Sumrana Yasmin
Khalid Saifullah
Hassan Minto
Given the paucity of human resources for eye health, especially in developing countries,
innovative approaches need to be developed and primary eye care components strengthened.
A child after vision correction as part of a school eye health programme. PAKISTAN
The importance of a child's eye health cannot be understated. Poor vision can affect
a child's educational attainment and thereby have a negative impact on a child's future
life.
1
As data from the Sustainable Development Goals suggests, educational attainment has
a direct impact on future indicators for individual (and national) economic growth,
and, more importantly the health and educational outcomes of children.
2
Eye health is an essential part of a school health programme. It should be comprehensive
and respond to a wide range of eye conditions and diseases prevalent in the project
area. Given the paucity of human resources for eye health, especially in developing
countries, innovative approaches need to be developed and primary eye care components
strengthened. This could include training non-clinical personnel like school teachers
and community-based workers to undertake basic eye health screening and appropriate
referrals to the primary eye health system for further management.
This paper describes the institutional approach to a school eye health programme in
Pakistan. The programme engages multiple stakeholders to provide primary eye care
and this has led to improved access, especially for children in rural communities.
The estimated population of Pakistan is 195 million
3
− 41% of which are below the age of 18 years
4
and among them 90% are enrolled at schools.
5
More than half of this population lives in rural areas. Pakistan is ranked 147th on
the human development index.
6
More than one-third of the population lives below the national poverty line. According
to the recently conducted Rapid Assessment of Refractive Error in Children in Pakistan
(2016–2017) by the Brien Holden Vision Institute, the prevalence of significant refractive
error is 5.4% in the age of 5–15 years (in a study submitted for publication).
However, no reliable data exists on the prevalence of ocular morbidity in children
in Pakistan and it is estimated that more than 10% of the children suffer from some
form of ocular morbidity, predominantly due to Conjunctivitis, Trachoma, and Ocular
Trauma. In countries like Pakistan, eye care is normally considered a subject of secondary
and tertiary health interventions; increasing the cost to patients and the health
system. The secondary and tertiary eye health facilities are inadequate and inequitably
distributed across the country. The need for the development of primary eye health
services is crucial. It requires capacity building of diverse cadres in public and
private sectors to strengthen the primary eye health workforce. This needs inter-
and intra- departmental partnerships with the public and private sectors, and civil
society.
School health and school eye health is neither a prioritised theme for public sector
education and health departments nor is eye health integrated in the school health
agenda. Only Non-Governmental Organisations (NGOs) are implementing the school eye
health (SEH) programmes in collaboration with public sector health and education departments
in select geographical locations. In most cases, NGOs work with the education department
while implementing their SEH programmes. In Pakistan, a number of other public and
private sector organisations that run different types of schools, are normally discounted
from such SEH programmes. In order to develop a comprehensive SEH programme that can
claim to be inclusive, all such actors need to be involved that are directly or indirectly
engaged in education and health interventions. There is a dire need to develop a comprehensive
and practical framework that can cater to diverse needs and engage various stakeholders
in education and health sectors to deliver integrated school eye health programmes.
School Eye Health Programme
School eye health is an effective strategy for implementing eye care programmes including
correction of vision impairment due to uncorrected refractive error. Early intervention
can prevent the child from losing vision due to Amblyopia. Given the huge unmet need
and lack of standardised approaches to school health in Pakistan, the Brien Holden
Vision Institute (the Institute) prioritised SEH as a key focus for its child eye
health intervention. The SEH strategy emphasises the following:
To ensure accessibility of high quality eye health services to all children.
To actively advocate the importance and integration of school eye health initiatives
into existing education and health systems.
To strengthen the institutional capacity of key stakeholders in planning, implementation,
and effective delivery of SEH interventions leading to policy development.
The programme demonstrates the potential for adoption by the government and other
eye care and non-eye care development partners.
Roles of various stakeholders
Developing a comprehensive school health programme requires partnerships both at the
substructure and superstructure levels. Partnership at the level of superstructure
results in ownership of the programme, its sustainability and integration of best
practices into the policy discourse. Active engagement at substructure level ensures
the effective transfer of knowledge and skills to clinical and non-clinical primary
cadres, extensive school screening, community participation, and appropriate referrals.
In the implementation of a SEH programme, diverse organisations can be engaged to
reach out to a larger number of children. The table below explains the types and roles
of the different organisations engaged in the programme to promote SEH (Table 1).
A comprehensive SEH programme, developed with the active ownership of diverse stakeholders
serves the following key functions:
Links schools, communities, government departments, private sector and civil society
organisations.
Increases early detection of vision impairment among children and facilitates provision
of appropriate solutions.
