|Year : 2020 | Volume
| Issue : 2 | Page : 49-56
Assessment of Resources for Primary Eye Care Delivery in a Rural Area, South East Nigeria
C.C. Eze1, B.I. Eze2, C.M. Chuka-Okosa2, N. Okoloagu1
1 Department of Ophthalmology Enugu State University Teaching Hospital, Enugu, Nigeria
2 Department of Ophthalmology, University of Nigeria Teaching Hospital, Itukur Ozalla, Enugu, Nigeria
|Date of Submission||11-Aug-2019|
|Date of Decision||03-Mar-2020|
|Date of Acceptance||18-Jun-2020|
|Date of Web Publication||05-Mar-2021|
Department of Ophthalmology, Enugu State University Teaching Hospital, Parklane, Enugu
Source of Support: None, Conflict of Interest: None
Objectives: To determine the human and material resources available for primary eye care delivery in Nkanu West Local Government Area (LGA), Enugu state. Materials and Methods: This was a Cross-sectional descriptive survey of the health facilities in the area. The location, and distribution of these facilities were determined using the health map of the LGA. At each centre, using a questionnaire, data on human and material resources were obtained. Statistics was performed using Chi-square test for discrete/categorical variables and student t-test for continuous variable. In all comparisons all P values < 0.05 with the associated odds ratios, at 95% confidence intervals was considered statistically significant. Results: There were 119 primary eye care workers (ECW) in Nkanu West LGA out of which 102 participated in the study giving a survey participation rate of 85.7% (102/119). The participants comprised 98 females (96.1%) and 4 males (3.9%), (M: F=1.0:25.0), with a mean age of 33.4 years. The majority of the participants (78.4%) possessed basic qualification of Community Health Extension Workers (CHEW). The health facilities were not evenly distributed in the four health districts. There are 18 PEC facilities, 15(83.3%) stocked some basic drugs used for eye care; none of the centres stocked all the basic drugs. An inventory of equipment for primary eye care delivery in the 18 centres showed that none of the centres had adequate basic equipment. None of the centres had adequate basic material resources for eye care. Conclusion: Human resources were adequate for PEC delivery in the LGA. There were inadequate material resources and uneven distribution of health facilities.
Keywords: Human resources, material resources, primary eye care, rural
|How to cite this article:|
Eze C, Eze B, Chuka-Okosa C, Okoloagu N. Assessment of Resources for Primary Eye Care Delivery in a Rural Area, South East Nigeria. Niger J Ophthalmol 2020;28:49-56
| Introduction|| |
The World Health Organisation (WHO) jointly with International Agency for the Prevention of Blindness (IAPB), in 1999, launched the global initiative ‘Vision 2020-the right to sight’ to eliminate the main causes of avoidable blindness in the world by the year 2020.
WHO estimated that 285 million people were visually impaired, out of which 39 million were blind. About 80% of blindness was avoidable, and 90% of visually impaired people live in low- and middle-income countries (LMICs), proportionately more of these countries are in Africa. The availability and distribution of human and material resources for eye-care have a direct bearing on the quality and coverage of eye care delivery. In many countries, there are inadequate number of eye care personnel and uneven distribution of eye care resources. This huge deficit of human resource constitutes the greatest barrier to qualitative eye care delivery.
Ophthalmologists are mainly concentrated in the urban areas, while far flung rural areas are underserved. A study in an urban area in Southeast Nigeria reported a pro- urban distribution of available eye care workers. Provision of quality care by eye care workers require appropriate infrastructure, equipment, equipment maintenance, and supplies. In Oman, qualified medical graduates provided eye care services at primary health centers and the country had adequate eye care workers per population. The adequacy of eye health workers could be as a result of a high proportion of migrant eye care workers hired from other countries.
In a related survey of human resources for eye care in the North West Province of Cameroon, the number, distribution and skill mix, of eye care workers in the Province were grossly inadequate. To provide quality care, eye care workers require appropriate infrastructure, equipment, equipment maintenance and supplies. In Tanzania, Byamukama et al. found that basic equipment and supplies were often lacking for eye care. Thus, lack of equipment was a major barrier in the productivity of health workers.
Periodic assessment of the availability and distribution of PEC resources is needed to create, and sustain the delivery of efficient and effective eye care services. This study will generate information on availability of PEC resource in the locality and enable eye care providers, eye care planners and implementers to strategize for realisation of the goals of VISION 2020.
| Materials and Methods|| |
This was a cross-sectional descriptive study.
