Step by step: Integration of eye health into the Primary Health Care system in Pakistan

A significant step towards health service integration in Pakistan was taken 25 years ago when a community health workers programme was launched – known as the “National Programme for Family Planning and Primary Health Care (FP&PHC)”[1]. It set out to fulfil the unmet health needs of people living in rural areas by providing essential primary health services at community level.[2] Since then it has grown and now has more than 110,000 Lady Health Workers covering the four provinces and two regions of the country who carry out monthly home visits.  Each Lady Health Worker looks after about 1,000 people, addressing maternal, new-born and child care needs particularly for rural women.  Nevertheless, until recently, primary eye care was not one of the areas they addressed.

INTEGRATION OF EYE HEALTH INTO PRIMARY EYE CARE

As a signatory to the Alma Ata Declaration of 1978[3], the Government of Pakistan is devoted for integration of health services using primary care approach. A phased-approach is used in Pakistan to the integration of primary eye care into primary health care that has gradually built the skills and knowledge of Lady Health Workers.

PHASE-1 INTEGRATION OF PEC INTO PHC CURRICULUM:

The first phase, 2008-2013, involved embedding skills and knowledge of primary eye care into the training curriculum. Sightsavers and other international organisations work closely to support the National Programme of Prevention and Control of Blindness (NPPCB) to:

• Develop and integrate a training module into the training curriculum for LHWs.
• Build the capacity of more than 50,000 LHWs and Lady Health Supervisors (LHSs), and managerial cadres at district, provincial and federal level.
• Develop a referral chain from community to the First Level Care Facilities (FLCFs).
• Integrate indicators on eye health into the monthly reporting tools of LHWs so they were reporting on the number of patients seen and referred.

PHASE-2 INTEGRATION IN PRACTICE:

In the second phase, Sightsavers and the Fred Hollows Foundation (FHF) are currently implementing a four year project (2016-2020) titled “New Vision of Eye Health in Pakistan’s Khyber Pakhtunkhwa Province”, supported by “Seeing is Believing”’ The project is implementing in four districts of the Khyber Pakhtunkhwa province of Pakistan and is making significant contributions to the integration of primary eye care into primary health care. The project’s contributions are:

• Capacity Building of LHWs: more than 3,000 LHWs in the project districts have been provided with training in primary eye care so they can screen eye patients at household level. And 195,862 community members have been screened.
• Meeting the communities health care needs: The government programme focused on public sector health facilities yet the private and charity sector plays a key role in the elimination and control of blindness. The project works with four government and four charity hospitals.
• Strengthening of the Referral System: No data was previously available on the number of patients referred by LHWs from the community to health facilities. Nor was the Provincial Program Implementation Unit capturing gender-disaggregated data of the patients screened and referred by LHWs. The project has strengthened the referral system through creating a system for the collection and reporting of gender-disaggregated data. And Out Patient Department data shows that 4,296 eye patients had been referred from the community.
• Compliance with referrals: LHWs are screening and referring large numbers of patients. However, the compliance rate is lower and one in seven patients referred by LHWs and two out five patients referred by MOs and MTs are actually seen at hospital units. Sightsavers has commissioned a research to explore the reasons for this low compliance. The results of the study will inform future projects and interventions to strengthen primary eye care services.
• Multi-service delivery points: The project also enhanced integration through capacity building of primary health care workers, including Medical Officers and Medical Technicians, and developing one stop optical shops at charity hospitals in the project areas. These optical shops provide subsidised quality spectacles to people with refractive errors.
• Operationalisation of additional health facilities: The project has successfully strengthened eye acre services at primary level by supporting the operationalisation of eye care services at three additional sub-district level hospitals which brings eye care services closer to the communities.
• Governance and accountability at local level: The project played a key role in the establishment of District Coordination Committees in the project districts, headed by Deputy Commissioners, who are the administrative head of the district. These forums have proved to be effective in promoting eye care services, improving accountability and governance and in organising further outreach to disadvantaged and vulnerable communities in the project areas.

The results of the project have paved the way for the creation of additional positions for optometrists to be deployed at provincial health facilities. The provincial Health Department has committed to funding 96 additional positions. This will be a significant step forward in the integration of primary eye care into primary health care.

Itfaq Khaliq Khan,

Senior Programme Officer,

Sightsavers

Khurram Shehzad,

Project Officer,

Fred Hollows Foundation

[1] Hafeez, A., Mohamud, B. K., Shiekh, M. R., Shah, S. A. I., & Jooma, R. (2011). Lady health workers programme in       Pakistan: challenges, achievements and the way forward. JPMA: Journal of the Pakistan Medical Association, 61(3), 210.

[2] World Health Organization. (2008). Country Case Study-Pakistan’s Lady Health Worker Programme.

[3] https://www.who.int/publications/almaata_declaration_en.pdf