Strategies to improve delivery of primary eye care in public health care institutions in Sri Lanka
Primary eye care is integrated within the public health care system by providing primary eye care at the outpatient departments of secondary and tertiary heath care institutions, with unrestricted access.
Despite a strong primary health care system in Sri Lanka, the successful integration of eye care services at the primary level of health service delivery is still evolving. The majority of eye care service provision is at the secondary and tertiary levels.
According to a study of blindness and visual impairment in Sri Lanka that examined a nationally representative sample of 5,779 people aged ≥ 40 years, the prevalence of blindness in the country is 1.7% and that of low vision is 17%. Cataract (66.7%) and uncorrected refractive errors (12.5%) are the most common causes of blindness.1 Blindness is significantly higher in those aged ≥ 70 years, as compared to those aged 40 to 49 years.1 The data are helpful for assessing and planning for the eye care needs of the population. The focus on improving service delivery at the primary eye care level is an important step in identifying the needs early.
Government policy on primary health care
The Sri Lanka National Health Policy 2016–2025 endorses a people-centred health system based on universal health coverage.2 The National Health Policy builds on the mandates of quality health care and equitable coverage, which are the focus points of the 2018 policy on health care delivery for universal health.3 The provision of first contact care through the strengthening of the primary care system has been given top priority. In this strategic approach, primary eye care is integrated within the primary health care system.
The provincial health ministries manage the primary health care (PHC) institutions in the nine administrative divisions, or provinces, in Sri Lanka.3 The Sri Lankan government aims to provide health services free of charge at the point of delivery and spends 3.24% of gross domestic product on health. The organisational structure consists of 1,067 public sector heath care facilities: all tertiary (22) and most of the secondary level (94) health care institutions under the ministry of health centrally; and several secondary and all primary level facilities (470 divisional hospitals and 475 primary care units) under the provincial councils at the sub-national level, give access to a health care facility within a 4.8 km range in any region. One primary care institution covers about 5,000 people at the community level. The public sector provides 85 to 90% of the inpatient care. Sri Lanka delivers primary health care, inclusive of eye care, through two models: preventive services and curative interventions.4
Primary eye care service delivery
Primary health care delivery is through a range of health care facilities: central dispensaries, peripheral units, and divisional hospitals—all designated as primary care medical institutions (PMCIs)—which are equipped to provide basic eye care, such as treating chalazion and conjunctivitis, screening for visual acuity to identify refractive errors and cataract, and referring patients for further care at a specialist eye clinic at the secondary or tertiary level. The new essential services package strategy aims to strengthen the delivery of primary eye care services at primary care medical institutions by improving the availability of medical supplies and equipment. A qualified medical officer provides services in most of these institutions; however, there is no specific ophthalmic training for these medical officers at present other than any training they may have obtained optionally under the basic medical degree.
A key feature of the current health system is that strategies are being identified and developed for the integration of primary eye care service delivery with the outpatient departments of secondary and tertiary level health care institutions, with unrestricted access and no charge. Figure 1 describes the existing policies and programmes, service packages, and delivery models with respect to primary eye care.
Although Sri Lanka has an exemplary primary health care service network, it needs to strengthen the delivery of primary eye care services. A shortage of appropriately skilled mid-level eye care personnel and a lack of medical supplies and technology have been identified as the main barriers.5 The current unrestricted referral system is leading to overcrowding in specialised clinics at the secondary and tertiary levels.
Service delivery that can meet individual and population needs, effective training modules for mid-level eye health personnel, multisectoral collaboration, community participation, and the development of infrastructure in rural areas to bridge disparities are essential strategies to serve the country’s evolving eye health needs.6,7 There is a high potential for a successful blindness prevention programme in Sri Lanka, based on systems established under the VISION 2020 country programme in previous years.
• National health policy 2016–2025
• Policy on health care delivery for universal health coverage 2018 (enacted)
• Health policy and strategic plan on prevention and control of chronic non-communicable diseases (under discussion)
• Proposed policy brief on diabetic retinopathy screening, using handheld retinal cameras (under review)
Health care delivery programmes, with respect to eye care
• School eye inspection conducted by the family health bureau: checking early for visual impairment, especially refractive errors
• Essential services package, inclusive of eye health, provided at primary medical care institutions
• Shared cluster system: referring an assigned population (5,000 to 10,000 people) to one curative primary health care institution to improve uptake at the primary eye care level and to regularise the referral system
Service delivery of primary eye care
Basic eye examination
• Primary eye care service delivery at outpatient departments (OPDs) of secondary and tertiary health care institutions, with unrestricted access and without need for a referral
• Availability of distant vision screening at OPDs at all levels of service delivery
• Availability of fundoscopic examination by a physician, using direct ophthalmoscope at all OPDs
• Screening for visual acuity of those aged ≥ 35 years at healthy life centres (1,007 centres country-wide)
• Eyehealthservicesdeliveredbymedicalofficers of health (in 355 clinics country-wide) and by public health midwives at the community level (e.g., vaccination, vitamin A supplementation, neonatal eye care)
Referral for specialised care
• Unrestricted referral system to access specialised care, without geographical or administrative boundaries
Health education and training
• Health educational programmes at OPDs
• Training of 500 medical officers (a pilot project) in screening for diabetic retinopathy, using handheld digital retinal cameras (proposed)
Figure 1 Integrating primary eye care with public health care
1 BanagalaC,GilbertC,Murthy G, Schmidt E, Mahipala P. Prevalence, causes, magnitude and risk factors of visual impairment and blidnenss in Sri Lanka. Ceylon Med J. 2018;63(S2):s10–7. Available from: https://cmj.sljol.info/articles/abstract/10.4038/cmj.v63i5.8736/ (accessed 10 January 2021).
2 MinistryofHealth,Nutrition, and Indigenous Medicine. Sri Lanka national health policy 2016-2025 [Internet]. 2017. Available from: http://www.health.gov.lk/NationalHealthPolicy2016-2025.pdf (accessed 10 January 2021).
3 MinistryofHealth,Nutrition, and Indigenous Medicine. Policy on healthcare delivery for universal health coverage. [Internet]. 2018.
Available from: http://www.health.gov.lk/UHC%20Policy.pdf (accessed 20 April 2021).
4 PereraS,NieverasO,DeSilva P, Wijesundara C, Pendse R. Accelerating reforms of primary health care towards universal health coverage in Sri Lanka. WHO South East Asia J Public Health. 2019;8(1):21-5.
5 WorldHealthOrganization. Primary health care systems (PRIMASYS): case study from Sri Lanka. Alliance for health policy and systems research [Internet]. 2017. Available from: https://bit.ly/3AX5Rfe (accessed 20 April 2021).
6 BurtonM,RamkeJ,MarquesA, Bourne R, Congdon N. The Lancet global health commission on global eye health: vision beyond 2020. Lancet Glob Heal. 2021;9:e489- 551. Available from: doi: 10.1016/S2214- 109X(20)30488-5 (accessed 10 January 2021).
7 SenanayakeS,SenanayakeB, Ranasinghe T, Hewageegana N. How to strengthen primary care services in Sri Lanka to meet the future challenges. J Coll Community Physicians Sri Lanka. 2017;23(1):1-7.