Background: Over two-thirds of Africans have no access to eye care services. To increase access, the World Health Organization (WHO) recommends integrating eye care into primary health care, and the WHO Africa region recently developed a package for primary eye care. However, there are limited data on the capacities needed for delivery, to guide policymakers and implementers on the feasibility of integration. The overall purpose of this study was to assess the technical capacity of the health system at primary level to deliver the WHO primary eye care package. Findings with respect to service delivery, equipment and health management information systems (HMIS) are presented in this paper. Methods: This was a mixed-methods, cross sectional feasibility study in Anambra State, Nigeria. Methods included a desk review of relevant Nigerian policies; a survey of 48 primary health facilities in six districts randomly selected using two stage sampling, and semi-structured interviews with six supervisors and nine purposively selected facility heads. Quantitative study tools included observational checklists and questionnaires. Survey data were analysed descriptively using STATA V.15.1 (Statcorp, Texas). Differences between health centres and health posts were analysed using the z-test statistic. Interview data were analysed using thematic analysis assisted by Open Code Software V.4.02. Results: There are enabling national health policies for eye care, but no policy specifically for primary eye care. 85% of facilities had no medication for eye conditions and one in eight had no vitamin A in stock. Eyecare was available in < 10% of the facilities. The services delivered focussed on maternal and child health, with low attendance by adults aged over 50 years with over 50% of facilities reporting ≤10 attendances per year per 1000 catchment population. No facility reported data on patients with eye conditions in their patient registers. Conclusion: A policy for primary eye care is needed which aligns with existing eye health policies. There are currently substantial capacity gaps in service delivery, equipment and data management which will need to be addressed if eye care is to be successfully integrated into primary care in Nigeria.
Methods leading up to the facility survey included a literature review to identify a relevant theoretical feasibility framework, a literature review of PEC in sub-Saharan Africa, a Delphi exercise to finalize statements on the technical feasibility and capacities needed to deliver the PEC package, and the development of a number of study instruments based on the agreed statements [19, 20]. In this paper we report the findings of a policy document review and facility survey in relation to service delivery, health management information systems (HMIS) and equipment, technology and consumables. The desk review included a range of policy documents of relevance to the delivery of PHC and eye care in Nigeria (Additional file 1). Statements on service delivery, equipment, consumables, infrastructure and the data collected for HMIS which would support the WHO AFRO PEC package were extracted and mapped onto the WHO health systems framework [21]. The PHC facility survey was conducted in Anambra state in south-eastern Nigeria which has a population of 5.53 million [22]. 75.1% of the population aged ≥6 years are literate [23] and 11.3% are poor [24]. There are two tertiary hospitals, 35 secondary hospitals, and 347 PHC facilities comprising 235 health centres and 112 health posts. Details of how facilities were selected for the study are described in detail in a protocol paper [19]. In brief, 48 PHC facilities in six districts were selected using two stage, stratified random sampling, ensuring a proportionate mix of health centres and health posts, in rural, urban or semi urban locations. Observational checklists were used to assess infrastructure, equipment, drugs and consumables and data recording systems, including the number of patients who attend the facility overall and by age group. Structured questionnaires were administered to facility heads (who comprised a range of different cadres) about the services provided, and referral activities and mechanisms. Nine facility heads were purposively selected for in-depth interviews based on an interim analysis to identify the highest and lowest scoring facilities in terms of patient attendances /1000 population, the health workforce and regularity of supervision. These were stratified by location (urban, rural or semi urban) and type of facility (PHC or health post). Six health centres and three health posts were selected. Semi-structured interviews were conducted with district supervisors for health in the six selected districts. Topic guides were used to explore the challenges they encounter in delivering PHC and their views on the feasibility of delivering PEC. All interviews were conducted in English by the principal investigator (AA) and were recorded after informed consent had been obtained. Data were recorded on paper forms and entered into separate Microsoft Access® databases for the questionnaire and checklists and were transferred into STATA V,15.1 (Statcorp, Texas) using STATransfer for analysis. Frequency tables were generated from the data. Simple descriptive analyses were performed e.g., the proportion of facilities visited with space for visual acuity assessment. Differences in quantitative variables between health posts and health centres were explored using the z-test statistic. Tests of significance were set at the 95% level. The interview recordings were transcribed verbatim, checked for accuracy and coded by AA. The WHO health systems building blocks were used as the framework for analysis after familiarisation of the data by re-reading, indexing, charting, mapping and interpretation. Open Code Software V. 4.02 was used to assist analysis. Ethical approval was obtained from the ethics review boards of the Federal Ministry of Health, Nigeria, the University of Nigeria Teaching Hospital and the London School of Hygiene & Tropical Medicine. Permission to collect data from the state Ministry of Health and district departments of health was obtained. All participants gave written informed consent including to audio record interviews and use of anonymous quotes where appropriate. The following steps were taken to ensure confidentiality; no names were collected for any component of the study and each facility and participant was allocated a unique code. Supervisor codes did not include the district.