Primary health care facility readiness to implement primary eye care in Nigeria: equipment, infrastructure, service delivery and health management information systems

  • BMC Health Services Research, Volume 21, No. 1, Year 2021

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Study Justification:
– Two-thirds of Africans lack access to eye care services.
– Integrating eye care into primary health care is recommended by the World Health Organization (WHO).
– Limited data on the capacities needed for delivery of primary eye care exist.
– Policymakers and implementers need guidance on the feasibility of integrating eye care into primary care.
Study Highlights:
– Enabling national health policies for eye care exist, but there is no specific policy for primary eye care.
– 85% of facilities surveyed had no medication for eye conditions, and one in eight had no vitamin A in stock.
– Eye care services were available in less than 10% of the facilities.
– Services delivered focused on maternal and child health, with low attendance by adults aged over 50 years.
– No facility reported data on patients with eye conditions in their patient registers.
Study Recommendations:
– Develop a policy for primary eye care that aligns with existing eye health policies.
– Address substantial capacity gaps in service delivery, equipment, and data management.
– Ensure availability of medication and vitamin A for eye conditions in primary health facilities.
– Increase access to eye care services in primary health facilities.
– Improve data collection and management for patients with eye conditions.
Key Role Players:
– Policymakers and government officials responsible for health policy development and implementation.
– Health facility managers and heads of primary health facilities.
– District supervisors for health.
– Eye care professionals and specialists.
– Community health workers and primary health care providers.
Cost Items for Planning Recommendations:
– Procurement of medication and vitamin A for eye conditions.
– Training and capacity building for primary health care providers.
– Infrastructure improvements and equipment procurement for eye care services.
– Development and implementation of data management systems for eye conditions.
– Monitoring and evaluation of the integration of primary eye care into primary health care.
Please note that the cost items provided are general categories and not actual cost estimates. The actual cost will depend on various factors such as the scale of implementation and specific needs of each primary health facility.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are areas for improvement. The study used a mixed-methods approach, including a desk review of relevant policies, a survey of primary health facilities, and interviews with supervisors and facility heads. The findings highlight substantial capacity gaps in service delivery, equipment, and data management for primary eye care in Nigeria. However, the abstract does not provide details on the sample size or response rate of the survey, which could affect the generalizability of the findings. Additionally, the abstract does not mention any limitations of the study or potential biases. To improve the evidence, future studies should consider increasing the sample size and response rate, and should clearly state any limitations or biases in the methodology.

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.

Based on the information provided, here are some potential recommendations for innovations to improve access to maternal health:

1. Develop a policy for primary eye care: Establish a specific policy for primary eye care that aligns with existing eye health policies. This will help guide the integration of eye care services into primary health care facilities.

2. Increase availability of eye care services: Expand the availability of eye care services in primary health care facilities. This can be done by training health care providers in basic eye care and ensuring that facilities have the necessary equipment and medication for eye conditions.

3. Improve data management systems: Implement health management information systems (HMIS) that capture data on patients with eye conditions. This will help monitor the demand for eye care services and identify areas where additional resources or interventions are needed.

4. Enhance infrastructure and equipment: Assess and improve the infrastructure and equipment in primary health care facilities to support the delivery of eye care services. This may include providing space for visual acuity assessment and ensuring that facilities have the necessary tools and technology for eye examinations.

5. Strengthen referral mechanisms: Establish effective referral mechanisms between primary health care facilities and higher-level health care facilities for cases that require specialized eye care. This will ensure that patients with complex eye conditions receive appropriate care in a timely manner.

6. Promote community awareness and education: Conduct community awareness campaigns to educate individuals, especially pregnant women, about the importance of eye care during pregnancy and the postpartum period. This can help increase demand for eye care services and encourage early detection and treatment of eye conditions.

These recommendations aim to address the capacity gaps identified in the study and improve access to maternal health by integrating eye care services into primary health care facilities.
AI Innovations Description
The recommendation to improve access to maternal health based on the provided information is to develop and implement a policy specifically for primary eye care (PEC) that aligns with existing eye health policies in Nigeria. Currently, there are substantial capacity gaps in service delivery, equipment, and data management that need to be addressed in order to successfully integrate eye care into primary care.

