WHOLE1.indd ABSTRACT Objective: Endeavor to improve (i) the quality of Primary Eye Care with the aid of an Eye Health Care Programme and (ii) the resourcing Primary Eye Care in Ministry of Health Institutions in 200. Method: In this descriptive study, staff were randomly selected from 84 health institutions and representing 36 primary health institutions to carry out quality assurance procedures. Oph- thalmologists trained in this evaluation were field staff who evaluated the resource status, such as health staff, space for eye care deliv- ery, instruments, materials for health education, referring cases (for continuous medical education of the primary health staff ), drugs for eye care, etc., in each health institution. In addition to availability, the standards of eye care delivery were also estimated. Results: The health institutes of Oman have adequate resources for Primary Eye Care. Additional requirement of ophthalmic loupes and medicaments would further improve Primary Eye Care in Oman. Conclusion: It is recommended that such a review of the health care programme and its resources and quality be periodically conducted as a part of a system of quality assurance in primary health care. Key words: Primary Health Centers, Oman, Eye Health Care Program, Quality assurance, Quality improvement. Health Facilities for Primary Eye Care in Sultanate of Oman Primary Eye Care Study 2000 *Rajiv Khandekar1, Ali J Mohammed2 SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL JUNE 2006 VOL 6, NO. 1 SULTAN QABOOS UNIVERSITY© PRIMARY PREVENTION OF COMMON EYE DIS-EASES and early detection of sight-threatening eye diseases are possible with the existing Pri- mary Health Care (PHC) services of our country. Peri- odic evaluation of available resources for Primary Eye Care would strengthen the endeavor of national health care programmes to attain the goal of quality primary health initiatives.1 The Sultanate of Oman is a country in the Arabian peninsula. Health services provided to the citizens of Oman are universally free. It is one of the landmark achievements in last two decades. Eye care is an impor- tant part of the health initiatives in the Sultanate. Blind- ness is prevalent at a rate of 1.1%, and 80% of cases were due to preventable causes or curable diseases.2 It is cru- cial that the existing PHC practitioners detect common and sight threatening eye diseases at early stages. The Ministry of Health (MOH) has prioritized eye prob- lems in a ‘Specific Disease Control Program’ in the next five-year plan.3 Thus the commitment to strengthen the PHC will be stronger in the next ten years. Since 1991, Primary Eye Care was offered to all the schools in Oman through Eye Health care programme. Trained school health staff annually screened students 1 Eye & Ear Care Department, DSDC, DGHA, Ministry of Health (HQ), Sultanate of Oman, 2 Director General of Health Affairs, Ministry of Health (HQ), Sultanate of Oman *To whom correspondence should be addressed. Email: rajshpp@omantel.net.om O R I G I N A L S T U D Y عمان سلطنة في األولية العني لرعاية الصحية اإلمكانيات ٢٠٠٠ األولية العني رعاية دراسة وزارة منشآت في األولية" "رعاية العني موارد و(٢) العني، صحة رعاية برنامج مبساعدة األولية العني (١) رعاية حتسني امللخص: الهدف: محاولة ١٣٦ مركزا صحيا متثل صحية ٨٤ منشاة من عشوائية بصورة اختيروا عاملني تقييم الوصفية، مت الدراسة هذه الطريقة: في الصحة لسنة ٢٠٠١. في العاملني مثل املورد، حالة تقييم احلقل في هذا في املدربون العيون أطباء قام عالي. معيار الدراسة ذو أن من للتأكد اجلودة ضمان عبر طرق أوليا (للتعليم الطبي املستمر احلاالت إحالة الصحي، التثقيف املستخدمة في املواد األجهزة، بالعني، خدمات العناية لتقدمي مساحة توفير الصحة، مجال من التأكد مت فقد ذلك، إلى توفر إضافة صحية. مؤسسة كل في العيون..الخ. في طب املستعملة األدوية ، األولية) الصحية الرعاية في للعاملني إضافة جهاز ." للعني األولية "الرعاية ل الكافية املوارد متتلك عمان سلطنة في النتائج: املؤسسات الصحية العني. رعاية في اخلدمات تقدمي مستوى الصحية الرعاية كهذا لبرنامج تقييم أن يجرى اخلالصة: نوصي عمان. في " للعني األولية "الرعاية أكثر ستحسن واألدوية (loupe) للعني خاص األولية. الصحية الرعاية جودة لضمان النظام من كجزء دورية بصورة والنوعية واملوارد R A J I V K H A N D E K A R , A L I J M O H A M M E D 22 from the 1st Primary, 4th Primary, 1st Preparatory and 1st Secondary classes in order to detect and manage common eye diseases and provide visual assessment.4 In 1995, the Primary Eye Care was initiated in 136 MOH institutions all over Oman with the help of a regional cadre of program managers using standard tools.5 This study was accomplished with the objective of evaluating the available