5: Case studies

Zambia

School-based eye health programme in Zambia: opportunities for scaling-up and integration

Yong Ai Chee, Anne Buglass, Godfrey Mwelwa, Ronnie Graham, Hannah Faal and Ving Fai Chan

 In 2017, Vision Action piloted a school-based eye health programme (SBEHP) in Kafue district, Zambia. After screening 18713 children, 3.33% had vision-impairing uncorrected refractive errors, and 17% had non-refractive eye conditions, showing that there are critical unmet eye health needs among Zambian children. These findings are essential for future planning since there were no reliable national estimates on vision impairment among children.

The SBEHP aligns with the Zambian National Health Strategic Plan 2017–2021 and the National Eye Health Strategic Plan 2017–2021. The National School Screening Programme Protocol 2020 was also developed through the pilot. All the learning from the Kafue Pilot Programme points us to the need for upscaling the programme interventions in Zambia. The question is, how can it be done systematically to ensure its effectiveness and sustainability?

What is next?

At the conclusion of the Pilot Programme, Vision Action conducted a robust upscaling assessment¹ using the WHO-ExpandNet framework to determine the potential to upscale the SBEHP, the scope of SBEHP, partner organisations’ roles, responsibilities and capacities, the resources needed to operationalise SBEHP and the facilitators and inhibitors for scaling up.

What did we find?

• The Innovation: The pilot SBEHP comprehensively covered all aspects of child eye health. The SBEHP addressed the shortage of ophthalmic health workers by training schoolteachers as screeners and bringing services closer to the community using the Mobile Eye Health Clinics. There is a need to strengthen community and local leaders’ sensitisation to secure commitment and support.
• User Organisations: All three user organisations – Vision Action, MOH, and MoGE – agreed to upscale the comprehensive SBEHP. The roles and responsibilities are clear: MoGE will be the main implementer in Zambia, supported by the Ministry of Health, Vision Action and any other NGO partners. There is a great need to involve other potential partners working in child and eye health to scale up the SBEHP.
• Resource Team: The local team implementing the pilot project could be employed for future upscaling because they understand the political, social, and cultural environments and can plan and implement the upscaling effectively. They have also built strong relationships with relevant stakeholders. Nevertheless, capacities such as monitoring, evaluating, and advocating for formalising the programme must be strengthened further.
• Environment: The schools and communities showed no objections to the SBEHP. Enabling environments such as supporting teachers with training, small incentives and meals, and transportation reimbursement might lead to schoolteachers’ dedication to the programme. The identified inhibiting factors include the shortage of funding and the limited supply chain, the risk of discontinuation of advocacy efforts if there are changes in government administration and uncertainty about the timeline for the inclusion of SBEHP into the existing School Health and Nutrition Programme.
• Horizontal Scaling-up: It would be more realistic to gradually expand the SBEHP to a new district rather than a province without compromising the essential components of the programme. The pilot project evidenced this – 154 schoolteachers were trained to screen 18,713 schoolchildren in 73 schools over 6 months, based on the needs and existing financial and human resources available within the user organisations. The cost to screen and/or treat a child (with eye drops/spectacles) was estimated to be £3.35. The success of scaling up will depend on the accuracy of key data and our ability to convert this into a budget.

Future considerations and opportunities

Two issues remain. One, the Mobile Eye Clinic approach may be effective in reaching the community in the short term, but we will need to address its sustainability issue in the long run. Two, there is still a large number of out-of-school children who are not reached through the SBEHP. Both issues highlighted the need to invest in Zambia’s primary eye care and vision centres, the two key components of a successful school eye health programme. A reliable supply of eye drops for conjunctivitis is to be prescribed and supplied by the nearest Heath Centre/Health Posts. A supply of spectacles from the nearest Vision Centre is to obviate the need for outreach.

Conclusion

Despite school eye health being included in the Zambian National Health Strategic Plan and National Eye Health Strategic Plan, concrete action was not highlighted or emphasised. Integration of the comprehensive SEHP into the existing School Health and Nutrition Programme is crucial, and this formal institutionalisation secures government funding, and therefore programme sustainability can be ascertained. An implementation study in Zanzibar also showed that an integrated school eye health programme is more cost-effective and performs better than a standalone programme.² Continued efforts such as constant engagement with the government and working closely with strong advocates within the government departments will contribute to the integration’s success. A similar scaling assessment has also since been conducted by Vision Action in Ethiopia.  Although it faced some additional challenges due to civil conflict in the region, there were many similarities in terms of enabling and inhibiting factors to scaling up SBEH.

References

1. Yong AC, Buglass A, Mwelwa G, Abdallah I, Chan VF. Can we scale up a comprehensive school-based eye health programme in Zambia? BMC Health Serv Res. 2022;22:945.
2. Chan VF, Omar F, Yard E, et al. Is an integrated model of school eye health delivery more cost-effective than a vertical model? An implementation research in Zanzibar. BMJ Open Ophthalmol. 2021;6(1).

Zanzibar

Zanzibar’s school eye health programs traditionally took a vertical approach, often led by non-governmental organizations. This method, while offering strong technical and financial control with focused objectives^1–3 in a limited timeframe⁴, frequently halted abruptly when funding ceased. In low-resource settings, school health programs are closely linked to feeding initiatives due to high child malnourishment rates.⁵ While effective in improving attendance, reducing dropouts, and enhancing literacy,^1,2 we argue that addressing only nutritional needs may be insufficient. Even well-nourished children may experience eye health issues, negatively impacting children’s wellbeing.

