BackgroundVisual impairment is a public health problem in sub-Saharan Africa, affecting nearly 5% of the population. Efforts to combat avoidable causes have been hampered by weak health systems and little evidence exists to suggest what interventions may be effective to improve the situation. Despite this, there are calls to promote some specific interventions, one of which being the closer integration of eye health services into health systems, often focusing on training primary health workers to deliver basic eye health services. This study seeks to understand how eye health services are delivered by primary health workers who have received training and what constraints remain to effective service provision.MethodsThis was a qualitative investigation into the experiences of 20 primary health workers trained in primary eye care and eight key informants working within specialist eye health services or regional and district health management positions in two districts in Tanzania.ResultsDespite feeling confident in their own eye care skills, most primary health workers felt constrained in the services they could provide to their communities by insufficient resources needed for diagnosis and treatment, and by lack of systematic supportive supervision to their work. Specialist ophthalmic staff were aware of this issue, although for the most part they felt it was not within their capacity to remedy and that it fell within the remit of general health managers. Many participants discussed the low support to eye health from the national government, evidenced through the lack of dedicated funding to the area and traditional reliance on outside funds including international charities.ConclusionsAlthough training of primary health workers is useful, it is recognised that is not sufficient to address the burden of eye health disease present in rural communities in Tanzania. It is likely that broader engagement with the general health system, and most likely with the private sector, will be necessary to improve the coverage of eye health care to remote and poor communities such as those in Morogoro. Further investment is needed to develop innovative approaches to delivering eye health services, including preventative, curative and rehabilitative services.

BackgroundThere are 285 million people with visual impairment (VI) worldwide including 39 million who are blind; 15 % of those with VI live in Africa, and around 80 % of VI is preventable or treatable with the right equipment, information and skills. The scarcity of human resources for eye health, particularly in Sub-Saharan Africa, is a key challenge towards achieving this goal. Therefore training primary health workers (PHW) in providing eye-care services has been seen by some authors as a way to improve access to eye-care services in remote communities. However, the package of interventions which could be effectively delivered for eye-care at the primary-care level or the set of skills and competencies that PHWs need has not yet been delineated. The aim of the study was to evaluate the effectiveness of a four day training programme of PHWs in primary eye-care conducted in Morogoro, Tanzania in 2010/2011.MethodsA mixed methods study using pre- and immediate post-training knowledge assessment of 60 trainees, and in-depth face to face interviews with 20 PHWs and 8 service managers 2 to 3 years after the training.ResultsPre-and immediate post-training assessments indicated improvement in health worker knowledge about eye-care in the short term. Qualitative investigations 2 to 3 years after the training showed that although staff could make the correct management decisions when presented with eye-health problems, they often could not make a correct diagnosis. PHWs and managers reported satisfaction with the content of the training but some of the less well qualified staff found it overwhelming. Theoretical teaching was appreciated by most participants but almost all suggested increasing the time spent on acquiring skills. The training manual was accepted by many and some improvements were recommended. All interviewed PHWs were keen to improve their skills and knowledge. Acquired skills and knowledge were used for identification, referral of patients and for eye-health promotion.ConclusionThe training program in Morogoro was considered by PHWs as broadly successful and satisfying in terms of content, methods and duration of training. However, any future programme needs to be considered within the context of strengthening wider health systems.

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