resources for Primary Eye Care at MOH Health Institutions (HI) of Oman and recommending policies for further strengthening it. M E T H O D Facilities for Primary Eye Care exist in 136 MOH HI in 10 health regions in the Sultanate. An estimated representative sample with 95% confidence intervals, 5% possible errors and 80% of primary Health Insti- tutions (HIs), have facilities to provide standard eye care; 88 HIs were enumerated. These samples were further stratified by region. Then the regional propor- tion of HI (related to eye care) was used as a sample (mentioned in the “Annual Statistical Report 1999” of MOH)6 to calculate the sub-sample. Using all listed institutions from the random number table gave the required samples for Primary Eye Care evaluation. Ten selected ophthalmologists acted as Field Inves- tigators. The details of Health Institution staff and the population of the catchment areas were obtained from the HI authorities and the references were collected by using health documents. Then the information on the availability of resources was gathered through person- al observation and interviews with the health staff on duty and by recording their performance using a spe- cifically-devised pre-tested standard data collection form. In case of non-availability of required resources for eye care, the official in-charge had to furnish de- tails of action to procure them. To ensure a high quality survey, various steps of randomization, the use of instruction manuals, con- ducting training and standardizing workshops, a pilot study and the auditing of data collection forms were carried out. During pilot stage inter-observer varia- tions were verified. The data collection form and computer format were matched prior to the field work. The forms were audited in the regions and then forwarded to the data manager for computing. Complete data was input in a specially-designed software termed EPI6. With the range of through checking and random variable tabu- lation, the process of sorting of data was carried out. The analysis was carried out using the Statistical Pack- age for Social Studies (SPSS 9). The frequency and percentage proportions of important results were cal- culated. Verbal consent of regional and local health ad- ministrators was taken for the study. The results and recommendations were given to the regional adminis- trators for further improvement of resources and eye care delivery at primary health centers. R E S U L T S SAMPLE PROFILE: Of 88 samples enumerated, 84 HI were examined in this study. Due to logistic problems, 4 could not be examined. The coverage rate was 96%. As to the hu- man resources for Primary Eye Care qualified gradu- ate medical doctors provided eye care at these insti- tutions. The nursing staff of the HIs were graduate nurses. These staff had limited training in eye care during their studies so additional training was given after they joined the MOH in the Sultanate. The catch- ment area population reported was based on mid- 1999 population projections.6 The number and ratio to population is specified in Table 1. Space for Eye Care: Most of the HIs have separate doctor’s examination rooms, nursing stations, waiting areas for male and female patients and a pharmacy for dispensing medi- cations. Also, 73 HIs (87%) were with adequate space for vision assessment and other activities related to standard eye care. In eight HIs (9.5%), visual testing was performed in the corridor or waiting area if the doctor thought it essential. In three HIs (3.5%), this facility was missing. HI with information on human resource related to eye care 84 Primary Eye Care doctors 167 Primary Eye Care nursing sta 725 Population of catchment area 960, 625 Doctor: Population ratio 1:5, 752 Nursing staff: population ratio 1:1, 325 Primary Eye Care staff: population ratio 1:1, 077 Table 1. Human resource for Primary Eye Care (Pri- mary Eye Care study 2000) H E A LT H FA C I L I T I E S F O R P R I M A R Y E Y E C A R E I N S U LTA N AT E O F O M A N ( P R I M A R Y E Y E C A R E S T U D Y 2 0 0 0 ) 23 INSTRUMENTS FOR PRIMARY EYE CARE: Torches: All 84 HIs used torches to examine eye cases. Howev- er, only 68 (81%) of them had torches with good focus; in the remaining 16 HI (19%), the torches had either poor illumination or poor focus. Snellen’s Distant Vision Chart: Of 84 HIs, 76 (91%) had Snellen’s distant vision “E” chart and 9% HIs did not have vision charts. Among those having these charts, 56 HIs (74%) were displayed properly, while 20 HIs (26%) did not display them as per the recommended