National Eye Health Strategic Plan Zambia

MINISTRY OF HEALTH

NATIONAL EYE HEALTH STRATEGIC PLAN ZAMBIA

(YEAR 2017-2021)

Developed and Compiled and adopted by National Prevention of Blindness Committee (NPBC) Technical Committee

January 2017

THEME FOR THE NEHSP 2017 TO 2021

”Universal Eye Health Coverage as we Enhance Primary Eye Health Care, Research and Technology in attaining the Vision 2020’’

TABLE OF CONTENTS

TABLE OF CONTENTS ...... ii ABBREVIATIONS AND ACRONYMS ...... iv ACKNOWLEDGEMENTS ...... vii STATEMENT BY THE HONOURABLE MINISTER OF HEALTH ...... ix EXECUTIVE SUMMARY ...... xi 1.0. INTRODUCTION...... 1 2.0. NATIONAL HEALTH STRATEGIC PLAN ...... 5 3.0. NATIONAL EYE HEALTH STRATEGIC PLAN ...... 6 3.1 Vision ...... 6 3.2 Aim ...... 6 3.3 Values ...... 6 3.4 General Objectives ...... 6 4.0 EFFECTIVE EYE HEALTH SYSTEM ...... 7 4.1 Eye Health Promotion and Primary Eye Health Care ...... 7 4.2 Eye Health Service Delivery ...... 7 4.2.1 Cataract ...... 8 4.2.2 Trachoma ...... 9 4.2.3 Refractive Errors ...... 10 4.2.4 Low Vision...... 10 4.2.5 Glaucoma ...... 111 4.2.6 Childhood blindness...... 111 4.2.7 Retinoblastoma ...... 12 4.2.8 Diabetic retinopathy ...... 12 4.2.9 Corneal diseases ...... 13 4.3 Human Resources for Eye Health ...... 14 4.3.1 Eye health worker training ...... 14 4.3.2 Continuous Medical Education (CME) ...... 18 4.4 UTHs’ EYE HOSPITAL STRUCTURE ...... 20 4.4.1 ORGANOGRAM OF THE SENIOR MANAGEMENT UTHs’ EYE HOSPITAL ... 20 4.4.2 ORGANOGRAM OF CLINICAL CARE UTHs’ EYE HOSPITAL ...... 21 4.4.3 ORGANOGRAM OF ADMINISTRATION UTHs’ EYE HOSPITAL ...... 22 4.5 Infrastructure, Equipment and Medical and Surgical Consumables ...... 23 4.5.1 Infrastructure Development ...... 23 4.5.2 Equipment ...... 23 4.5.3 Supplies for optical services ...... 24 4.5.4 Medicines and surgical consumables ...... 24 4.6 Health Management Information Systems (HMIS) ...... 25 4.7 Leadership and Governance ...... 26 4.7.1 National Prevention of Blindness Committee (NPBC) ...... 26 4.8 Finances and Resource Mobilisation ...... 27 5.0 INTEGRATION WITH THE WIDER HEALTH SYSTEM ...... 29 5.1 The role of non-eye health workers in eye health ...... 29 5.2 Referral system ...... 29

5.3 Integration in schools ...... 30 6.0 EQUITY AND UNIVERSALITY OF ACCESS TO EYE HEALTH SERVICES ...... 31 6.1 Equity of access ...... 31 6.2 Information, education and communication (IEC) material development ...... 31 7.0 STRONG AND EFFECTIVE PARTNERSHIPS ...... 32 8.0 RESEARCH ...... 35 9.0 MONITORING AND EVALUATION ...... 36 9.1 Measurement ...... 36 10.0 SWOT ANALYSIS ...... 43 11. 0 REFERENCES ...... 48 12.0 APPENDICES ...... 49 12.1 APPENDIX 1: Tools for Monitoring and Evaluation...... 49 12.2 APPENDIX 2: List of equipment and surgical instruments recommended according to the level of facility ...... 58 12.3 APPENDIX 3: List and amounts of essential eye medicines according to level of facility ...... 66 12.4 APPENDIX 4: Terms of Reference of the NPBC ...... 76 12.5 APPENDIX 5: Dispute Settlement ...... 78 12.6 APPENDIX 6: Detailed Budget for the NEHSP 2017 to 2021 ...... 79

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ABBREVIATIONS AND ACRONYMS

ADR Alternative Dispute Resolution AIDS Acquired Immune Deficiency Syndrome CHAZ Churches Health Association of Zambia CME Continuous Medical Education CMV Cytomegalovirus CMVR Cytomegalovirus Retinitis CSR Cataract Surgical Rate DCR Dacryocystorhinostomy DCCDS Director Clinical Care and Diagnostic Services DM Diabetes Mellitus DR Diabetic Retinopathy FAMS Financial Administration Management System GG Geneva Global GET 2020 Global Initiative to Eliminate Trachoma GRZ Government of the Republic of Zambia HAART Highly Activated Antiretroviral Therapy HIV/AIDS Human Immune Virus/Acquired Immune Deficiency Syndrome HMIS Health Management Information Systems HSRP Health Sector Reform Process HTEP Harmful Tradition Eye Practices HZO Herpes Zoster Ophthalmicus IAPB International Agency Prevention of Blindness IEC Information Education Communication IEW Integrated Eye Worker IOL Intra-Ocular Lens IOP Intra-Ocular Pressure ITI International Trachoma Initiative IVV International Vision Volunteers KCH Kitwe Central Hospital LAN Lions Aid Norway