The study was conducted in Nkanu-West LGA, one of the 17 LGAs of Enugu state. It has a land mass of 227.57 km2and a population of 247,385 people (Males, 12706; Females, 12679).
Selection of study area
The selection procedure was a multi-stage random sampling technique. In stage 1, Enugu East senatorial zone which consists of six LGAs was selected by balloting. In stage 2, one LGA out of the six LGAs in the senatorial zone was selected by random balloting and Nkanu west LGA was selected.
All consenting health care personnel working in the health facilities and involved in eye care delivery in the study area.
The following categories of health staff were excluded from participation in the study: Support staffs like drivers, security men, ward orderlies, etc. Adhoc/casual/non-permanent staff in the LGA’s health department, such as. the National Youth Service Corps members, and students on posting e.g. student nurses on rural posting.
This was adapted from a previous study in Enugu.
The health map of the study LGA showing the number and distribution of the health institutions was obtained from the Health Department of the LGA’s headquarters at Agbani. The projected population of the LGA for the year was calculated based on the 2006 census figure obtained from the Website of the National Population Commission. All the health care facilities identified in the LGA’s health map were visited. At each health facility, the questionnaire was self administered on facility head and all eligible workers, after obtaining an informed written consent from each respondent. Additionally, at each centre, data on material resources for delivery of eye care services were collected and cross checked with WHO recommended checklist. This was done by an interviewer administered questionnaire to the head of each PHC.
Ethical clearance for the study was obtained from the Health and Medical Research Ethics Committee (Institutional Review Board) of University of Nigeria Teaching Hospital (UNTH) Ituku-Ozalla, Enugu, before the commencement of the study. The approval of the Head, Department of Health, Nkanu West LGA was obtained on behalf of the Executive Chairman of the LGA.
The data collected was cleaned and coded, and analyzed using the Statistical Package for Social Sciences (SPSS), version 20 (SPSS Inc, Chicago, Illinois, USA, P values < 0.05 was considered statistically significant.
| Results|| |
Human resources for primary eye care delivery
There were 119 primary health care workers (PHCW) in Nkanu West LGA out of which 102 participated in the study giving a survey participation rate of 85.7%. The participants comprised 98 females (96.1%) and 4 males (3.9%) who were aged between 21 and 60 years. The sex ratio was M: F= 1:25. The mean ages were 33.4 ±11.7 SD years for females and 35.5SD± 7.6 years for the males. The mean age of the participants did not differ significantly by gender (male vs. female; mean 35.5 SD 7±.6 vs 34.3 SD ±11.7, t = 0.20, P = 0.84.)
The majority of the participants, 80 (78.4%) possessed basic qualification of community health extension workers [Table 1]. They comprised 31 (30.4%) junior community health extension workers and 35 (34.3%) community health extension workers. Over half of the health workers 65(63.7%) had no formal training in eye care [Table 1]. The PHCW: Population ratios for the districts are shown in [Table 2]. Overall, the PHCW: population ratio for the LGA was 1:2,079. The distribution of PHCW: to population ratio in the four health districts are shown in [Table 3].
|Table 1 Socio demographic and job characteristics of PHC workers in Nkanu West LGA|
Click here to view
|Table 2 Number, type, and distribution of health care centres in the four health districts in Nkanu West LGA. PHC= Primary Health Centre. MCHC= Maternal &Child Health Centre. HC= Health Centre|
Click here to view
|Table 3 Distribution of health facilities/population of the health districts|
Click here to view
The LGA had 18 Primary Health Care facilities. These comprised 17 (94.4%) government owned Health centres and 1 (5.6%) Mission owned Health Centre. The facilities were not evenly distributed in the 4 health districts in the LGA, but each Ward had at least 1 PHC. The number, type and distribution of the centres are shown in [Table 2]
All the health facilities had an outpatient clinic with rooms, tables and chairs for consultation, 17 (94.4%) of the health centres had an inpatient facility with at least four beds for admission. The health post centre did not have an in-patient facility. With a projected population of 247,385, the health facilities to population ratio is 1:13743.6. The health facilities to population ratio in the district are shown in [Table 3]; Akpugo district had the highest ratio while Agbani district had the lowest ratio.
Material resources for delivery of eye care services
Some materials required for basic primary eye-care were available for other reasons and not used for eye-care; for instance, torch during power outages, plaster for pasting notices on the wall. Of the 18 Primary Healthcare (PHC) facilities, 15 (83.3%) stocked some basic drugs for eye care [Table 4].
