Can we scale up a comprehensive school-based eye health programme in Zambia?

The ExpandNet-WHO Nine Steps was used to guide the assessment for developing a scaling-up strategy for SEHP in Zambia [16]. It supported a systematic approach for institutionalising and expanding the comprehensive SEHP based on experience derived from the pilot project. We identified and assessed all the elements, including the innovation, user organisation, resource team, environment, and vertical and horizontal scaling-up strategies. (Table 1) We also explored these elements’ strengths and weaknesses, facilitating and inhibiting factors. Based on the findings, we made recommendations and proposed potential strategies for the scaling-up. Subsequently, the ExpandNet-WHO Checklist for assessing the potential scalability of pilot projects or other programmatic research [17] was completed to determine how much information or action is needed to facilitate a sustainable scaling up. The checklist was organised into 12 questions based on the elements outlined in the ExpandNet-WHO Nine Steps for Developing a Scaling Up Strategy [16].

Individuals and the representative of the institutions who were involved and engaged in the pilot project were identified as key informants for the assessment. The key informants included the representative of the Zambian Ministry of Helath and Ministry of Genereal Education, local project coordinator and director, and Vision Aid Overseas’ Programmes Director and the Deputy Programmes Director.

A global health optometrist (ACY) engaged in several eye health projects in low resource settings conducted the scalability assessment from September to December 2020, employing a mixed-methods approach. ACY reviewed the literature on proven strategies in reducing the burden of childhood VI, the credibility of SEHP, which is implemented in both high-income and low- and middle-income countries, and the effectiveness of a comprehensive SEHP in improving health and educational achievement. ACY also reviewed the Standard Guideline for a Comprehensive SEHP developed by the International Agency for the Prevention of Blindness, [13] project reports from Vision Aid Overseas, the Zambian National Health Strategic Plan 2017–2021, [18] National Eye Health Strategic Plan 2017–2021, [19] and the National School Screening Programme Protocol 2020.

After the literature and reports’ review, a set of questionnaires exploring the five assessment elements was developed. (Online Supplementary File 1.) Based on the experience gained from the recent pilot project, the local stakeholders completed the questionnaire. Due to the COVID-19 pandemic, interviews with the key informants were conducted via an online platform and phone call. A semi-structured guide was developed to collect information relating to stakeholders’ views on consensus and partnership, integration of SEHP into the existing School Health and Nutrition Programme (SHNP), and the health information system in Zambia. (Online Supplementary File 2.) Because the interview was not recorded, after inserting key informants’ inputs according to the interview questions in a Word document, the interviewees were asked to re-check the content and make amendments accordingly to ensure data accuracy. Given the small sample size and to protect the confidentiality of the identity, we utilised “QR” when reporting the findings from the questionnaires, “KII” for key informant interviews, and “DLR” for document and literature review.

The Worksheets for Developing a Scaling-up Strategy provided a detailed set of questions for the strategic planning process [20]. We tabulated the findings from the three different sources in a table, where we grouped the findings into themes. The themes included facilitating and inhibiting factors at the micro- and macro-level, lessons learnt from the pilot project, capacity within the resources teams, potential to include additional local key stakeholders during the scaling-up and the approaches, and views on strategies to scale up the SEHP horizontally and vertically. We triangulated the data by comparing the responses from the questionnaires, the outcomes of the interviews, and extraction from literature and document reviews within the themes to determine the convergence, complementarity, and divergence of information.

The comprehensive SEHP piloted in the Kafue district has demonstrated remarkable achievement in the Zambian context (from 17th June 2019 to 17th December 2019). The pilot screened 18,713 Grade 1 to 9 children (coverage of 43.15%) from the 73 schools and identified 3817 children with eye problems (dispensed 600 pairs of spectacles, referred 68 children to a tertiary hospital for further care, and prescribed more than 3000 bottles of eye drops). Out of all the screened children, 33.9% were aged 14 and older, 29.7% were 11 to 13 years, and 36.4% were younger than 10 years old. (Table 2) The most common ocular conditions were allergic conjunctivitis (80.5%) and uncorrected refractive error (16.7%). (Table 3) A total of 621 children were prescribed spectacles, and 67.0% of them were short-sighted.