standards. Ophthalmoscope: Although it is not an essential instrument for Primary Eye Care, all HId were provided with a diagnostic set having a combined ophthalmoscope and otoscope. Out of 84 Hs, 73 (86%) had this instrument; in 11 HIs (11%) it was not available. Among 69 HIs with this in- strument, 60 (95%) had them in working condition, while in 4 HIs (5%) they were not working. Ophthalmic loupe: An ophthalmic loupe is an asset to primary staff to di- agnose minute details of ocular tissue, especially for accurately diagnosing trachoma. Health staff of pres- byopic age would benefit if an ophthalmic loupe were available. Only 2 HIs (2%) had an ophthalmic loupe. In 82 HIs, (98%) it was not available. Material for Health Education on Eye Care: For the Eye Health Care program (EHCP), MOH had prepared and supplied four posters to all MOH Insti- tutions in 1999. These posters are related to ocular hy- giene, vision hygiene, cataract and “Nutrition and Eye Health”. Health staff used the posters for promoting safe preventive practices for eye care. They are in lo- cal language and have self-explanatory pictures. Of 84 HIs, 79 (94%) had posters on eye care, while in 5 HIs (6%) these posters were not available. Among those HI having the posters, 49 HIs (58%) had all four posters, 9 HIs (11%) had three, 15 HIs (18%) had two and 11 HIs (13%) had only one poster displayed properly. Reference material on Eye Care for Health staff: For the EHCP, the MOH had prepared and supplied flow charts to guide the trained health staff in policies for eye care for common eye diseases. The standard operating procedures and policies of MOH for eye care in Oman are stipulated in the Eye Health Care (EHC) manuals – 1st and 2nd Editions. Ophthalmolo- gists reviewed the availability of these reference mate- rials. This information is given in Table 2. Drugs for Primary Eye Care: The MOH has stipulated for HIs a drug policy on Pri- mary Eye Care. The ophthalmologists collected infor- mation on available medicines in the HIs. If medicines other than those recommended in drug policy were present in the HI, the staff provided the reason for keeping them. The profile of drugs and disposables for Primary Eye Care is shown in Table 3. D I S C U S S I O N Primary Eye Care as an integral part of Primary Health Care, is a key strategy that is adopted by na- tional health programs on recommendation of the World Health Organization (WHO). It includes pro- motion of eye health and provision of basic preventive Items Yes No Missing At HI For each Sta Both # % # % # % # % # % Flowchart 45 54 - - - - 14 17 29 30 Eye Health Care Manual 1st Edition 57 68 9 11 17 20 1 1 - - Eye Health Care Manual 2nd Edition 45 54 5 6 12 14 22 26 - - Table 2. Reference material for Primary Eye Care (Primary Eye Care study 20004,5) R A J I V K H A N D E K A R , A L I J M O H A M M E D 24 and/or curative treatment for common eye disorders. The Sultanate of Oman in its five-year health plans has stressed this strategy since 1990. The national survey for blindness and common eye diseases, which was conducted in Oman in 1996-97, suggested that Oman had prevalence rates of blind- ness, which is less than other developing countries but more than industrialized countries. More than ¾ of the blindness was reported to be due to either curable or preventable causes. The communicable eye disease, trachoma, was prevalent at a rate of 2.2%. Further strengthening of Primary Eye Care would enable to further reduce blindness and communicable eye dis- eases. Providing the required resources for effective Pri- mary Eye Care has enabled the MOH to consolidate Primary Eye Care at all MOH Institutions since 1995. Our assessment on the results of five years of estab- lishing Primary Eye Care should be useful for health planners to formulate future strategies for human re- source development and further strengthening of Pri- mary Eye Care in the Sultanate. Our sample has an adequate unbiased representa- tion. With the random selection procedures adopted, all HIs had an equal chance of being assessed. Thus, the results of this assessment represent the overall situation of Primary Eye Care facility in the Sultanate of Oman. Qualified medical graduates provide the eye serv- ices in Oman at primary health centers. A large pro- portion of the professionals is hired from other coun- tries. Graduate nursing staff provides the nursing care to eye patients, many of whom graduated in Oman. However, the distribution of Omani nursing staff is not uniform. In small HIs, the nursing staff manage eye