LAT Leadership, Accountability and Transparency LCD Liquid Crystal Display LEH Lusaka Eye Hospital LV Low Vision LVD Low Vision Device MDA Mass Drug Administration MoH Ministry of Health MoU Memorandum of Understanding HTEP Harmful Traditional Eye Practice NECC National Eye Care Coordinator NEHSP National Eye Health Strategic Plan NGO Non-Governmental Organization NHSP National Health Strategic Plan NPBC National Prevention of Blindness Committee NTD Neglected Tropical Disease NTH Ndola Teaching Hospital NTTF National Trachoma Task Force OCO Ophthalmic Clinical Officer OCT Optical Coherence Tomogram OEU Operation Eyesight Universal ON Ophthalmic Nurse OPD Outpatient Department OSEA Ophthalmological Society of Eastern Africa OSSA Ophthalmological Society of Southern Africa ROP Retinopathy of Prematurity RTSA Road Transport and Safety Agency SICS Small Incision Cataract Surgery SSI Sightsavers International TAP Trachoma Action Plan UNZA University of Zambia USD United States Dollar

UTHs University Teaching Hospitals VF Visual Fields WCO World Congress of Ophthalmology WHO World Health Organization ZFDS Zambia Flying Doctor Service ZOS Zambia Ophthalmological Society

ACKNOWLEDGEMENTS

The National Prevention of Blindness Committee is highly indebted to the following individuals for the invaluable contribution towards the development of the third National Eye Health Strategic Plan 2017 to 2021:

Dr. Jabbin Mulwanda - Permanent Secretary Health Services, Ministry of Health Dr. Kayawe Kamanga - Chairperson, Public Service Commission Dr. GardnerSyakantu - Chairman NPBC, Director, Clinical Care And Diagnostic Services, Ministry of Health Dr. Mzaza Nthele - Deputy Director, Clinical Care and Diagnostic Services, Ministry of Health Dr. Kennedy Lishimpi - Director Cancer Diseases Hospital, CDH Dr. Namasiku Siyumbwa - Deputy Director, Non-Communicable Diseases, MoH. Dr. Jelita Chinyonga - PMO, Southern Province Dr. Consity Mwale - PMO (Ophthalmologist), Copperbelt Province Dr. Grace Chipalo – Mutati - Senior Medical Superintendent, UTHs’ Eye Hospital Dr. High Namani Monze - District Director of health, Lusaka District Dr. Lillian Chinama – Musonda - Head Ophthalmology Department, KCH Dr. Alemayehu Tefera - Technical Advisor, Sightsavers Ms. Glenda Mulenga - Country Director, Sightsavers Mr. Andrew Griffiths - Head of Advocacy, Sightsavers Mr. Nicholas Mutale - Country Director, Lions Aid Norway Mr. Kashinath Bhoosnurmath - Global Director, OEU Mr. Mainetti Sergio - Country Director, CBM Ms. Karen Edwards - Country Director, Vision Aid Overseas, Zambia Mr. Franklin Daniel - Asst. Director, OEU Mr. PatsonTembo - Country Manager, OEU Mr. Generous Mukanga - Country Representative, Orbis Dr. D. J. Kwendakwema - Consultant Ophthalmologist, Beverly Eye Centre, Ndola Dr. Edith Pola- Smith - Consultant Ophthalmologist, Mopani Copper Mines Hospitals, Kitwe Dr. Teddy Sokesi - HIV Specialist, Ndola Teaching Hospital Dr. Janie Yoo - Medical Director (Consultant Ophthalmologist), Lusaka Eye Hospital Dr. David Kasongole - Consultant Ophthalmologist, UTH-Eye Hospital Dr. Misa Funjika - Ophthalmologist, Ndola Teaching Hospital Dr. Mary Miyanda - Consultant Ophthalmologist, Kabwe General Hospital

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Dr. Alex C. Mumba - Senior Lecturer Ophthalmologist, Chainama College of Health Sciences Dr. Simon Chisi - Ophthalmologist,Medical Superintendent, St. Francis Mission Hospital Dr. Kayula Chansa - Ophthalmologist, Acting Medical Superintendent, Solwezi General Hospital Dr. ChisangaChelu - Ophthalmologist, Mansa General Hospital Dr. Willard B. Mumbi - Ophthalmologist, Kabwe General Hospital Dr. Mutale Nyaywa - Ophthalmologist, UTHs’ Eye Hospital Dr. Phyllis Moonga - Ophthalmologist, UTHs’ Eye Hospital Dr. Elijah Mutoloki Munachonga - Ophthalmologist, UNZA Dr. Felida J.Mwacalimba-Chilufya - Ophthalmologist, UTH-Eye Hospital Mrs. Faustina M. Chisenga - Pharmacist, UTH-Eye Hospital Ms. Nancy N. Wamundila - Chief Nursing Officer, UTH-Eye Hospital Mrs Irene M.M. Sililo - Human Resource Management Officer, UTH-Eye Hospital Ms. Nawa Macwani–Chisala - Programofficer, UTH-Eye Hospital Ms. Monde Mungwaluku - Registered Ophthalmic Nurse, UTH-Eye Hospital Ms. Jessie M.I. Nyalazi - Registered Ophthalmic Nurse, UTH-Eye Hospital Mrs Lucia S. Kafunda - Assistant Account, UTH-Eye Hospital Mr. Isaac MpunduSiame - Assistant Account, UTH-Eye Hospital Mrs Caroline S. Masaiti - Purchasing and Supplies Officer, UTH-Eye Hospital Mr. Roux Shiyala - Principle Eye Care Officer, Chongwe District Hospital Mr. Abel Sakala - Optometry Technologist, UTH-Eye Hospital Mr. Robert Ntitima - Programmes Officer, Lions Aid Norway Mr. Kennedy Phiri - Programme Manager, Sightsavers Dr. Kangwa I. M. Muma - Secretary NPBC, NECC Ministry of Health, Consultant Ophthalmologist, UTHs-Eye Hospital Mrs. Vita Banda-Phiri - Secretary, MoH Ms. Aulelia Haakabbila - Secretary, UTH-Eye Hospital

Special thanks to the Ministry of Health for facilitating the process of developing this strategic plan.

