The health system profile of Gurage Zone in 2018 had a total of 71 health facilities, of which 64 (90.1%) were public and 7 (9.9%) were NGO. Five hospitals were primary hospitals and one was a secondary hospital. In the Gurage Zone, only 5 (7%) facilities provided eye care services.
There has been no survey conducted on the prevalence and causes of blindness specifically by the Guarage Zonal Health Bureau. Instead, there were Zonal Health Office reports indicating that cataract and trachoma were the top causes of blinding disease. A focal person was assigned to the zonal office in the neglected tropical diseases division to focus on eye health and prevention of blindness. The focal person was aware of the VISION 2020 program. However, there was no VISION 2020 committee established at the zonal level and therefore there were no previous systematic evaluations of eye care services according to VISION 2020 in Guarage Zone.
Orbis and Christian Blind Mission (CBM) were the main partners of the zone health bureau supporting a trachoma prevention and treatment program. Partner support included finance, training, and program evaluation. The partners made progress and played a crucial role in combating trachoma in the Guarage Zone. There was no comprehensive eye care service regulation program based on written protocol and code of conduct. 11 Despite the absence of a regulated comprehensive eye care service system, the zone conducts an evaluation of the prevalence and management of active trachoma, as well as an assessment of the availability of Trachomatous Trichiasis (TT) surgical coverage, every three years.
The budget of the zonal office in 2018specifically allocated for eye care services was 0.69% of the annual capital budget. It was mainly allocated for the TT program. There was no budget allocation for medical equipment and technology transfer. The budget support from partners was a hundred times higher than the government's budget allocation. The strongest secondary eye care unit (SECU) in the zone was the one that had an ophthalmologist and was supported by a partner in terms of finance, equipment fulfillment, and management. Despite regular trachoma activities and cataract monitoring, there were no eye health promotion activities and no national eye care quality standard controlling mechanism at this zonal level.
Eye care centers
Five (7%) of the health facilities in the zone provided eye care, three of which are health centers and two of which weredistrict hospitals. Of these five facilities, two were equipped as primary eye care centers and three were secondary eye care centers, but no tertiary eye care center exists. These five facilities saw 118,900 patients in the 2017/2018 budget year. On average, the facilities had been open for 11.4 years. The first eye care center in the zone was established in 1995 and the rest were established after the launch of VISION 2020. All the eye care centers were supported by government and non-governmental organization (NGO) funding and planning. The government provided 80% of the funding, with NGOs providing the remaining 20%. Orbis, CBM, and Light for the World were the NGOs supporting the centers. Only one secondary eye care center had inpatient care with 60 beds, which made the inpatient bed to population ratio 1:28,550. Outreach services were provided by all but one of the eye care centers, and those services included cataract surgery, trachomatous trichiasis (TT) surgery, and refraction.
There were only two primary eye care units (PECU) for a catchment area of more than 1.7 million people. This was by far below the recommended number of primary eye care centers for this catchment area. The numbers of PECU and SECU per million populations at the zonal level were 1.2 and 1.75, respectively. The overall fulfillment of PECU and SECU as per the national standard which was adopted from VISION 2020 in terms of human resources, services, and equipment was 42.8% and 55.5%, respectively (Figure 1).
Human Resource
Of the 3,700 health care providers in the Guarage Zone, there were 23 eye care workers (0.62%), of whom 16 (69.5%) were males and 7 (30.5%) were females, giving a male to female ratio of 2.3:1. There was one ophthalmologist (0.15:250,000) who was working in an NGO hospital, 3 cataract surgeons (0.4:250,000) (1 working in an NGO hospital), 5 optometrists (0.17:50,000) (3 working in an NGO hospital), and allied eye health professionals (0.7:100,000) (1 ophthalmic clinical officer and 5 ophthalmic nurses working in an NGO hospital). There was no specific eye health human resources strategic plan prepared or implemented at the zonal level. There has been an increasing trend in the number of TT surgeons over the past five years. There were a total of 3 ophthalmic nurses who were practicing in primary eye care centers and one ophthalmologist, 3 cataract surgeons, 5 optometrists, and 9 ophthalmic nurses were practicing in secondary eye care centers.
All eye health care workers were Ethiopians who were trained in Ethiopia. The places of training were: Gonder University, Quiha Hospital, Addis Ababa University, Jimma University, Alert Hospital, Yirgalem Hospital, and Hawassa University. One maintenance technician was trained in India. On average, the healthcare workers had 10.4 years of experience, with a range of one to twenty-three years of practice. The monthly salary of the staff ranged from $160 USD to $1805 USD.