patients in the absence of doctors. Thus, they also are important primary care staff. The MOH has pro- vided training to health staff in Primary Eye Care since 1995 with the help of mid-level managers of the eye health care program in all regions. The WHO has recommended increasing the popu- lation of ophthalmic nurse in Asian countries from 1: 200,000 in 2000 to 1:50,000 by 2020.7 The study has shown that the Primary Eye Care doctor to popula- tion ratio in Oman is nearly 1: 5,750, while the nursing staff to population is 1: 1,350. The ratio of Primary Eye Care staff to population is 1: 1,100. In view of the low proportion of skilled Omani health staff, this ratio is misleading as far as sustained health services are con- cerned. The calibre of these primary health staff is of para- mount importance for quality eye care. Efforts to con- tinuously improve their calibre through training and supervision are the responsibility of the regional eye care program management. Health centers have been established in all health regions of Oman in the last 20 years. The buildings have standard health care facilities. Required alterations to provide standard Primary Eye Care were made within the existing facilities in 1995. This study showed that nearly 90% had adequate space for providing stand- ard eye care. In the remaining HIs, arrangements are made to assess the visual acuity on a need basis and provide eye care without compromising quality. Lack of space in these institutions could discourage health staff from assessing visual acuity in all eye patients. Some of the patients with visual impairment but with- out symptoms could be missed in such circumstances. The cases referred from these institutions on an emer- gency basis for further care at secondary level will also be without standard vision assessment and this may cause medico-legal problems. Simple tools for standard eye examination are nec- essary to accurately diagnose eye conditions and pro- No. of HI % Chloramphenicol eye drops Available 82 97.6 Not Available 2 2.4 Tetracycline eye ointment Available 84 100.0 Antihistamine eye drops Available 74 88.0 Not Available 10 12.0 Azithromycin sus- pension/tablet Available 13 15.5 Not Available 68 81.0 Missing Info. 3 3.5 Fluoresciene strip Available 23 27.4 Not Available 59 70.2 Missing Info. 2 2.4 Eye pad & dressing material Available 57 68.0 Not Available 26 31.0 Missing Info. 1 1.0 Eye Wash facility Available 73 87.0 Not Available 9 11.0 Missing Info. 2 2.0 Extra medication Available 31 37.0 Not Available 53 63.0 Table 3. Drugs for Primary Eye Care (Primary Eye Care study 2000) H E A LT H FA C I L I T I E S F O R P R I M A R Y E Y E C A R E I N S U LTA N AT E O F O M A N ( P R I M A R Y E Y E C A R E S T U D Y 2 0 0 0 ) 25 vide quality eye care. For example, a torch with poor illumination or without good focus, can cause misdi- agnosis especially of trachoma and small foreign bod- ies etc. The majority of HIs had good torchs. The rest should procure them as soon as possible through their regional administrators. HI staff should also ensure good maintenance and supply of spare batteries in or- der to keep them in good working condition. Distant vision is tested in the Sultanate by us- ing Snellen’s Illiterate‘E’ chart. They are periodically provided by the programme in the required number. Placement of the chart is of paramount importance. The regional ophthalmologists during their HI visits should demonstrate the use and positioning of the ‘E’ chart to obtain standard results in vision testing. Because Oman is a trachoma endemic country, primary health staff should treat active trachoma cas- es frequently. To differentiate the follicles of trachoma and allergic conjunctivitis and to locate foreign bodies on the cornea etc., it is essential that eyes be exam- ined using magnification. Ophthalmic loupes would be useful for this purpose. All HIs should be provided with ophthalmic loupes in the required quantity. Ophthalmoscopy is a skilled procedure and pri- mary staff would take a long time to be proficient in this procedure, hence it is not recommended as a standard operating procedure. However, the medical graduates in their curriculum are trained to use oph- thalmoscopes. They could evaluate the hypertensive, diabetic and disc changes in intra-cranial lesions. In the present study, this tool was found to be underuti- lized in most of the HIs. Promotion of safe preventive practices is part of Primary Eye Care. The Eye Health care program pro- vided posters for public display at HIs. Only 60% of HIs had all