Dr. Gardner Syakantu Chairperson, National Prevention of Blindness Committee Director, Clinical Care and Diagnostic Services Ministry of Health

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STATEMENT BY THE HONOURABLE MINISTER OF HEALTH

In its pursuit to improve the health status of its people, my Government has continued to strengthen health services across the continuum of care in the country through health promotion, preventive, curative and rehabilitative medicine. This is envisaged in government’s decision to increase the 2017 budgetary allocation to Ministry of Health (MoH) by 30% and through being a signatory to the World Health Organisation’s (WHO) Vision 2020 ‘The Right to Sight’ and ‘Universal Eye Health – A Global Action’ which has inspired the development of the third National Eye Health Strategic Plan (NEHSP) 2017-2021.

The NEHSP provides a strategic direction for eye health from 2017 to 2021, highlighting the goals, objectives in the elimination of avoidable blindness in Zambia. As Ministry of Health our plan is to anchor service delivery to primary health care and the desire of the NEHSP is to take the prevention of blindness programme to a higher level, through strengthening eye health systems across the continuum of care, focusing on interventions that promote good health at household and community levels.

In order to achieve the objectives of NEHSP, my government recognises the significant contribution of the Cooperating Partners (CPs), the private sector, civil society, the corporate sector and other line-ministries. Therefore, my ministry shall work hand in hand with the Cooperating Partners in achieving the NEHSP objectives, while observing agreed upon governance systems, management and capacity strengthening plans, resulting in positive developments in the area of transparency and accountability.

As I thank all the stakeholders for their roles played in successfully implementing the NEHSP 2012 – 2016, I urge all stakeholders to fully dedicate themselves to this important national assignment, with the assurance that my Ministry will remain committed to the successful implementation of the plan.

We should move towards evidence based practice through strengthened monitoring and evaluation of programmes and research. This should be anchored on robust and well Co- ordinated health management information systems supported with exceptional data capture.

FOREWORD

The provision of quality eye health services remains a priority for the Government of Zambia, as demonstrated through the procurement of eye health equipment for the whole country, the recruitment of optometry technologists for the first time into the civil service and the establishment of an Eye Hospital at the University Teaching Hospitals. The hallmark of this commitment has been embedded in the development of this third NEHSP 2017-2021, which outlines the implementation of eye health services in the country, in line with government policy. This is a clear demonstration of government’s dedication in attaining the ‘Vision 2020-The Right to Sight’ strategy for all Zambians.

The prevalence of blindness in Zambia is estimated to be 2% giving an estimate of 339,081 blind people in the country, within a population of 16 954 051people.1 Over 80% of these cases could have been avoided if only adequate health promotion, preventive and curative measures had been in place, which this plan seeks to do. The major causes of blindness include cataract, glaucoma, trachoma, refractive errors, corneal opacity and diabetic eye diseases, of which 50% is due to cataract.1, 2The ministry of health notes with gratitude that in the last NEHSP implementation the eye health service coverage increased to 70% in seven provinces except in Luapula, Muchinga and Northern, where it is 33%, 27% and 20% respectively.1, 2

The foregoing situation has inspired the formulation of this NEHSP, to provide a path and framework to guide the planning, delivery, management and implementation of quality eye health services at community, district, provincial and national levels, in order to increase eye health coverage across the country to at least 90% by the year 2021. This NEHSP highlights what eye health services the Zambian government wants to deliver to its citizens in line with the seventh National Development Plan and the National Health Strategic Plan, 2017-2021.

The Ministry of Health encourages all stakeholders, implementing agencies and co-operating partners to refer to this Strategic Plan for any eye care programmes that they would like to participate in. This way, we can join hands and work together effectively and efficiently to accomplish the strategies under pinning this plan in order to reduce avoidable blindness.

In the past 5 years, government, through the Ministry of Health has enjoyed good relations with eye health partners and the private sector in the delivery of the NEHSP 2012-2016, and remains confident that the same shall be the case in the implementation of the NEHSP 2017- 2021.3

EXECUTIVE SUMMARY

Zambia, with a population of 16 954 051, is one of the highly urbanized countries in Africa with 51% of its population living in urban areas.4 Population growth and disbursed rural populations have strained the Government’s ability to provide quality and equitable basic social services, including education, adequate water, sanitation and health care.

In order to improve the quality of health care services, the Government of the Republic of Zambia has implemented a policy of providing Zambians with equity of access to cost effective quality eye health care as close to the family as possible. This is achieved through:

i. Decentralising decision making and budgetary control to provincial and district medical offices ii. Retaining the Ministry of Health as a policy making body

National Eye Health Strategic Plan, 2017-2021

The third National Eye Health Strategic Plan (NEHSP) 2017-2021 provides a framework for the planning, delivery, and management of quality eye health care services at all levels of eye health delivery systems in Zambia. It aims to address the many eye problems that our people face in this country, which are caused mainly by cataract, glaucoma, trachoma, refractive errors and cornea opacities. It addresses these through a strategic approach to eye health system strengthening (especially human resources, infrastructure), integration with the wider health system, improving equity of access and strengthening partnerships. It sets a strong governance framework, with clear criteria of success in the section on monitoring and evaluation.