Basic equipment for eye care delivery was inadequate in all the centres. Most of the health centres-15 (83.3%) had proper referral forms and kept medical records of their patients, while 6 (33.3%) had visual acuity charts and 7 (38.9%) had eye health promotion materials. Ten (55.5%) of the PHC had torch light with batteries while only 7 (38.9%) had consumables and tray.
All the health centres practiced PEC by giving of vitamin A supplements, measles immunization [Table 4]. The pattern of delivery of curative eye care services showed that majority 11(61.1%) of the PEC centres treated conjunctivitis/lid infections while only 8 (44.4%) treated minor eye injuries. Only 2 (11.1%) centres performed removal of superficial ocular foreign bodies while none of the centres did epilation of lashes.
| Discussion|| |
Primary health centres constituted 83.3% of the health facilities in the LGA. This is similar to findings by Eze et al. where PHC made up 92.9% of the health facilities in Enugu Urban. These health centres are unevenly distributed in the four health districts in the LGA. This could be partly due to inequality in the number of wards that constitute the four health districts, and partly political, as the distribution of health facilities usually might have political undertone. Agbani district, which has the administrative headquarters (Agbani town) of the LGA, with a population of 55,745 people, had 6 (33%) centres, while Akpugo district with a population of 95148 had 5(28%) centres. Despite the observed mal-distribution, with a projected 2015 population of the LGA at 247385, and the health facility to population ratio of 1:13743.6, the number of health facilities were adequate to provide PEC needs in the LGA.ref. The adequacy of the health facilities was in agreement with the findings of Onakpoya et al. in a related study in rural south western Nigeria. The similarities between the two studies could be geographic, (both studies were based in rural areas).
The available numbers of PHC workers in the study LGA were adequate by WHO standard. The PHCW per population ratio is 1:2079 compared to recommended WHO ratio of 1:10000. Additionally, PHC workers were fairly evenly distributed in the 4 health districts, but not in the facilities. Furthermore although majority of these PHC workers were untrained in eye care, they provide some basic but inadequate PEC in all the centres.
This partly agrees with the findings by Eze et al. who reported adequate but grossly mal-distributed eye care workforce in Enugu urban. The finding of adequate PHC workers in this study was contrary to the findings in the study in Kenya where the eye care workforce was not adequate as a result of shrinking public health workforce and a long recruitment process in the public sector.
However, the observed numerical adequacy might not translate to provision of adequate eye care services. Therefore, manpower-related interventions to improve eye care services in the LGA should address issues like in-service eye care training and staff remuneration/motivation, not further staff recruitment. The development of human resources for eye care has been consistently recognized as central to eye health service delivery in global initiatives. The Global action plans for the prevention of avoidable blindness and visual impairment recommends that national programs train and maintain an eye health workforce whose size and composition is proportionate to the eye care needs in a population.
The PHC workers were predominantly married females, aged forty years or younger, who had less than 10 years of work experience. The observed female gender preponderance corroborates the finding by Shiweobi, Eze et al. in Enugu, Nigeria, and Khandekar et al. in the sultanate of Oman. These agreed with the WHO report that the majority (70%–80%), of the world health care workers are females. The participants gender profile coupled with their marital status has favourable implication for stability of their service. Their age and duration of work experience imply future temporal stability of available workforce in the LGA given that the mandatory retirement age in Nigeria is 60 years, and the maximum length of service is 35 years.
There was gross deficiency of material resources available for eye care in all the PHC facilities in Nkanu-West LGA. Vitamin A capsule was the only basic drug for eye care delivery that was available in all the centres. Similarly in a study in Rwanda, only tetracycline ointment and gutt chloramphenicol were available in primary eye health centres. This was attributed to that nation’s insurance policy that covered only the two drugs for eye care. This finding is also similar to that of Onakpoya et al.’s in Southwest Nigeria where none of the centres studied had all the materials for basic PEC delivery; and Eze et al. study wherein drugs for eye care delivery were found to be insufficient in Enugu urban. The scarcity of basic drugs for eye care delivery could be as a result of poor funding of health care. Eye care may not be a high priority for the government, compared to potentially life-threatening maternal and child health issues. In 2015, the health budget of Enugu State government was a mere 5.1% of the state budget. These percentage figures fall far short of the WHO recommendation of 15 %. In contrast, in Oman and Saudi Arabia, basic drugs for eye care were available. This could be as a result of better funding of eye care and the high priority given to elimination of preventable blindness in the countries. The non-availability of basic drugs for eye care has adverse implications for effective and efficient primary eye care delivery as the workers may have difficulty in treating simple eye diseases. This may lead to low patronage of PEC services by the communities, and possibly push them to either patronize traditional medicine practitioners or embark on self-medication, often with disastrous visual outcomes. A similar pattern of deficiency was noted when the basic equipment for delivery of eye care was assessed compared to WHO recommended basic requirement. Functional torches were available in only 55.6% of the PHC centres, while only 33.3% of the PHC centres had visual acuity charts. These findings are in contrast to observations in Oman, and the Kingdom of Saudi Arabia where equipment, both for diagnoses and management of eye diseases, were available in all zones of the Kingdom. However, the findings were similar to those in Eze’s and Onakpoya’s studies. This similarity in the findings of the three studies could be geo-political. The consequences of lack of basic equipment are possible wrong diagnoses, wrong treatment, inappropriate or delayed referral, and poor treatment outcomes. This will further erode the host community’s confidence in the PEC centres leading to poor patronage.