Many school vision screening projects conducted in Zambia were mainly event-based (routine practice), lacking consistency and scale. NGOs heavily drove the project, and as a result, the establishment of local ownership and leadership was limited. Table 4 demonstrated the advantages of the Zambia model that was piloted over other routine practices using the 3-point scale. A few prominent components in the pilot Zambian model were (i) the inclusion of local community engagement, (ii) programme monitoring and evaluation, and (iii) building a vision for up-scaling the programme. The local stakeholder reflected and stated, “engagement with local authorities and communities are the entry points to any community, without which no community-based programme can succeed.”(QR 2).

A SEHP protocol that the MOH, MoGE and VAO developed included a comprehensive care package consisting of crucial components in improving child eye health by enhancing services uptake and awareness. Table 5 details the descriptions of components applied in different settings.

All three organisations (VAO, MOH and MoGE) were involved fully in the Kafue district’s pilot project. VAO took the lead on supervision and coordination while the National Eye Care Coordinator (representative of the MOH) and District Education Board Secretary (representative of the MoGE) closely supported VAO. The collaboration relationship and future partnership for the scaling-up among the three organisations were clear when interviewing the local stakeholders, “The existing roles and collaboration among them are fine” (KII 1). However, VAO, the lead institution for the pilot project, suggested that “Ultimately, MoGE will be the owner for the SEHP. Therefore, a Memorandum of Understanding between the Ministries should be signed to ensure that each party plays its role accordingly during the scaling-up”(QR 1).

Organisations’ competency in various sectors, namely leadership, training capacity, technical skill, project implementation, financial resources, and human resources, were explored. Our document review showed that MOH could effectively train schoolteachers as screeners, while local human resources such as OCOs, ONs and OTs can be mobilised to districts where health personnel are limited. Four local institutions can train eye health personnel: Levy Mwanawasa Medical University, University of Zambia, Kitwe Teaching Hospital, and Ndola Teaching Hospital. Triangulation of questionnaires and interview findings suggested that the leading team will need to be further equipped with managerial skills, capacity for advocating and researching, and monitoring and evaluation skills.

The scaling-up of the SEHP requires a team working from the top at the national level to the province and district level, and finally to schools and communities. “The situation is that we have already got the support from the national level, and now we can work with the ground – the district level planner. The national level has to authorise first before we can work with the district level.”(KII 2) The leading team which developed and tested the pilot project will be readily available during the scaling-up. The assessment through questionnaires and interviews demonstrated that they possess capacities such as:

Nevertheless, continuous effort to strengthen the capacities within the leading team is needed.

The National Health Strategic Plan 2017–2021 (NHSP) has included eye health as a non-communicable disease that needs to be prioritised [18]. The 3rd National Eye Health Strategic Plan (NEHSP) aims to achieve eye health coverage across the country to at least 90% by 2021 [21]. Furthermore, SEHP will likely cover the maximum number of children and be a practical approach to achieving this goal.(DLR).

Despite the strategy of capacity building among schoolteachers and community leaders to detect common eye diseases as mentioned in NHSP 2017–2021, a description of the comprehensive SEHP was not highlighted nor emphasised. The outcome evaluation of the pilot project has shown that SEHP has excellent potential to contribute to a few critical objectives stated in NEHSP 2017–2021.(Table 6) Therefore, a policy change is considerably needed.

The government’s full support ensures SEHP’s sustainability, referring to resource allocation such as human resources (eye health personnel in public hospitals) and funding (national health budget). Therefore, the integration of SEHP into the SHNP is critical if the government includes eye health as one of the components of SHNP. One strategy to achieving this is through advocacy to the government (i.e. vertical upscaling).