Goal: To reduce avoidable and/or preventable blindness in Zambia, by providing equity of access to cost effective and quality eye health services as close to the family as possible and within the global initiative for the reduction of avoidable blindness.

The estimated budget for the NEHSP, 2017-2021 is ZMW 663,817,740.80 [USD 66,381,774.08] for five years. The Ministry of Health is committed to funding 65% of this budget whilst the Co-operating partners will fund the rest for efficient and successful implementation of the NEHSP.

This NEHSP, 2017-2021 will supersede all eye programmes that have been implemented based on the 2012 to 2016 National Eye Health Strategic Plan. Certain programmes and MoUs will be reviewed in order to conform to its provisions, recommendations and aspirations.

Table 1: Summary of Objectives:

Objectives 4.1.1 - To promote good eye health and prevention of eye diseases by 100% 4.2.1.1 - To increase the Cataract Surgical Rate by 100% 4.2.1.2 - To reduce the prevalence of active trachoma by 50% in children 1-9 years of age 4.2.2.2 - To reduce the prevalence of trichiasis by 50% among those 15 years and above 4.2.3.1 - Provide refractive services in more than 50% of the districts in the country 4.2.4.1 - Develop low vision units at UTH-Eye hospital and two other eye centres 4.2.5.1 - To establish a glaucoma department at UTH-Eye hospital with trained specialists 4.2.5.2 - To screen all adults visiting UTHs’ Eye Hospital and all other eye departments for glaucoma 4.2.6.1 To establish Paediatric and Strabismus services with trained specialists at UTH-Eye Hospital

4.2.6.2 - To enhance paediatric and strabismus surgery services at Kitwe Central Hospital and UTH Eye Hospital 4.0 Eye Health System 4.2.7.1 To establish Oculoplastic and Orbital tumour services with trained Strengthening specialists at UTH-Eye Hospital 4.2.7.2 - To train 50% 100% of mid-level eye health workers on retinoblastoma 4.2.8.1 - To establish Vitreous and Retina services with trained specialists at UTH-Eye Hospital

4.2.8.2 - To establish comprehensive DR services at 5Eye Centres 4.2.8.3 - To establish DR screening in all general hospitals 4.2.9.1 - To construct and establish an Eye bank at UTH-Eye Hospital 4.2.9.2 - To expand corneal transplant services to UTH-Eye Hospital and Kitwe Central hospital 4.2.9.3 - To establish Cornea and Refractive surgery services at UTH-Eye Hospital 4.3.1.1 - To increase the number of trained eye health workers, in line with the WHO recommendations 4.3.1.2 - To have eye health workers deployed in accordance with the agreed recommendations 4.3.2.1 - Each eye health worker to attend at least 10 accredited CME courses per year 4.3.2.2 – UTH-Eye Hospital and all Eye Centres to provide for skills transfer xii

4.5.1.1 - To construct a state of the art eye hospital at UTH befitting that of a national referral centre

4.5.1.3 - To support and equip the two eye centres that are under construction 4.5.1.5 - To set up functional eye units in district hospitals 4.5.2.1 - To ensure that all eye health facilities are equipped according to the standard list appropriate to the level of care 4.5.3.1 - To set up a laboratory for production of optical devices at at UTH-Eye hospital 4.5.3.1 - To ensure all vision centres are well stocked with sufficient supplies for optical services 4.5.4.1 - Ensure that all eye health facilities stock essential medical and surgical consumables appropriate for the level of care 4.5.4.2 - To integrate an improved list of eye health indicators into the National 4.7.1 - Strengthen eye health governance and leadership 4.8.1 - To ensure sufficient financial resources are available for eye health 4.8.2 - To ensure efficient use of financial resources for eye health

5.1.1 - To ensure non-eye health workers have a better understanding of eye health conditions and are able to take appropriate actions 5. Integration with 5.2.1 - To increase the number of eye health referrals that receive the wider health treatment in eye health facilities by 20% system 5.3.1 - Children with eye conditions are identified through a school vision screening programme

6.1.1 - People in rural areas access basic eye health services in district hospitals 6. Equity of Access 6.1.2 - Gender disparities in eye health conditions are reflected in those to Eye Health accessing services Services 6.1.3 - Data on access to services for people with disabilities, older people and marginalised groups is available 6.1.4 - To increase demand for eye health services

7. Strong and 7.1 - To enhance partnership between government, private institutions Effective and co-operating partners in eye health sector Partnerships

8. Research and 8.1 - To generate an evidence based data for eye health specific to the Evidence Zambian context

9. Monitoring and 9.1 - To strengthen the monitoring and evaluation in the delivery of the Evaluation NEHSP, 2017-2021

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1.0. INTRODUCTION

Zambia is a landlocked country surrounded by eight (8) neighbouring countries (Figure 1, below). It has 10 provinces and a population of 16 954 051(8 498 629 females, 8 455 422males) with 51% of the population living in urban areas.4 The influx of people from rural to urban as well as retention of more people in urban towns has continued to pose a serious challenge on government’s ability to provide quality and equitable basic social and health services, including adequate water, sanitation, and health care. In the rural areas the geographical challenges, failure to retain adequate qualified human resource and general poverty has negatively affected provision of quality health care as well as access.