To develop this innovation, the following steps can be taken:

1. Conduct a comprehensive literature review: Review existing literature on primary eye care integration in sub-Saharan Africa and identify a relevant theoretical feasibility framework.

2. Engage stakeholders: Involve key stakeholders such as policymakers, healthcare providers, and community members in the development and implementation of the policy. Their input and perspectives will be valuable in ensuring the policy is effective and feasible.

3. Conduct a Delphi exercise: Use the Delphi method to finalize statements on the technical feasibility and capacities needed to deliver the primary eye care package. This exercise will help gather expert opinions and consensus on the necessary components of the policy.

4. Develop study instruments: Based on the agreed statements from the Delphi exercise, develop study instruments such as questionnaires and observational checklists to assess the readiness of primary health facilities to deliver the primary eye care package.

5. Conduct facility surveys: Select a representative sample of primary health facilities in Nigeria and conduct surveys to assess their capacity in terms of service delivery, health management information systems (HMIS), equipment, technology, and consumables. This will provide valuable data on the current state of primary eye care in the country.

6. Analyze data: Analyze the survey data using appropriate statistical methods to identify gaps and areas for improvement in service delivery, HMIS, equipment, and data management. This analysis will help inform the development of the policy and identify specific interventions needed to improve access to maternal health.

7. Develop and implement the policy: Based on the findings from the surveys and analysis, develop a policy specifically for primary eye care that aligns with existing eye health policies. Ensure that the policy addresses the identified capacity gaps and includes strategies for improving service delivery, HMIS, equipment, and data management.

8. Monitor and evaluate: Implement the policy and establish a monitoring and evaluation system to track its impact on access to maternal health. Regularly assess the implementation progress, identify challenges, and make necessary adjustments to ensure the policy’s effectiveness.

By following these steps, the recommendation to develop a policy for primary eye care can be transformed into an innovation that improves access to maternal health in Nigeria.
AI Innovations Methodology
The study described in the provided text aimed to assess the technical capacity of the health system at the primary level to deliver the World Health Organization (WHO) primary eye care package in Anambra State, Nigeria. The study utilized a mixed-methods approach, including a desk review of relevant Nigerian policies, a survey of 48 primary health facilities, and semi-structured interviews with supervisors and facility heads.

To simulate the impact of recommendations on improving access to maternal health, a methodology could be developed using the following steps:

1. Identify the key recommendations: Based on the findings of the study and the specific context, identify the key recommendations that could improve access to maternal health. These recommendations could include improving service delivery, ensuring availability of necessary equipment and medication, strengthening health management information systems, and addressing capacity gaps.

2. Define indicators: Define specific indicators that can measure the impact of the recommendations on improving access to maternal health. These indicators could include the number of facilities with adequate medication for maternal health, the percentage of facilities providing maternal health services, the attendance rate of pregnant women, and the availability of data on maternal health in patient registers.

3. Collect baseline data: Collect baseline data on the identified indicators before implementing the recommendations. This data will serve as a reference point for comparison and evaluation of the impact of the recommendations.

4. Implement the recommendations: Implement the identified recommendations to improve access to maternal health. This could involve policy changes, capacity building initiatives, infrastructure improvements, and strengthening of health systems.

5. Monitor and evaluate: Continuously monitor and evaluate the implementation of the recommendations. Collect data on the identified indicators at regular intervals to assess the progress and impact of the recommendations on improving access to maternal health.

6. Analyze the data: Analyze the collected data to assess the impact of the recommendations. Compare the post-implementation data with the baseline data to determine the extent of improvement in access to maternal health.

7. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the impact of the recommendations on improving access to maternal health. Identify any gaps or areas for further improvement and make recommendations for future interventions.

By following this methodology, policymakers and implementers can simulate the impact of recommendations on improving access to maternal health and make informed decisions to address the identified gaps in the health system.

Statistics:
Citations: 1
Authors: 5
Identifiers:
DOI: 10.1186/s12913-021-07359-3
Research Areas:
Health System and Policy, Maternal and Child Health, Quality of Care, Social Determinants, Technology and Innovations
Study Countries:
Nigeria
Study Design:
Cross Sectional Study
Study Approach:
Mixed-methods, Qualitative, Quantitative, Systematic Review
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