BMC Health Services Research volume 13, Article number: 361 (2013) Cite this article



In South Africa, the health service is based on a Primary Health Care (PHC) philosophy with the District Health System (DHS) as the locus of delivery. However eye care services, particularly primary eye care, refractive error and low vision, have not been prioritised accordingly. Hence the aim of the Giving Sight to KwaZulu-Natal (GSKZN) project was to integrate the delivery of eye care services into the district health system, with emphasis on addressing the need for uncorrected refractive error and low vision services.

The project was implemented in the KwaZulu-Natal province, South Africa, to scale up the delivery of refractive error services utilising a four pronged approach; including advocacy, human resource development, equipment provision and research.


This paper is a description of the project and a retrospective analysis of data received through the course of the project from July 2007 to June 2011. Data were collected from training registers, equipment schedules and service delivery reports from institutions. Reports from the data base were then analysed and achievements in training and trends in service delivery were determined.


Over a four year period (July 2007 and July 2011) 1004 persons received training in rendering eye health services appropriate to their level of deployment within the DHS. During the course of the project, these 1004 persons examined 1 064 087 patients. Furthermore, the total number of clinics offering primary eye care, refractive error and low vision services increased from 96 (10%) to 748 (76%). With increased numbers of PHC Nurses trained in primary eye care, a subsequent decrease of 51.08 percent was also observed in the number of patients seeking services at higher levels of care, thus streamlining eye health service delivery.


This project has shown that scaling up can occur in delivering eye health services within a health district, through a multi-faceted approach that encompasses focused training, advocacy, development of appropriate infrastructure and the development of referral criteria with clear guidelines for the management of patients.

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Refractive error

Six hundred and forty (640) million people worldwide are estimated to be either blind or visually impaired due to uncorrected refractive error [12]. Refractive error refers to the measure of a person’s short-sightedness (myopia), far-sightedness (hyperopia) and/or astigmatism (corneal curvature). In the absence of any organic cause for poor vision, refractive error can easily be corrected with a pair of spectacles [3]. Uncorrected refractive error is the second leading cause of blindness after cataract and the main cause of low vision. Overall, it is the cause of almost half of all visual impairment [3]. Annually, the global economy loses $269 billion in productivity due to uncorrected refractive error [4].

Visual disability resulting from uncorrected refractive error has a major impact on the life of the affected person as they are more likely to be excluded from education opportunities, suffer from isolation and have fewer employment opportunities thus perpetuating the vicious cycle of poverty [5]. A Refractive Error and Visual Impairment study (RESCA) conducted in Durban, South Africa in 2003, found that of those children with reduced vision, 63% was due to refractive error. In addition, the study found that only 20% of the children that needed spectacles had them, indicating that four out of every five children with vision problems were unnecessarily visually impaired or blind [6].

The Giving Sight to KwaZulu-Natal project

The District Health System (DHS), which has been identified as an appropriate building block for a National Health System by the World Health Organisation (WHO), is a framework for the delivery of Primary Health Care (PHC) – a model promoted as a solution to creating access at a local level [7]. In South Africa, the DHS has been the cornerstone of government policy on health; however the delivery of eye health services within the DHS has been poorly defined. There is a lack of comprehensive programmes to ensure that the various cadres within eye health are integrated into a seamless unit of service delivery and appropriate referral. Thus the incorporation of eye health into the DHS was an urgent priority in ensuring appropriate delivery of eye health services, more specifically, refractive error and low vision services.

South Africa has a population of 50.59 million (South African census 2011) [8]. The project was implemented in the province of KwaZulu-Natal (KZN) with a population of 10 819 130. Forty-three percent (43%) of the KZN population lives in urban areas. The province consists of eleven health planning regions [9].

Currently in South Africa, the role of various eye health personnel within DHS has not been clearly defined [10]. Whilst the policy for the DHS demands that integrated and essential PHC services are available to the entire population at the first point of contact, these basic service packages did not include eye health services. Therefore, the Brien Holden Vision Institute (formerly the International Center for Eye Care Education) supported by Standard Chartered Bank’s “Seeing is Believing Campaign”, embarked on a project to integrate the delivery of eye health services, with emphasis on uncorrected refractive error and low vision, into the DHS. This development was designed to scale up the delivery of refractive error and low vision services within the DHS of South Africa.