1.0.0 Map of Zambia

Figure 1: Zambia and its neighbouring countries

Currently, there is one (1) physician for every 17,000 inhabitants.5 The scenario is worse for delivery of eye health services where one (1) ophthalmologist is responsible for 1,000,000 citizens.2The under-five mortality rate is about 119 per 1,000 and only 50% of the entire population has access to safe water.3 It is therefore imperative that appropriate strategies are revised or developed and implemented to improve the prevailing scenario.5

The eye health sector has made tremendous progress ranging from infrastructure development and equipment procurement to quality service delivery as close to the family as possible. A total number of 5 Eye Centres have been set up, namely; University Teaching Hospitals-Eye Hospital, Kitwe Central Hospital, Lewanika General Hospital, Ndola Central Hospital and Livingstone Central Hospital. The two other Eye Centres are under development at Chipata General Hospital and Kabwe General Hospital respectively. As part of operationalization of the 2012 to 2015 National Eye Health Strategic Plan, the ministry of health (MoH) in collaboration with cooperating partners procured and installed state of the art ophthalmic equipment across the country.

Partnerships significantly contribute to eye health sector development through leveraging of financial, technical, material and logistical support. The National Prevention of Blindness Committee works to provide guidance to MoH and CPs and is responsible for developing the NEHSP.

Review of the 2012-2016 strategic plan A number of successes were scored during the last strategic plan. Some of the successes are as follows:  NPBC established in 1981, but first appointed by the Minister of Health in 2013. This included the technical and expanded committee.  National Trachoma Action Plan(TAP) formulated and implemented to spearhead treatment and prevention  Rolled out Mass Drug Administration (MDA) in the first districts that were mapped between 2008 and 2012.  Completed country wide trachoma mapping in 2016  Impact assessment surveys were carried out in 5 districts at year 1 post MDA  Guidance on importation of corneal tissue into the country for transplantation was adequately provided by the Ministry of Justice  Incorporated Trachoma activities into Neglected Tropical Disease (NTD) programmes  Established vision centres with the support of Vision Aid overseas in 9 Provincial Hospitals and in 2 districts with help of Onesight  Commissioned five (6) eye health centres of excellence including an Eye Out Patient Department in Senanga.  Procurement of state of the art ophthalmic equipment and consumables  Secured sponsorship through MoH and cooperating partners for 3 ophthalmologists to specialise in vitreo-retinal surgery  Strengthened links with co-operating partners.  Commencement of the MMed training at the University of Zambia, School of Medicine in 2011

 Secured international lecturers to support teaching in the absence of a faculty at the University of Zambia  The placement of mid-level ophthalmic personnel on the establishment; Registered Ophthalmic Nurses, Ophthalmic Clinical Officers, optometrists and optometry technologists.

Having achieved the above successes, a number of challenges below were faced:

 Inadequate research at both national and facility level  Inadequate human resources for eye health  Securing training posts for sub-specialities  The planned target for scaling up the number of ophthalmologist was not met due to the challenges being faced by the postgraduate training at UNZA and lack of support from co-operating partners.  Inadequate faculty to facilitate postgraduate training  The HMIS does not comprehensively capture eye diseases as a tool resulting in poor collection and handling of data.  The cataract surgical rate remains low.  Inability to upgrade to newer cataract surgery methods-Phacoemulsification to deal with Immature cataract and paediatric cataract in all of the centres except KCH  Inadequate consumables for eye surgery  The procurement of Ophthalmic surgical consumables process is elaborate and tedious  Lack of availability of eye preparations in hospitals despite them appearing in the Essential Medicine List for Zambia

Situation analysis

Eye Health services are available mainly at provincial and tertiary centres. The existing eye health outreach programmes are inadequate and confined to selected parts of the country.

The Ministry remains committed to the provision of comprehensive eye health services across the country through providing infrastructure, procurement of equipment, instruments, consumables (medical and surgical) and funding training for eye health personnel and also by providing an enabling working environment for all CPs. Furthermore, the ministry in collaboration with the eye health partners has introduced eye health care services at the primary level which are accessible free of charge.

The current situation on eye health services and disease burden in Zambia is as shown below in Tables 2 and 3 respectively.

Table 2: Current Human Resources for Eye Health Situation HUMAN RESOURCE CURRENT SITUATION 2017 1 OPHTHALMOLOGISTS PUBLIC PRIVATE Central Province 2 0 Eastern Province 1 0 Copperbelt Province 7 2 Luapula Province 1 0 Lusaka Province 10 4 Muchinga Province 0 0 North-western Province 1 0 Northern Province 0 0 Southern Province 1 0 Western Province 1 0 TOTAL 24 6

OTHER EYE HEALTH PERSONNEL 2 Ophthalmic Clinical Officers 49 4

3 Registered Ophthalmic Nurses 78 6 4 Optometrists 4 0 5 Cataract surgeons 8 7 6 Optometry technologists 34 0 TOTAL 173 13

Table 3: Current eye health service delivery

ITEM CURRENT SITUATION Cataract Surgical Rate 732 per million population per year (the recommended minimum (CSR) for Africa is 2000) Optical Workshops in 17 (UTH-Eye hospital, Mwami, Mansa, St. Paul’s, St. Francis, GRZ and Mission Mukinge Hospital, Kasempa, Lewanika, Ndola, Kasama, Hospitals Livingstone, Chainama, Solwezi, Kitwe, Kabwe, Lundazi, Petauke) Prevalence of Estimated at 2 % (339,081) – based on RAAB study in 20121 blindness Childhood blindness estimated at 0.9% per 1000 children (6700) – based on WHO estimates Estimated 24,000 children need spectacles for refractive errors Cataract (55%) Main causes of Trachoma (16%) blindness Glaucoma (15%) Corneal opacities (12%) Others (2%)

Planning framework

The NEHSP is influenced and guided by several frameworks including the National Health Strategic Plan, Global Action Plan for the Prevention of Blindness (WHO), The SAFE Strategy framework for Zambia and National Human Resources Plan.