Recognizing the shared characteristics of high burden,^3,6 negative educational impact, demonstrated positive outcomes^7,8 and cost-effectiveness^9–11, our team piloted an integrated program in 2016 in Zanzibar. This initiative combined eye health into nine schools with an existing feeding program in Zanzibar and compared its performance¹² and cost-effectiveness¹³ to a traditional vertical school eye health program in ten schools. The study also identified the contextual factors influencing successful integration.¹⁴

In the vertical model (VM), only eye health interventions were implemented, involving an awareness program through teachers, Information, Education, and Communication materials. This was followed by teacher-led eye health screenings and referral of identified pupils to the nearest vision center. Conversely, the integrated model (IM) included eye health interventions in the existing school feeding program, encompassing feeding, deworming, sanitation awareness through teachers, and anthropometry measurements to identify and refer children with nutritional issues for appropriate management.

The findings show that IM achieved higher coverage (96%; n=5992/6257) than VM (90%; n=5142/5713) within four months, with increased voluntary engagement in seeking eyecare services (IM=63.6%; n=77/121 vs VM=46%;n=46/100) and better compliance with wearing eyeglasses (IM=71%; n=22/31 vs VM=13.3%; n=4/30).¹² IM also proved more cost-efficient, with the cost per child screened at USD1.23 for IM and USD1.31 for VM, and the cost per child identified at USD24.76 for IM and USD51.75 for VM.¹³

Six key contextual factors impacting the integration of eye health into the school eye health program were identified. Stakeholders/political factors highlighted the importance of ministry coordination, defined roles, and resource mobilization. Institutional factors emphasized the need for coordination, clinic space, human and financial resources, and strategic advocacy. The physical factor focused on challenges related to long travel distances. Cultural factors underscored low awareness of eye health among parents, teachers, and children. The delivery system factor called for a practical approach, using teachers as screeners and addressing workload issues. Lastly, the “Others” category emphasized the importance of comprehensive training materials, effective delivery, improved curriculum, teacher selection, supervision, and incentives.¹⁴

In conclusion, adopting a holistic whole-school approach that encompasses nutrition, health, and addresses eye health issues is vital for fostering the academic performance and overall well-being of children, especially in low-resource settings. This approach provides a strategic, pragmatic, and cost-effective method for delivering essential eye health services to children in such resource-constrained environments.

References

1. Pizzol D, Tudor F, Racalbuto V, Bertoldo A, Veronese N, Smith L. Systematic review and meta‐analysis found that malnutrition was associated with poor cognitive development. Acta Paediatr. 2021;110(10):2704-2710.
2. Zerga A, Tadesse S, Ayele F, Ayele S. Impact of malnutrition on the academic performance of school children in Ethiopia: a systematic review and meta-analysis. SAGE Open Med. 2022;10:20503121221122400.
3. World Health Organisation. World Report on Vision. Vol 214. Geneva; 2019.
4. Cairncross S, Periès H, Felicity C. Vertical health programme. Lancet. 1997;349:S20-S21.
5. Global System for Mobile Communications. Treating malnutrition in Zanzibar: Empowering health workers with an mHealth solution. https://www.gsma.com/mobilefordevelopment/programme/mhealth/treating-malnutrition-in-zanzibar-empowering-health-workers-with-an-mhealth-solution/. Published 2012.
6. WHO. Malnutrition. https://www.who.int/news-room/fact-sheets/detail/malnutrition. Published 2023.
7. Govender P, Yong AC, Mashige K, Naidoo K, Chan VF. The impact of spectacle correction on the well-being of children with vision impairment due to uncorrected refractive error: a systematic review. BMC Public Heal. 2023;23(1):1-5.
8. Wang D, Shinde S, Young T, Fawzi W. Impacts of school feeding on educational and health outcomes of school-age children and adolescents in low-and middle-income countries: A systematic review and meta-analysis. J Glob Heal. 2021;11.
9. Kristjansson E, Gelli A, Welch V, et al. Costs, and cost-outcome of school feeding programmes and feeding programmes for young children. Evidence and recommendations. Int J Educ Dev. 2016;48:79-83.
10. Baltussen R, Naus J, Limburg H. Cost-effectiveness of screening and correcting refractive errors in school children in Africa, Asia, America and Europe. Health Policy (New York). 2009;89(2):201-215.
11. Seelam B. Implementation of a large-scale school eye health program for Indian children. 2021.
12. Chan VF, Yard E, Mashayo E, et al. Does an integrated school eye health delivery model perform better than a vertical model in a real-world setting?: a non-randomised interventional comparative implementation study in Zanzibar. Br J Ophthalmol. 2022:In press.
13. Chan VF, Omar F, Yard E, et al. Is an integrated model of school eye health delivery more cost-effective than a vertical model? An implementation research in Zanzibar. BMJ Open Ophthalmol. 2021;6(1):561. doi:10.1136/bmjophth-2020-000561
14. Chan V, Yard E, Mashayo E, Mulewa D, Drake L, Omar F. Contextual factors affecting integration of eye health into school health programme in Zanzibar: a qualitative health system research. BMC Heal Serv Res. 2023;23(1):1414.