Strengths and weaknesses of eye care services in sub-Saharan Africa: a meta-synthesis of eye health system assessments

Governments across the world face diverse challenges in meeting their populations’ health needs [1]. This is especially the case in sub-Saharan Africa, where, despite significant reductions in infant and maternal mortality in recent decades, the burden of both communicable and non-communicable diseases remains high [2, 3]. There is an increasing global consensus that to be able to address the multiple challenges faced by some of the poorest countries in the world, “a health system strengthening” approach is required [4‐6].

The World Health Organization (WHO) emphasized the importance of strengthening health systems in its 2007 framework for action [7] and in a range of other more recent publications and tools [8, 9]. The health system strengthening focus is also commonly acknowledged as an essential pre-requisite for achieving Universal Health Coverage, which has become a major global priority and a goal for health reforms in many Member States [10].

With 36 million people being blind and another 217 million living with moderate or severe visual impairment, eye health continues to be a global health problem, particularly in low income countries, where the delivery of eye care services is undermined by the scarcity of infrastructure, shortage of human resources and high user fees [11‐15]. The WHO Global eye health action plan 2014–2019 aims to reduce avoidable visual impairment and secure access to rehabilitation services for the visually impaired and is built on the health system approach, which encompasses the integration of eye care services into the broader health systems at all levels [16].

With the understanding that the effectiveness of eye service delivery can only be improved through a better understanding and strengthening of eye health system functions, the WHO developed the Eye Care Service Assessment Tool (ECSAT), which provides guidance for assessing the status of a country’s eye care and helps decision-makers to identify gaps and strengthen access to and quality of services [17]. A few years earlier, a comparable tool, called the Eye Health System Assessment (EHSA) tool, was developed by a consortium of eye care and health experts coordinated by the International Centre for Eye Health (ICEH) at the London School of Hygiene and Tropical Medicine (LSHTM) with funding from Sightsavers [18]. Both tools are based on the six blocks of the WHO framework for strengthening health systems [7] and aim to identify strengths and weaknesses in eye care service provision within the wider health system context.

Completion of the ECSAT relies largely on desk review of publically available documents, reports, and other accessible secondary data sources. The EHSA tool on the other hand goes beyond desk review and incorporates the conduct of structured face to face interviews with several key actors at the Ministry of Health and other relevant government departments, professional societies, civil society organizations, relevant iNGOs and agencies working in-country. The in-depth nature of the questions that these respondents are usually asked allows for change on the different indicators to be probed and ascertained compared to previous years.

The purpose of this review is to synthesise data collected using the EHSA/ECSAT on governance, financing, provision and organisation of eye care services across different sub-Saharan Africa contexts, in order to gain a more comprehensive understanding of the current systems and how they can be strengthened to meet the objectives of the global eye health action plan and ultimtely better eye health for people in low resource settings.

The review utilized the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines [19].

To the best of our knowledge, this is the first meta-synthesis to explore and attempt to learn from assessments that document the strengths and weakness of eye care delivery in sub-Saharan Africa countries. We found marked strengths and improvements in the governance, financing, organisation, and provision of eye care services across the countries included in this review. Significant progress has been made in developing national governance frameworks, co-ordination structures, and regulatory mechanisms aligned with the rest of the sector. Even in some of the poorest countries, our meta-synthesis revealed that governments had made noteworthy efforts in taking over the responsibility for funding eye care infrastructure and salaries of eye care personnel. Similarly, important steps have been made in strengthening multi-sectoral collaboration and partnerships with disabled persons organisations.

However, despite these significant improvements, a range of systemwide weaknesses continue to impede the performace of eye health systems across the sub-Saharan Africa settings we reviewed and prevent them from achieving better results. Low per capita spending on health coupled with the historically vertical nature of eye care funding and delivery through private for profit and not-for profit providers continue to limit meaningful integration of eye care within the broader healthcare systems, particularly at the local level, where most of the service delivery takes place. As is true of most countries in Africa, the limited number of health workers in general and eye care workers in particular, continues to be a major problem creating service delivery bottlenecks at all levels. Although most of the countries attempted to develop pre-payment schemes and exemptions for vulnerable populations, the actual mechanisms of how these schemes work and their effectiveness for achieving universal health coverage remain unclear.

In addition, this review found that there was a lack of detail available across the different blocks of the health system. There are interrelated operational and broader health system causes for this lack of detail. Information and issues may be known to some actors in the system, but often there is no proper documentation or records management thus making over-reliance on desk-review as a data collection method largely ineffective. The ECSAT appear to have been designed on the assumption that the information is out there, documented – and that somebody only needed to conduct a desk review, but we found that not to be the case. The EHSA tool attempts to go around this problem by incorporating a heavy focus on primary fieldwork through face to face interviews with relevant stakeholders but the people who would be best positioned to answer questions tend to be ‘too busy’ and rarely make themselves available for an in-depth interview. However, our findings in no way imply that that government officials are reluctant to share information. Rather, the findings point to an urgent need for enhanced government efforts to strengthen internal mechanisms, infrastructure, and capacity to support and enable timely flow and sharing of information. Data are collected and analysed within vertical programmes but often reports are not distributed widely among the relevant government departments or partners. Sightsavers approach has been to try to work in collaboration with governments to make these eye health system assessment reports available online and provide some assistance for the countries included in this review to be able to host the assessment reports on MOH websites. Additionally, there is a page for the ECSAT tool on the WHO website – presumably, a link to the reports could be possible and make the reports more widely available.

The challenges identified in this review are not new and have been previously documented [14, 30, 31]. But the two tools used to guide the assessments included here provide new opportunities for reflection and rethinking of how best to work within struggling health systems to foster the necessary changes that would assure constant improvements in the organization and delivery of vision and eye health services. Meaningful progress toward the VISION 2020 goals require a foundation based upon ‘health systems as learning systems’, data synthesis and use [32]. In line with Blanchet et al. [11, 14, 31, 33], who have previously advocated for system thinking in eye health, we would encourage national governments and iNGOs to invest in conducting and wider use of these assessments. Such analyses are particularly useful in building links between different system elements and in finding innovative, more flexible solutions and partnerships, which can ultimately help to eliminate avoidable visual impairment in resource-poor settings.

It does feel that there should be some further discussion about the usefulness of the two tools, however, we had only one ECSAT report therefore such a discussion appears to be beyond the scope of this study. We do not claim that one tool is better than the other, but given the limited documentation and poor records management within government departments in the region, a tool that prioritizes primary fieldwork through in-depth interviews with the different actors would seem best suited in these settings.

A few potential limitations must be considered when interpreting our findings. First, the focus on assessments conducted in sub-Saharan Africa precludes the generalizability of our findings to other parts of the world. Second, despite the comprehensive searches conducted and informal discussions in-country with the national eye care coordinators, we cannot be sure that we captured all the relevant studies as we did not formally contact MOH or WHO to identify the existence of unpublished reports. Third, the EHSA/ECSAT methodology uses primarily qualitative inquiry with purposively selected stakeholders – and the tools were designed to collect and report evidence in a format relevant to decision-making in a particular context. It would therefore be difficult to compare them against one unified tool for quality assessment.