Assessment of the distribution of human and material resources for eye health in the public sector in Nampula, Mozambique

Nampula province is the most populous province in Mozambique, with 20.6% of the population (5 483 382 inhabitants). It is located in the north of Mozambique, with an area of 81 606 km² and a population density of 78.2 inhabitants per km². Most of the population of Nampula lives in rural areas (67.8%). Nampula Province is divided into 23 districts, and Nampula City is its provincial capital [25, 26].

The National Health System in Mozambique is organized into 4 levels of service delivery (primary level: Health Posts and Health Centers; secondary level: Rural, District, and General Hospitals; tertiary level: Provincial Hospitals; and quaternary level: Central and Specialized Hospitals) [27, 28]. The primary (Health Posts and Health Centers) and secondary (Rural, District, and General Hospitals) levels are dedicated to Primary Health Care. The tertiary (Provincial Hospitals) and quaternary (Central Hospitals) levels offer secondary and tertiary health care [27]. Nampula Province contains 240 health facilities, of which 95 are Health Posts, 137 Health Centers, 3 District Hospitals, 3 Rural Hospitals, 1 General Hospital, and 1 Central Hospital.

Primary eye care services focus on the diagnosis and treatment of simple eye conditions, refraction services, emergency detection and referral, cataracts and other causes of visual impairment, and rehabilitation services. Secondary eye care services are dedicated to the diagnosis and management of the main causes of VI, in addition to refractive errors. These services include surgery (cataracts and glaucoma) and laser and injection therapies (for diabetic retinopathy and age-related macular degeneration). Tertiary eye care services comprise a range of sub-specialized services for the management of more complex eye conditions and training programs [29].

The human resources involved are the main categories of eye health professionals in Mozambique: ophthalmologists, optometrists, and OTs. The ratio of eye health professionals per inhabitant was estimated for each group (ophthalmologists, optometrists, and OTs) at provincial and district levels in Nampula province, taking into account the ratios recommended by the WHO (1:250 000 or 4:1 million inhabitants for ophthalmologists and optometrists, and 1:100 000 or 10:1 million inhabitants for OTs) [3, 6, 14].

The balance of human resources is the result of the relationship between the number of existing professionals and the ideal number of professionals. Thus, negative values express a deficit of professionals (the number of eye health professionals in short supply to reach the recommended ratio) and positive values express an excess of professionals (number of professionals above the recommended) by province and district.

Regarding equipment for eye health, a list was made taking into account the standard and essential equipment determined by the International Agency for the Prevention of Blindness (IAPB) [17‐21]. This includes equipment for services of refraction, diagnosis and management of glaucoma, cataract, diabetic retinopathy, and trachomatous trichiasis. Only operational equipment was included in the study.

Data collection took place through document analysis and the application of a questionnaire to the heads of the ophthalmology department in each health facility. Information on the number of inhabitants at provincial and district levels was extracted from the Definitive Results of the 2017 General Population and Eligibility Census [26]. Information on the number of eye health professionals in the public sector in each district of Nampula province was obtained from the Annual Report of the Eye Health Program 2021 [30].

Through the Nampula Provincial Directorate of Health, all health facilities with eye health services across Nampula province and the respective heads of the ophthalmology department in each health facility were identified. A list of all facilities with eye health services, their heads, physical address, and contact (telephone and email) was prepared.

The questionnaire on human resources, infrastructure, and equipment available developed by WHO and IAPB [31] was adapted taking into account the standard list of essential equipment (for refraction services, management of glaucoma, cataract, diabetic retinopathy, and trachomatous trichiasis) of the IAPB [17‐21]. A qualitative pre-test interview was previously conducted with four eye health professionals with at least five years of experience (one ophthalmologist, one OT and two optometrists) who were not heads of the ophthalmology department of any of the health facilities.

The questionnaire's final version was structured, self-administered and not validated (see Additional file 1). It was applied to the heads of the ophthalmology department of health facilities with eye health services to collect information on the material resources for eye care available in each health facility. The questionnaire and the respective informed consent form were shared by email with each interviewee. Data collection took place from April 2021 to November 2021.

This study was previously authorized by the Provincial Health Service of Nampula and the Provincial Health Directorate of Nampula, and later by the Institutional Committee of Bioethics for Health of Lúrio University, with the ref: 05/Feb/CBISUL/21, on 25 February 2021. All interviewees were previously informed about the nature of the study and participated in the study by signing an informed consent form. Therefore, this study followed the principles of the Declaration of Helsinki.

The types of equipment were grouped into 4 categories (refraction services, cataract surgery, glaucoma, diabetic retinopathy, and trachomatous trichiasis management) according to the IAPB Standard Equipment List [17‐21, 32]. The calculation of the ratio of professionals resulted from dividing the number of inhabitants by the number of professionals in each category. To calculate the balance of human resources in every province and each district of Nampula, the subtraction operation was used, where the number of existing professionals was subtracted by the ideal number as recommended by the WHO [3, 6, 14].