2.0. NATIONAL HEALTH STRATEGIC PLAN

In 1991, the government of Zambia embarked on the Health Sector Reforms Programme (HSRP) whose ultimate aim was to provide equity of access to cost effective and quality health services as close to the family as possible. The major objective was the development of district health systems by providing Basic Health Services to all parts of the country. The process entailed decentralization of administrative and financial powers to the districts and provincial level hospitals and the district health boards in order to ensure active involvement and participation of local communities in the decision – making process.

The reform process involved redefining Ministry of Health (MoH) as the health policy making body responsible for the delivery and implementation of the Health Reforms. The major thrust in the formative stage of the reform was systems development at the district level to support the decentralization programme. This led to the establishment of the Health Information Management System (HIMS) and Financial Administration and Management Systems (FAMS) so as to enhance Leadership, Accountability and Transparency (LAT).

It is against this background that MoH and cooperating partners jointly developed the framework for the implementation of the services in the country. As a result, a basket fund was created for pooling of resources by all stakeholders so as to support priority programmes at the district.

In 1999, a Memorandum of Understanding (MoU) was signed by MoH and cooperating partners, which heralded a new beginning in the Health Sector Reform process. The immediate focus was to develop the action plans for MoH as well as production of the National Health Strategic Plan 2001-2005. Since then, the National Health Strategic Plan has been used as a tool to enhance health delivery services in Zambia and all the other national strategic plans developed by specific health programmes draw their aspirations from this fundamental document. The Government has since developed the sixth National Development Plan, into which the National Health Strategic Plan is incorporated. The National Eye Health Strategic Plan 2017-2021 is part of this National Health Strategic Plan 2017 - 2021.

3.0. NATIONAL EYE HEALTH STRATEGIC PLAN

This National Eye Health Strategic Plan provides a framework for planning, delivery, and management of quality eye health care services at all levels of eye health delivery systems in Zambia.

3.1 Vision A nation of healthy and productive people

3.2 Aim To reduce avoidable blindness in Zambia, by providing equity of access to cost effective and quality eye health services as close to the family as possible and within the global initiative for the reduction of avoidable and/or preventable blindness

3.3 Values Accountability, transparency, honesty, integrity and corruption free

3.4 General Objectives 1. To promote good eye health and prevention of eye diseases 2. To strengthen and enhance eye health 3. To develop and implement policies, plans and programmes to support the integration of eye health with the wider health system 4. To improve the equity and universality of access to eye health services 5. To strengthen eye health service delivery through multi-sectoral engagement and effective partnerships 6. To generate evidence on the magnitude and causes of visual impairment and eye health services 7. To advocate greater for political and financial commitment for eye health

4.0 EFFECTIVE EYE HEALTH SYSTEM

The NEHSP demonstrates the application of an eye health system that includes eye health promotion, disease prevention, curative and rehabilitative services. The approach will be multi- sectoral to include community participation and ownership built on evidence based community interventions. 4.1 Eye Health Promotion and Primary Eye Health Care

Consistent community actions towards eye health promotion and disease prevention are the most efficient and sustainable ways of ensuring better and equitable health outcomes. Eye Health promotion will be utilized in enabling the people to increase control and improve their eyehealth seeking behaviour. Therefore the focus will be on individual behaviour towards a wide range of social and environmental interventions.7

Objectives:

4.1.1 To promote good eye health and prevention of eye diseases.

Strategies: 1. To orient school teachers and community leaders on how to identify pupils and community members who have eye ailments 2. To work with the ministry of education in introducing eye health education in primary school curriculum 3. To collaborate with partners in eye health promotion 4. To promote eye health seeking behavior 5. Train personnel to ensure data is captured well and adequately monitored

4.2 Eye Health Service Delivery

Service delivery is a fundamental input to populations’ health status, along with other factors, including social determinants of health. In a well-functioning health system, the network of service delivery should have the following key characteristics: 1. Comprehensiveness: A comprehensive range of health services is provided, appropriate to the needs of the target population, including preventative, curative, palliative, rehabilitative and health promotion services. 2. Accessibility: Services are directly and permanently accessible with no undue barriers of cost, language, culture, or geography. Health services are close to the people, with a routine point of entry to the service network at primary care level rather than at specialist level. The Services may be provided in the home, community, workplace, or health facilities as appropriate. 3. Coverage: Service delivery is designed so that all people in a defined target population are covered, i.e. the sick and the healthy, all income groups and all social groups.