posters. All had at least one poster dis- played. The Policy of framing posters before display in HIs of some regions was responsible for not hav- ing these posters properly displayed. A large number of posters to be displayed by different programs have made it impossible for the HI to have all posters dis- played at a time. Use of handouts, as done for the eye changes of diabetes, trachoma, cataract etc., could be an alternative to poster display. The health staff had sufficient reference material for eye care. This material was used extensively in the initial part of launching the program. Periodic read- ing in clinical meetings or journal clubs would ensure proper utilization of these reference materials. Medicines for Primary Eye Care were available in the required quantity in all HIs. In the year 2001, Azi- thromycin is to be supplied to all HI to treating ac- tive trachoma cases. The consumption of tetracycline will reduce in future. All HI should be provided with fluorescein strips for detecting foreign bodies and di- agnosing corneal ulcers. The medicines prescribed by ophthalmologists to chronic eye patients are be- ing collected from the parent HIs. This was the main reason for keeping extra eye medication at some HIs. Regional procurement of sulphacetamide and the pro- vision of it to HIs should be checked. Drug policy for local antibiotics for eye care should be reviewed peri- odically. RECCOMMENDATIONS Based on the evaluation, the following recommenda- tions were proposed. Ophthalmic loupes should be provided to all institutions. All new HIs should have standard eye care facilities. Antihistamine eye drops, Azithromycin suspension/capsule and fluoresceine strips should be supplied to all HIs. Health staff should use reference material for eye care in the journal clubs and when holding periodical clinical meetings. The national and regional health managers should review the constraints and solve them so that posters on eye care can be displayed in waiting areas. Pamphlets on common eye diseases should be distributed to inter- ested clients at all HIs. Strict policies for vision testing should be implemented for all cases that are referred to ophthalmologists for further care. The literature does not report the criteria of ac- creditation of health institutions for Primary Eye Care. However, the model of labeling HIs as baby friendly institutions and breast feeding health initiatives at MOH Institutions of Oman could also be applied for the accreditation for eye care. In the present study, the distribution of human resources, the availability of materials for eye care and the level of trained staff were measured. However, such point evaluation may have to be supplemented with additional indicators, which could be assessed periodically and with uniform standards. The criteria of measuring the level of HIs ‘eye care delivery and patients’ satisfaction should also be included as a part of system for quality assurance and quality improvement procedures. R A J I V K H A N D E K A R , A L I J M O H A M M E D 26 C O N C L U S I O N • The assessment suggests that most of the resources for Primary Eye Care are available as per the na- tional policy in Oman and resource constraints are not a barrier for providing standard Primary Eye Care. • Such a review should be caried out periodically for resources and quality, in order to improve Primary Health Care. ACKNOWLEDGEMENTS We acknowledge the cooperation of Primary Health Staff, the ophthalmologists who worked as field inves- tigators, the staff of the regional directorate and the MOH and for their constant encouragement in all steps of this study. The WHO provided financial sup- port. We are also thankful to all the epidemiologists who assisted in the analysis part of this study. R E F E R E N C E S 1. Issues in Health Services Delivery. In: World Health Organization, WHO/EIP/00.1; 3-4. 2. Khandekar R, Mohammed AJ, Negrel AD, Riyami AA. The Prevalence and Causes of Blindness in the Sultanate of Oman: The Oman Eye Study (OES). Br J Ophthalmol 2002; 86:957-962. 3. Fifth 5-Year Health Development Plan. In: Ministry of Health, Sultanate of Oman, 1996; 32-36. 4. Eye Health Care Program. In: Oman & UNICEF ‘Eye Health Care Manual 1st Edition: Ministry of Health, 1995; 55-57. 5. Oman & WHO ‘Eye Health Care Manual 2nd edition’. In: Eye Health Care Program: Ministry of Health, 2000; 9-10. 6. Annual Statistical Report for Year 1999. In: Ministry of Health, Oman, 2000; 2-4. 7. Issues in Health Services Delivery. In: World Health Or- ganization, WHO/EIP/00.1; 24-25.