A database was created using Microsoft Excel (version 2010). Data were extracted from each completed questionnaire and entered into the database by two researchers (D.B.S and Z.M.A.S). The formulas for calculating the ratio and balance of eye health professionals were entered into the database. Using simple descriptive statistics, the proportions of equipment available at different levels of health care were identified.

Overall, Nampula Province has not reached the recommended ratio of eye health professionals per population in the different categories. The current numbers should be increased by 9 OTs, 14 optometrists, and 18 ophthalmologists to reach the recommended ratios. However, there was also an uneven distribution of eye health professionals across the province, with a greater concentration of professionals in the provincial capital (Nampula City), so most districts did not reach the recommended ratio, presenting a negative balance. Nampula City is the district with the best ratio of professional per inhabitants (in all categories), with a positive balance (Table 1).

Nampula province contains a total of 240 public health care facilities and only 26 (10.8%) provide eye health services. Most health facilities with eye health services are concentrated in Nampula City (with 8 public health care facilities with eye health services, corresponding to 30.8%), so the provincial capital has the best ratio of public health facility per inhabitants (Table 2 and Fig. 1). The districts of Moma, Angoche, Mogovolas, and Monapo have the worst ratio, and on the other hand, the districts of Lalaua, Larde, Mogincual, Mossuril, and Muecate do not have any health facilities with eye health services (Table 2), and therefore no eye health professionals (Table 1). Of a total of 26 public health care facilities with eye health services, 16 are primary level (Health Centers), 9 secondary level hospitals (2 Rural Hospitals, 6 District Hospitals, and 1 General Hospital), and one quaternary level hospital (Hospital Central de Nampula).

We report the distribution of eye care equipment in Table 3. All health facilities contain visual acuity measurement charts, trial lens sets, and trial frames. However, there is a lack of certain equipment for providing refraction services such as retinoscopes, autorefractors, and lensometers in primary and secondary health facilities. Primary health facilities do not contain this equipment, and only 33.3% of secondary facilities have an autorefractor and streak retinoscope.

The facilities at the primary level are quite limited in terms of diagnostic equipment for eye pathologies such as cataracts, glaucoma, and diabetic retinopathy (only 12.5% have a slit lamp, 50% a direct ophthalmoscope and 56.3% a Schiotz tonometer). At the secondary level, most facilities have minimal equipment for the diagnosis of ocular pathologies (44.4% have a slit lamp, 77.8% have a direct ophthalmoscope and 66.7% have a Schiotz tonometer). The Central Hospital of Nampula (CHN) has the best conditions not only for the diagnosis, but also for the surgical treatment of these conditions.

Regarding trachomatous trichiasis, most facilities are equipped for diagnosis, as most have a pen torch, hand magnifying lens or even a slit lamp. However, only the CHN is properly equipped for surgical treatment, while the primary and secondary facilities have equipment only for non-surgical interventions (most contain epilation forceps).

Overall, Nampula Province has not achieved the recommended ratio of eye care professionals to population in any of the classes (OTs, optometrists and Ophthalmologists). Nampula City (capital) was the only district with a recommended ratio in the three classes of professionals and a positive balance, resulting from the greater concentration of eye health professionals in the capital. This shows a great disparity between the capital and regions outside the capital (other districts, which, mostly, had a negative balance).

In the study carried out in the province of KwaZulu-Natal, South Africa [6], optometrists were the only class that reached the recommended ratio, while ophthalmologists and ophthalmic nurses presented a ratio far from the WHO recommendations. This difference may be due to the fact that South Africa has more optometrist training institutions and has been training optometrists longer than Mozambique, and KwaZulu-Natal had its first optometrist training institution in 1979 [34].

On the other hand, in the study carried out in Ogun State, Nigeria [35], ophthalmologists were the only class with the recommended ratio (5.4 per million inhabitants), while optometrists and ophthalmic nurses had a ratio below the recommended (with 3.8 and 6.3 per million inhabitants, respectively). This difference may be because Ogun State has 3 training programs for ophthalmologists and none for optometrists and ophthalmic nurses.

However, in the three studies there was a greater concentration of eye health professionals in the capital (urban area) [6, 35], which denotes an unequal distribution throughout the territory. We must not forget that in the three provinces (Nampula, KwaZulu-Natal and Ogun State) the population mostly lives in rural areas (3.715.849 people in Nampula live in rural areas, corresponding to 67.8% of its population) [26], so a large part of its population is left disadvantaged in eye health care, which can exacerbate the burden of eye diseases and VI in communities.