Design and implementation of the giving sight project delivery system

In South Africa, eye health services are delivered from PHC Clinics with referral pathways going up to Quaternary level hospitals if necessary [10]. Eye health workers active in the province include Ophthalmic Nurses, Optometrists and Ophthalmologists. To scale up the delivery of refractive error services, the following method was utilised:

  1. Advocacy for the delivery of primary eye care, refractive error and low vision services within all levels of the DHS.
  2. Training and deployment of the appropriate human resources.
  3. Development of infrastructure to enable the delivery of services.
  4. Development of a data collation and management system for the program.


The KwaZulu-Natal Department of Health (KZN DoH) was identified as the key stakeholder of the project. Stakeholder engagement on the value of developing a sustainable strategy for the delivery of refractive error services within the DHS was conducted. Consultative meetings included relevant persons within the KZN DoH. This resulted in the appointment of the steering committee responsible for the design of the project and development of the Memorandum of Understanding (MOU). The Health Operation Committee was further engaged to inform senior provincial and district managers about the project, inviting their input on proposed project plans. All district eye care coordinators were then engaged to discuss implementation of the project; these project implementation plans were subsequently reviewed at district meetings to address district specific needs.

  1. Development of Appropriate Human Resources
    A two-fold approach was utilised in the training component of the project. Firstly, eye care cadres who were already delivering refractive error services (ophthalmic nurses and optometrists) were appropriately up skilled. Secondly, primary health care nurses, who did not have previous primary eye care training were trained (Table 1). The training program for the PHC nurses was based on the development of competencies as defined in the National Guideline on Management and Control of eye conditions at a primary level [11].To enable the PHC nurses to act as effective “gate keepers” of the eye care pathway, core competencies such as visual acuity measurements and the detection of basic anterior segment pathological conditions were developed. KZN DoH provided a total of 924 PHC nurses selected from Health Districts in need of eye care services, to be trained in primary eye care. Of those trained, 75 PHC nurses received additional training enabling them to conduct posterior segment exams using a direct ophthalmoscope, usually part of the skills set of ophthalmic nurses. These nurses were selected from Health Districts where there were no ophthalmic nurses (ON), who would otherwise screen for posterior segment disease. This was seen as an interim measure to address the lack of ophthalmic nurses in such areas.
  2. Development of appropriate infrastructure
    Recommendations were made to the KZN DoH Infrastructure Development Unit to allocate appropriate space for eye clinics in the future planning of institutions. In addition, equipment, as shown in Table 2 was provided to all cadres trained to ensure that they were able to adequately function at the recommended level within the DHS. Equipment donated to the various health institutions was taken into the institution’s stock management system to ensure that future maintenance and replacement would be the responsibility of the health institution.An assistive device delivery system was developed to facilitate affordable access for patients. An optical workshop was established at a central location and the supporting logistics to deliver assistive devices to patients was developed. Ready-made readers, single vision and bifocal spectacles with a multi-tiered pricing option were available to patients. Low vision devices were also available. All school children and indigent adults with significant vision impairment were provided with their assistive devices at no cost, subsidised by the sale to others.
  3. Data acquisition and management system of the program.
    Once trained, all trainees were requested to report data on a monthly basis for the purpose of monitoring the program. They were requested to collate and report on the following:
    – Number of patients examined
    – Number of patients who received treatment
    – Number of patients referred for further treatment

The KZN DoH had not collected eye health data at primary health care level prior to the implementation of the project and the data collection tools at secondary levels of health care had not been standardised. Therefore data collection forms were specifically designed to enable primary health care nurses, ophthalmic nurses and optometrists to record statistics of patients examined, treated and referred on a monthly basis. The standardised tool was hand recorded and submitted to the project office and DHIS office.

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