Eye care consumables and promotional materials for primary eye care were available in 38.9% of the centres. These findings are consistent with the report by Eze and Shiweobi, both in Enugu state, and Onakpoya et al. in southwest Nigeria. This impacts adversely the quality of promotive and curative eye care services provided by PEC workers.
| Conclusions|| |
There were uneven distributions of health facilities in the four Health Districts in Nkanu West LGA. There were adequate numbers, and appropriate distribution by cadre of available eye care workers in the four health districts of the LGA. The available material resources for PEC delivery in Nkanu West Local government were inadequate to deliver qualitative eye care services in the LGA. None of the health facilities in the health districts has adequate numbers of equipment as recommended by WHO as basic equipments for PEC. We recommend the LGA should strengthen the primary eye care personnel through needs-based training, and provision of adequate budgetary allocation for PEC
Limitations of study
Possible recall bias from the survey participants.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Google Search. Map of Enugu State, date accessed, 14/12/2015
Department of Health, Nkanu West Local government. Map of Nkanu West LGA showing health facilities and wards. 6/04/2015
| References|| |
Khandekar R, Mohammed A. Health facilities for primary eye care in Sultanate of Oman. Sultan Qaboos Univ Med J 2006;6:21-26.
Pascolini D, Mariotti SP. Global estimates of visual impairment, 2010. Br J Ophthalmol 2012;13:614-8.
Prozesky D. Advocacy for eye health. Community Eye Health 2007;20:57-8.
Ummuro A. The health worker recruitment and deployment process in Kenya: an emergency hiring program. Human Resources for Health 2008;6:19.
Odusote K. People deliver eye care: managing human resources. Community Eye Health 2005;8:117-9.
Eze BI, Madukar-Okafor FC. An assessment of the eye care workforce in Enugu state, South Eastern Nigeria. Hum Resourc Health 2009;7:38
Onakpoya OH, Adeoye AO, Adegbehingbe BO, Akinsola FB. Assessment of human and material resources available for primary eye-care delivery in rural communities of southwestern Nigeria. West Indian Med J 2009; 58: 472.
Nkumbe H. Situation analysis of human resources for eye care in the North West Province of Cameroon Community Eye Health 2007;20:13.
Byamukama E, Courtright P. Knowledge, skills, and productivity in primary eye care among health workers in Tanzania: need for reassessment of expectations? Int Health 2010;2:247-52.
Eze BI. Primary eye care in Enugu North Local Government Area of Enugu State: an evaluation of resource availability and utilization. Dissertation presented to National Postgraduate Medical College of Nigeria for award of final fellowship (FMCOph) in Ophthalmology, November 2000.
Courtright P, Ndegwa L, Msosa J, Banzi J. Use of our existing eye care human resources: assessment of the productivity of cataract surgeons trained in eastern Africa. Arch Ophthalmol 2007;13:684-7.
WHO Universal Eye Health: a global action plan 2014-2019; A66/ 11–28March 2013. Available on line at: http://www.who.int/blindness
. date acessed June 15, 2015.
Shiweobi OJ. Knowledge, attitude and practice of primary eye care among primary health care workers in Nkanu West LGA, Enugu State. Dissertation presented to West African College of Surgeons for award of Final Fellowship (FWACS) in Ophthalmology, October 2013.
Courtright P, Murenzi J, Mathenge W, Munana J, Müller A. Reaching rural Africans with eye care services: findings from primary eye care approaches in Rubavu District, Rwanda. Tropical Medicine & International Health 2010;15:692-6.
Mohd AK, Mahmooda SI, Mohd DK. Development of primary eye care as an integrated part of comprehensive healthcare. Community Eye Health 1998;11:24-26
[Table 1], [Table 2], [Table 3], [Table 4]