The province of Nampula has a total of 240 public health facilities. Out of these, only 26 (10.8%) provide eye health services, a relatively low percentage that may indicate poor investment in eye health in the public sector. Obviously, the sector is reinforced by the private sector, however the use of private eye health services entails costs and a large part of the population of Nampula does not have economic conditions to access them, as 55% of the population of Nampula lives in severe poverty (with less than 1.9 dollars a day) [36]. Therefore, the demand for eye health services in the public sector is greater. This results in overcrowding in public hospitals, longer waiting time in health facilities or in long distances to travel to enjoy eye health services, with additional transport costs. These factors constitute barriers to access to eye health services and a major obstacle in the fight against preventable and treatable VI [37].

The primary level facilities (Health Centers) have sufficient equipment for subjective assessment of refractive error, and most have the minimum conditions for preliminary screening of ocular pathologies. Trachomatous trichiasis can be managed non-surgically by 68.8% of health centers (as they contain epilation forceps). In studies carried out in Nigeria, health centers and health posts had only visual acuity tests and flashlights [38, 39]. Therefore, the health centers in Nampula were better equipped compared to the health centers in Nigeria. The equipment level of the facilities depends a lot on the guidelines and internal legislation of each country. However, taking into account that refractive errors are the main cause of VI in the world [40], health centers, being within reach of most communities, can be strategic to ensure greater coverage of refractive services. Considering that refractive services are part of the scope of primary eye care according to the framework for delivering eye health services integrated into the health system recommended by the WHO [29, 41, 42], it would be opportune for refractive interventions to be more effective at the community level that these facilities should be better equipped to provide refractive services.

The facilities at the secondary level (Rural, District, General Hospitals) are better equipped than those at the primary level (Health Centers), as was already supposed. However, a lack of important equipment was noted, such as the autorefractor and the Streak retinoscope, which are present in only 40% of the facilities. Most facilities have equipment that can detect eye conditions such as cataracts, glaucoma, diabetic retinopathy and trachomatous trichiasis. However, they do not have the capacity for (surgical) treatment and follow-up, and these patients must be referred to the CHN.

Similar results were found in Ghana [32], where most district, municipal and metropolitan hospitals did not have autorefractors and Streak retinoscopes. Some facilities were equipped to provide cataract surgery, although with certain limitations.

In Mozambican health legislation, secondary level facilities are also dedicated to primary health care, and at this level, it was expected that refraction services would be more complete. However, the lack of an autorefractor and a retinoscope makes it impossible for these facilities to perform objective refraction, limiting them to subjective assessment, which negatively impacts the effectiveness and quality of refraction services.

The CHN is the only hospital that provides tertiary eye care in the entire northern region of Mozambique (which involves Niassa, Cabo Delgado, and Nampula). It is very well equipped for refraction services and the diagnosis, treatment and follow-up of the most diverse eye pathologies. It is the only facility capable of performing surgery in cases of cataracts, glaucoma, diabetic retinopathy, and trachomatous trichiasis in Nampula, which shows the centralization of eye surgery services.

The centralization of services is the result of insufficient human and material resources, as well as their poor distribution. This results in increasing differences and inequalities between groups, thus violating one of the basic principles of the right to health, which is equity in health. The Mozambican Constitution (2004) enshrines the right to medical care for all citizens. It also guarantees that all citizens enjoy the same rights, regardless of color, race, ethnic origin, place of birth, religion, level of education, social position, or gender [43]. Therefore, it is the Government's responsibility to ensure accessibility to eye health services, especially for vulnerable groups and in remote areas.

As a way to increase the coverage of services, a team of health professionals from the CHN has periodically visited more remote regions in order to provide outpatient care and carry out surgery campaigns (especially for cataracts and trachomatous trichiasis). However, around 4.723.168 inhabitants living outside the capital (86% of the population of Nampula) can stay without access to these services for long periods, and this method may discourage the development of local eye care services [29].

Therefore, it is necessary to train the local workforce, as well as to equip the respective facilities with essential equipment to provide the most diverse services, especially surgical ones. As an example, some studies have shown encouraging results about cataract surgery performed by non-physician cataract surgeons after training. It has been a measure adopted mainly in low- and middle-income countries to compensate for the lack of ophthalmologists in remote areas [44].

Telemedicine and artificial intelligence can also be seen as an alternative. Despite the requirements for its operation, these have the potential to alleviate the lack of specialized health professionals and make services available in remote regions. Therefore, they can be an option in the medium and long term [45, 46].

Therefore, the solution does not only involve training more human resources. Future studies are needed that seek to analyze strategies and policies for the allocation of resources for eye care and retention of staff. These are factors that dictate the preference or choices of professionals with respect to their allocation or migration to other workplaces (rural to urban, and vice versa), as well as labor market trends.

However, for the effectiveness and quality of eye health services, more elements, in addition to human and material resources, need to be considered. These include financial resources, the information system, availability of supplements, and aspects related to leadership and service of delivery. Therefore, future studies that evaluate the other elements are equally necessary, since the proper functioning of the health system depends on the conjuncture of all these elements.