Raises eye health awareness at school, community and organisation levels.
Enables children with vision impairment to continue their education.
Promotes inclusiveness by providing primary eye care to all children regardless of
any difference.
Table 1
Type and role of the different organisations engaged in the programme to promote SEH
Nature of the organisations
Role in school eye health
Public sector
Ministries of Education, Health, Social Welfare, Child Welfare
District Governments
School management committees
Police departments
Integrating eye health into school health and primary health systems
Resource allocation for spectacle provision for those children who cannot afford them
Introducing SEH in schools run by government departments
Permitting different cadres for trainings on SEH to provide primary eye care at department,
community and school levels
Generating evidence to further incorporate in policy discourse
Civil society organisations
Local non-governmental organisations (NGOs)
International non-governmental organisations (INGOs) working on education, health,
hygiene, gender, livelihoods and child rights
Development of demonstration approaches based on best practice
Integrating child eye health into community-based projects on education, health, hygiene,
sanitation, child rights, and other relevant issues
Increasing eye health awareness among communities and schools in the project area
Promoting SEH in schools run by NGOs and associated communities
Advocating and lobbying at local levels with education and health departments
Private sector
Social entrepreneurs
Private eye hospitals and businesses
Integrating SEH in regular eye and health services
School screening and referring children with eye care needs to secondary and tertiary
eye health facilities
Ensuring the availability of affordable and good quality spectacles frames, lenses
and accessories for children of all ages
Media (print, electronic, social media)
Disseminating information on SEH to broad audiences
Promoting targeted eye health education and health promotion
Mobilising the communities in rural areas
Academia, particularly, health professionals
Eye health professional forums
Integrating SEH in eye health curriculums at all levels
Facilitating the engagement of optometry and ophthalmology graduates/undergraduates
in SEH programmes especially in trainings and outreach activities
Provision of good quality eye care enhances the confidence of children, especially
girls. PAKISTAN
In the last three years, through its SEH programme, the Institute has reached 520,000
children including 47% girls by engaging with public and private sector organisations,
academia and civil society organisations. The Institute has dispensed over 25,000
spectacles and 1,300 low vision devices to boys and girls in the programme's geographical
areas. Contributing to the broader SEH agenda along with other civil society organisations,
the Institute has built the capacities of more than 2,500 diverse cadres including
teachers, social workers, NGO employees, hygiene promoters and others in child eye
health and vision screening.
Key Lessons
A SEH system needs to be compatible with local culture and policy environment. Factors
which facilitated the effective implementation of SEH programmes in Pakistan are:
Partnership with education and health departments to build synergies; bring ownership,
ease of getting necessary approvals, continuity and sustainability.
Training teachers in primary eye health and appropriate referrals to build a community-based
cadre, given the scarcity of human resources for health care.
Availability of training material in the local language enables non-clinical cadres
to learn and understand SEH better.
Better-equipped trainers will keep the diversity of the participants in mind and provide
local and contextual examples.
Identifying potential women and men, especially in rural areas, to establish micro-social
enterprises, contributes to reaching more children both in and out of schools.
Strict implementation of a code of conduct for child protection reduces the risk of
harm to children and presents the staff engaged in SEH as positive role models for
children.
Eye health, being a high priority subject, is acceptable to all stakeholders involved
in the community development process.
Eye health is thematically and operationally compatible with regular education, health
and hygiene programmes.
Media is a valuable partner in eye health awareness especially in rural communities.
In low-income countries, different departments in public and non-government sectors
run their own schools. These schools need to be engaged in broader school health programmes.
Challenges
There were several challenges in implementing this programme and the following lessons
were learnt:
An enabling policy framework to support education and health sector reforms is needed
in Pakistan.
Education and health departments work independently, with little coordination between
them. An effective SEH programme requires efficient coordination among key stakeholders.
Non-availability of data related to schools run by NGOs, social welfare and other
departments.
A mechanism to provide financial assistance to children whose families cannot afford
to pay for services including spectacles.
Developing consensus to implement a broad monitoring, evaluation and learning framework
requires considerable discussion.
Figure 1
School eye health system with non-clinical and diverse stakeholders
Conclusion
In order to be effective and sustainable, a SEH programme must be integrated within
the education and health systems, particularly within the school health programme.
It is crucial to engage with diverse stakeholders for the implementation of SEH in
low income countries, especially ones which have large populations and a large number
of school-going children. Developing countries also have fewer eye health workers,
thus creating a space and need for other cadres to be involved in eye care. Coordination
is essential at all levels. Roles and responsibilities need to be clearly defined
for this system to function effectively. Integrating SEH into the broader health agenda
will also help in the pursuit of Sustainable Development Goals.