4. Continuity: Service delivery is organized to provide an individual with continuity of care across the network of services, health conditions, levels of care, and over the life-cycle. 5. Quality: Health services are of high quality, i.e. they are effective, safe, centered on the patient’s needs and given in a timely fashion. 6. Person-centeredness: Services are organized around the person, not the disease or the financing. Users perceive health services to be responsive and acceptable to them. There is participation from the target population in service delivery design and assessment. People are partners in their own health care. 7. Co-ordination: Local area health service networks are actively coordinated, across types of provider, types of care, levels of service delivery, and for both routine and emergency preparedness. The patient’s primary care provider facilitates the route through the needed services, and works in collaboration with other levels and types of provider. Coordination also takes place with other sectors (e.g. social services) and partners (e.g. community organizations). 8. Accountability and efficiency: Health services are well managed so as to achieve the core elements described above with a minimum wastage of resources. Managers are allocated the necessary authority to achieve planned objectives and held accountable for overall performance and results. Assessment includes appropriate mechanisms for the participation of the target population and civil society.7 This section attempts to describe a number of common eye health disorders and how the above key characteristics of good service delivery will be applied through the various objectives and strategies in this NEHSP

4.2.1 Cataract

According to the National Health Policy, cataract accounts for 55% of the causes of avoidable blindness.1Itis mainly caused by the normal aging process. Other causes include eye trauma, steroid use, uveitis, and diabetes mellitus. In children, it may be hereditary or congenital due to exposure to maternal infections, toxins and some medicines taken during pregnancy. There are no known ways of preventing cataract due to aging thus Treatment involves surgical removal of the natural lens, and implantation of an artificial intraocular lens (IOL).

The cataract surgical rate (CSR) is a measure of the availability of cataract services; it is the number of cataract operations per year per million populations. In Zambia the CSR is currently 732.1

Objectives

4.2.1.1 To increase the Cataract Surgical Rate by 100% 4.2.1.2 To perform cataract surgeries with IOL implantation accordingly 4.2.1.3 To attain a visual outcome of 6/18 or better in 80% of cataract surgeries

Strategies

1. Provide comprehensive static and outreach cataract surgical services in all 105 districts 2. Ensure that biometry is done for all cataract patients prior to surgery 3. To introduce phacoemulsification surgery to address cataract surgery backlog at UTH- Eye hospital; 4. Conduct capacity building training for community based volunteers and health workers to assist with identification of adult cataract and provide follow-up services 5. Conduct awareness campaigns and eye health education on cataract. 6. Ensure availability of transport for outreach services

4.2.2 Trachoma

It is an infectious disease involving the eyes and has been categorized as one of the neglected tropical diseases (NTD). It is the leading infectious cause of preventable blindness worldwide and is caused by the bacterium Chlamydia trachomatis with the vector is the common house fly.

Trachoma is endemic in virtually all ten provinces of Zambia. The provinces in which more than 50% of the districts were endemic for trachoma are Southern, Northern, Copperbelt, Muchinga, Central and Western provinces. The prevalence of active trachoma, trachomatous follicles (TF), among the one- to nine-year-olds were from Meanwhile, the prevalence of trachomatous trichiasis (TT) among the 15-year-olds and above ranged from 0% to 6.9%.9

Trachoma-endemic areas are characterized by perennial water shortages, inadequate sanitation, poor hygiene and poverty. The fight against trachoma involves a complete strategy of surgery, antibiotics, facial cleanliness, and environmental manipulation (SAFE).

Mass Drug Administration (MDA) addresses the “A” component of the SAFE strategy and is currently being implemented in twenty two districts. Out of these, five districts (Choma, Pemba, Mufulira, Chienge and Nchelenge) have completed three cycles of MDA, and impact assessment surveys have been done. These showed a reduction in prevalence to less than 10% in all the five districts.10

Objective

4.2.2.1 To reduce the prevalence of active trachoma by 50% in children 1-9 years of age 4.2.2.2 To reduce the prevalence of trichiasis by 50% among those 15 years and above

Strategies

1. To implement the full SAFE strategy in all trachoma-endemic districts (GET 2020) 2. Conduct Mass Drug Administration 3. Continue with community-based approach to trichiasis surgeries 4. Continue to engage Water, Sanitation, and Hygiene (WASH) partners in implementation of “F” and “E” components of the SAFE strategy 5. Update the Trachoma Action Plan (TAP)

6. Develop a National Trachoma Training Manual 7. Strengthen Trachoma Task Forces 8. Continue training of trichiasis surgeons

4.2.3 Refractive Errors

Refractive error causes reversible visual impairment, and low vision further contributes to decreased quality of life and productivity. Although management of low vision requires specialised attention, refractive errors can be managed by way of prescribing spectacles such as reading glasses. The correction of refractive errors could save sight, improve the quality of life and uplift the economic status of the country.

There are 17 Vision Centres that offer refractive services across the country in public institutions.

Objectives

4.2.3.1 Provide refractive services in more than 50% of the districts in the country

Strategies

1. Increase communities awareness on refractive services 2. Upscale optical glazing facilities at UTH-Eye Hospital to include Bifocal, Progressive and contact lens prescriptions. 3. Provide capacity building of optical glazing technicians and dispensers 4. Conduct primary school eye health screening 5. Establish Vision Centres in all the districts for the provision of refractive services

4.2.4 Low Vision

Low vision is the term used to refer to a visual impairment that is not correctable through surgery, pharmaceuticals, glasses or contact lenses. It is often characterized by partial sight, such as blurred vision, blind spots or tunnel vision, but also includes legal blindness. Low vision makes everyday tasks difficult. A person with low vision may find it difficult or impossible to accomplish activities such as reading, writing, shopping, watching television, driving a car or recognizing faces. Multi-disciplinary approach to the treatment of low vision is key for its success. Management of low vision include:  Optical devices to help one adapt, such as magnifiers, telescopes, or closed-circuit televisions  Techniques to help one utilize remaining vision  Environmental modifications to maximize one’s remaining vision  Adaptive non-optical devices, such as large-print books and talking watches.

