How can we make refractive error services sustainable?

Welcome. By the end of this presentation, you should be able to identify the considerations for sustainable refractive error services, and assess the alignment of refractive error services within health systems.

No matter where a service is being delivered, basic human resources, infrastructure, and equipment must be in place. To deliver comprehensive eye health, personnel need to be trained to provide both diagnostic and optical services, particularly in outreach settings.

The basic diagnostic equipment includes– the Snellen chart, torchlight, trial lens set, streak retinoscope, and stationery for prescriptions. Examination should ideally be carried out in a dark space. Whenever possible, optical services should be customised and not depend on ready-mades, especially for children. However, presbyopic correction can be done using ready-mades. Equipment for optical services includes– a portability edging machine, screwdrivers, frame warmers, and adjustment pliers, a trial set for quality control of lens powers, implements for marking, chipping, and cutting, trays and a table mirror.

Before setting up service provision in any area– whether static or outreach– it’s important to evaluate the sustainability options of the service. Key questions to ask are– Who are the customers? What can they afford? What is the range of pricing for the area? How many people in the eye team are needed to deliver refractive errors services? How many people in the market will need or want optical services? Is there a competing provider already in the area? What are the range of products on offer– spectacles, contact lenses, refractive surgery? What are the procurement sources? What is the revenue projection? And finally, is there a possible link with the school health programme?

There are several key considerations for managers before implementing refractive error services. The location must be visible, spacious, and easily accessible. Basic equipment must be obtained. The VISION 2020 Standard List provides a comprehensive guide, and resources for procurement. Setting up an efficient service requires a smooth patient flow

system and this will include: a waiting room, a refraction station, including a dark space for refraction, a space for patients to observe and select frames, and finally, a collection point for the spectacles. The space should also include a repair or maintenance section. At all times, refraction and optical services must be carried out by trained personnel.

As well as implementation, optical services managers must consider factors which affect procurement, quality, and efficiency. Good procurement management is essential for cost containment. Large volume spectacle orders usually work out at a lower cost, and identifying a range of sources is essential for buying effectively. Attention to quality means taking patient needs into account, and offering a choice of frames. It’s particularly important to encourage children and women to accept spectacle correction. Service delivery efficiency should be monitored and followed up, using output as an indicator. Output of refractive error services is measured as the number of refractions done per optometrist, per day. An estimate of the output of a good service is 15 refractions per optometrist, per day.

Optical lab output is based on the minimum number of spectacles dispensed each day. Some services work to a minimum output target of 10 spectacles dispensed per day.

Refractive error services need to be comprehensive, aligned with socioeconomic and educational priorities, and integrated into the health system. Effective, safe, and quality service provision at the primary level should include vision testing for children, and strengthening access to presbyopic correction. Refractive and optical dispensing services should be offered a secondary and tertiary levels, with specialisation, such as paediatric and contact lens services, being offered mostly at tertiary level. This approach provides the strongest horizontal linkages with education and social development.

The health workforce and teachers need to be trained and supported, with correct equipment for each level of service.

Paying attention to medical products and technologies ensures quality in both static and at outreach service models. In particular, attention should be paid to the quality of ready-mades, and recycled spectacles. Optical services need to work hand in hand with repair and maintenance services.

Health information is essential for good management. Data on refractive services and school vision testing needs to be collected, monitored, and evaluated. Identifying and addressing variations in services keeps high confidence and efficiency.

Health financing is an important component of the universal eye health approach. Affordability or subsidy option should be considered in order to ensure equity, as well as income generating mechanisms for sustainability. There are many financing options for different settings. Some examples include public private partnerships, health insurance schemes, and local financing options. Lastly, the balance between supply and demand needs to be planned and monitored.

Active leadership and governance ensures high quality and fair pricing of services, but also protects the needs of professionals through ethics and standards.

In conclusion, refractive error services must be planned for to improve access and coverage, particularly for children. Integration of services into the health system enables them to respond to priorities and needs. Quality of service provision must be managed by strengthening policy and safety standards. Affordability in financing options must be balanced with supply and demand. Management systems to monitor and respond to issues are essential to increase service delivery outputs. And advocacy for cost effective approaches in partnerships at government level, and with public/private consortia, is needed to address the burden of uncorrected refractive error.