The available human resource for eye care at zonal level was below the target of the VISION 2020 process indicators across all professions. The number of ophthalmologists and optometrists was critically low. The ratios for ophthalmologists and optometrists were 0.15:250,000 and 0.35:100,000, respectively (Table 2).
Table 2: Comparison of eye care personnel working in Gurage Zone and the VISION 2020 recommendation May, 2018
Profession
|
Number of Practitioners
|
VISION2020 Target for Number of Practitioners
|
Deficit
|
Need Met/Unmet
|
Ophthalmologist
|
1
|
7
|
6
|
Unmet
|
Cataract surgeon
|
3
|
7
|
4
|
Unmet
|
All surgeons
|
4
|
7
|
3
|
Unmet
|
Ophthalmic clinical officers (OCO) and nurses (ON)
|
12
|
17
|
5
|
Unmet
|
Optometrist
|
5
|
17
|
12
|
Unmet
|
Manager
|
1
|
2
|
1
|
Unmet
|
Technician
|
1
|
3
|
2
|
Unmet
|
At the national level, the number of professionals per million population was comparable with zonal status, but below VISION 2020 targets (Figure 2).
Equipment
Equipment fulfillment in PECU was 20% as per national standards and for SECU it was 70.4%. Of all the available equipment in the facilities, 82% was functional, 9.8% needed repair, and 8.2% was beyond repair. ( Figure 3) Both primary eye care centers didn’t have a slit lamp biomicroscope, and except for one secondary eye care center, all did not have IOP measuring equipment. Only one center had a maintenance technician. (Table 3)
Table 3: The number of equipment and the number of eye care centers with equipment in Gurage Zone Ethiopia, 2018
Equipment
|
Gov. Eye Care Unit (n=4)
|
NGO (n=1)
|
Total (n=5)
|
Equipment (n)
|
Unit (n, %)
|
Equipment (n)
|
Equipment (n)
|
Unit (n, %)
|
Loupe
|
4
|
2 (50%)
|
2
|
6
|
3 (60%)
|
SLM
|
4
|
2(50%)
|
3
|
7
|
3(60%)
|
Applanation Tonometer
|
0
|
0
|
3
|
3
|
1(20%)
|
Direct Ophthalmoscope
|
4
|
4(100%)
|
10
|
14
|
5(100%)
|
Indirect Ophthalmoscope
|
0
|
0
|
1
|
1
|
1(20%)
|
Trial Lens Set
|
6
|
3(75%)
|
4
|
10
|
4(80%)
|
Trial Frame
|
3
|
1(25%)
|
4
|
7
|
2(40%)
|
Cross Cylinder
|
1
|
1(25%)
|
4
|
5
|
2(40%)
|
A Scan
|
2
|
2(50%)
|
2
|
4
|
3(60%)
|
B Scan
|
0
|
0
|
0
|
0
|
0
|
Operating Microscope
|
3
|
2(50%)
|
3
|
6
|
3(60%)
|
YAG Laser
|
0
|
0
|
0
|
0
|
0
|
Cataract set
|
19
|
2(50%)
|
10
|
29
|
3(60%)
|
Services
There were five eye care centers, of which three were secondary eye care centers. Sixty percent were providing school screening, refraction services and cataract surgery. All the SECUs had operating theaters. Only one center provided inpatient care, low vision, and glaucoma surgery services. TT surgery was provided in all eye care centers. No SECU provided elective and emergency pediatric surgery, vitreo-retinal surgery, pan retinal photocoagulation, YAG capsulotomy or exenteration services.
Cataract Surgery
The total number of cataract surgeries performed in the previous calendar year was 3,373, including cataract surgery performed at outreach. From these, 2163 (64.2%) surgeries were done at the base unit and 1210 (35.8%) were done at outreach surgery. The cataract surgical rate (CSR) was 1,967. There was no data for calculating cataract surgical coverage (CSC). The average waiting period to receive cataract surgery was 12 days. The IOL implantation rate was 95%. All the centers had quality control mechanisms for cataract surgery outcomes, which were the IOL implantation rate, outcome tally, and complication auditing system. The zonal CSR and cataract surgery per surgeon (CSPS) were compared with the national level and VISION 2020 targets (Figure4).
Refraction
In the Gurage zone, only secondary eye care centers provide refraction services. Two out of the three secondary eye care centers had optical workshops, but only one was functional. Neither primary eye care center offered refraction services. Pediatric refraction and cycloplegic (retinoscope) refraction were available only in one of the SECUs. All secondary eye care centers had services for glass prescriptions in their compound, but only one had pediatric glass prescription services.