makalala and 5 other mainstream schools, and itinerant and contact teachers trained to support them. The evaluation team thought this to be a notable achievement which now needs to be rolled out to the remaining districts, along with increased provision of appropriate teaching and learning materials. Existing Government services did not extend to providing rehabilitation training for blind adults. The project therefore created the new volunteer cadre of CBERWs. At the time of the evaluation, activities were underway in two of the four Districts planned for the funding phase, and 300 people had completed a home-based training of up to 6 months, or were currently receiving training. The evaluation team thought highly of the rehabilitation training and support provided by this sytsem but had concerns about its costeffectiveness. Inputs continue to be required for the training, transport, and supervision requirements for an output of approximately 4-5 clients per pair of CBERWs. It was doubtful whether the cadre would continue to function without the resources of the project contributed by Sight Savers. Programme management issues As mentioned earlier, a key challenge in CES projects is to establish efficient coordination between service providers of eye care, education and rehabilitation. In the case of Iringa, services are the responsibility of regional and district staff in the Ministries of Health, Education, and Social Welfare and Culture. Moreover while the Ministries at national and regional level were involved in developing and establishing the project, subsequent implementation of Local Government and Health Sector reforms have devolved responsibility down the chain. National level personnel only really remain involved in the fields of disability, rehabilitation and special needs education, where local expertise is lacking. Responsibility for implementation has largely moved to district level where effective coordination between Ministries is uneven. Although informal collaboration is generally good, there is a need for a formal system of collaboration at district level to ensure that the referral mechanisms work. Another key issue identified was the need for SSI to be clear about its longterm objective: whether it is the assumption of ownership by the partner or sustained partnership. At present, the evaluation team felt that SSI was too involved in day to day project management. During the next phase of the project this issue needs to be resolved, the obligations of both parties stated, and a time-scale established for the withdrawal of SSI management input, although other types of support should continue. The Iringa CES project is a pilot which will be assessed by the National Eye Care Secretariat for its suitability for replication elsewhere in Tanzania. However, there is a need to set the assessment criteria, acceptable levels of coverage, and what is meant by 'comprehensive', for each of the CES components. These should be clarified by Sight Savers and by the GoT to enable them to decide when a replicable model has been established. The question has been asked by GoT in terms of whether a few people should enjoy a 'thick blanket' at the expense of a 'thin blanket' for many people. As a question of policy this is a matter not only within SSI and GoT but also a major question facing any organisation planning and implementing the Comprehensive Eye Services model. Progress towards objectives At the end of 5 years, the evaluation team found that the project had made good quality but somewhat slow progress. More participatory planning processes should enable the project to proceed at the speed desired by the districts. Linked to that it was recommended that advocacy activities be increased and the involvement of local NGOs and networks be sought in order to widen the range of stakeholders. Ms. Eleanor Cozens Sight Savers International Grosvenor Hall, Bolnore Road Haywards Heath West Sussex RH16 4BX UNITED KINGDOM Tel: +44-1444-446675 Fax: +44-1444-446677 Email: ecozens@sightsavers.org |