There are a few valid reasons that the inclusion of child eye health into SHNP will be an effective approach to address the burden of childhood blindness: (i) SHNP is already established in all the schools in Zambia, and therefore implementation will be made easier; (ii) besides nutrition and other health-related issues, eye health is vital in children’s cognitive and psychosocial development; (iii) the integration of the eye health into SHNP was shown to be more cost-effective as compared to the individual programme [22].

VAO has committed initial seed funding based on the available grants from international donors. Longer-term funding would need to be secured for national scale-up and may be done through bringing more stakeholders on board and/or the government securing bi-lateral funding for the programme. Due to the SEHP not being included in any public legal policies, there will be limited government support. Seeing this challenge, vertical upscaling plays a significant role in institutionalising the programme so that the MoGE can allocate that budget through the SHNP.

The inclusion of SEHP into the existing SHNP ensures sufficient financial resources to support the large-scale expansion. With this vision, the process of institutionalising the programme started in 2016. Resulting from the close collaboration among VAO, MOH and MoGE, a National School Vision Screening Protocol was developed. Besides, the government agencies’ involvement in designing and testing the Kafue district’s pilot project can help achieve this goal.

During the pilot project, VAO has supported all the expenses, including training and allowances for schoolteachers, consultancy fees for experts, spectacles and medications supplied to children, community sensitisation, mobile eye clinics’ incurred expenses (fuel, drivers, and vehicle maintenances), and allowances for the public sector eye health team (OCOs, ONs and ophthalmologist) during the activities. The MOH covered the public sector eye health team’s salary.

In Zambia, there are 10 provinces and 118 districts. According to the 2010 census, there were 4.2 million children aged 7 to 18 years in the country, representing approximately 23% of Zambia’s total population (18 million). The Zambian Educational Statistical Bulletin 2018 was referred to understand how many primary and secondary schools are located in a province and the number of children to aid in assessing potential scaling-up. (Table 7) Provinces located in the central region have a higher child population when compared to the east and west regions (Copperbelt, Central, and Lusaka), where more than 500,000 children live in each of these provinces.

When referring to provincial statistics, a detailed breakdown of the number of schools and children at the district level is needed to facilitate effective planning at the initial stage. Table 8 shows the school profiles in Lusaka province, the smallest region in Zambia but with a high population density.

When reflecting on the achievement and insights gained from the pilot project, where 154 schoolteachers were trained to screen 18,713 schoolchildren in 73 schools over 6 months, it will be more realistic to gradually expand the SEHP to a new district rather than a province without compromising the essential components in the programme. This is based on the needs and the existing financial and human resources available within the user organisations.

In terms of financial budget, the cost to screen and/or treat a child (with eye drops/spectacles) was estimated to be £3.35, based on the findings from the pilot (URE rate: 3.35%; allergic conjunctivitis rate: 17.0%). This covered the start-up and recurring costs: training workshop for health personnel, consumables, expenditure for MEHCs, transportation subsidy for some families, equipment, medications, and spectacles. By removing the start-up cost, such as the expenses of collaborative meetings and the consultant fees, the cost to screen and treat a child can be reduced by 37.3% (£2.10 versus £3.35). With this costing formula, an estimated £113,000 is required to screen 33,710 children and 1218 schoolteachers in the Chongwe district. (Online Supplementary File 3.)

When introducing SEHP to a new site, careful assessment of the local context is crucial to ensure better accommodation and embrace diversity in cultures. Adaptation of SEHP to local needs and settings cannot be neglected as this determines the level of receptivity among the target populations, which can directly influence the programme’s impact. There are different demographic characteristics and socioeconomic statuses within a country, and some may have cultural beliefs that are distinct from other groups of the population. Despite some inevitable adjustments and adaptations of the programme during scaling up, the essential component will remain intact as they are all inter-connected.