Objectives

4.2.4.1 Develop low vision units at UTH-Eye hospital and two other centres

Strategies 1. Train at least 6 low vision specialists 2. Procure low vision devices in UTH-Eye hospital and two other Eye Centres 3. Enhance rehabilitation services in all Eye Centres 4. Train mid-level eye health workers in low vision services

4.2.5 Glaucoma

Glaucoma is a group of non-communicable disorders characterised by optic nerve damage and subsequent visual field loss, often associated with high intraocular pressure. It is responsible for 15% of avoidable blindness in Zambia.1

Objectives

4.2.5.1 To establish fully functional Glaucoma department at UTH-Eye Hospital and one other centre with trained specialists 4.2.5.2 To screen all adults visiting UTHs’ Eye Hospital and all eye departments for glaucoma

Strategies

1. Build capacity for eye health providers, especially opticians, in skills for diagnosis and management of glaucoma 2. Ensure availability of equipment and consumables for the management of glaucoma at UTH-Eye Hospital and Kitwe 3. Increase awareness among high-risk populations of the need for regular check-ups 4. Sensitise the population through the observation of Glaucoma Week 5. Train 2 glaucoma specialists 6. Inco-operate Glaucoma screening during issuance and renewal of driving licence

4.2.6 Childhood blindness

The prevalence of childhood blindness is estimated at 0.9 per 1000 children (approximately 6,700). The main causes of childhood blindness include congenital cataract, hereditary conditions, uncorrected refractive error, congenital glaucoma, retinal disorders and corneal opacities. Corneal opacities can be caused by injuries, infections and harmful traditional eye practices (HTEP).

Objectives

4.2.6.1 To establish Paediatric and Strabismus surgery services with trained specialists at UTH- Eye Hospital 5.2.6.2 To enhance paediatric and strabismus surgery services at Kitwe central hospital

Strategies

1. Promote eye health programmes for early identification and referral of common treatable eye diseases 2. Build capacity of teachers in schools to take visual acuity and identify common eye conditions such as refractive errors and low vision 3. Provide refraction and low vision services through Vision Centres 4. Enhance identification of paediatric cataracts during under-five clinic visits and Child Health Week activities 5. Develop IEC materials on eye health 6. Train 2 paediatric ophthalmologist 7. Support Kitwe central hospital train paediatric oriented ophthalmic team 8. To train theatre nurses

4.2.7 Retinoblastoma

Retinoblastoma is the most common intraocular tumour of childhood. In Zambia, retinoblastoma has been reported to be the third most common tumour in children, based on the retrospective review conducted by Zambia National Cancer Registry (ZNCR) in 2008-2010. Due to late detection of this tumour in Africa, 40-70% of children with retinoblastoma die, compared with 3- 5% in Europe, Canada and the United States.

Objectives

4.2.7.1 To establish Oculoplastic and Orbital tumour services with trained specialists at UTH- Eye Hospital 4.2.7.2 To train 100% of mid-level eye health workers on retinoblastoma

Strategies

1. Include red reflex examination on the Under-Five clinic card 2. Enhance the existing referral system at all levels 3. Train ophthalmologists in oculoplasty and Orbital tumour surgery 4. Formulate protocols for counselling, treatment and follow-up of patients 5. Provide capacity building for mid-level eye health personnel on early identification of retinoblastoma 6. To train theatre nurses

4.2.8 Diabetic retinopathy

According to Vision 2020, in 2011 there were at least 366 million people worldwide with diabetes mellitus, a figure that is likely to increase by 54% to 552 million by the year 2030. And 80% of people with diabetes live in low-middle income countries. Poor sugar control, blood pressure, and cholesterol control all increase the risk of developing diabetic retinopathy (DR).

After 15 years of having the diabetes, 10% develop severe visual loss and about 2% become blind. After 20 years of having diabetes mellitus, more than 75% of diabetic patients will have some form of DR.

Worldwide, there are approximately 93 million people with DR.11It is now emerging as one of the fastest growing causes of visual loss. The management for DR includes medical treatment, laser photocoagulation and retinal surgery. Successful management involves optimal blood sugar control and early detection of complications.

Objectives

4.2.8.1 To establish Vitreous and Retina department with trained specialists at UTH-Eye Hospital 4.2.8.2 To establish comprehensive DR services at Eye Centres 4.2.8.3 To establish DR screening in all general hospitals

Strategies

1. Strengthen referral system for diabetic patients to eye health workers 2. Promote primary eye health on DR 3. Enhance collaboration with the Diabetic Association of Zambia and other medical disciplines 4. Train specialists and build capacity in screening and management of DR and related retina diseases in order to reduce referrals abroad 5. Procure essential Surgical equipment and consumables for Vitreous and Retina ailments 6. Conduct a country prevalence study on DR 7. To train two Retina surgeons and medical retina specialists 8. To train theatre nurses

4.2.9 Corneal diseases

In Zambia, it is approximated that 10.3% of all blindness is due to corneal opacities and disease.1Opacification of the cornea leads to decreased visual acuity and eventually blindness. The cornea can become scarred from a variety of conditions, such as keratoconus, corneal ulcers, trauma, postoperative sequelae and severe allergic disorders of the eye, congenital/hereditary corneal conditions, and glaucoma. In severe corneal disease, corneal transplantation may be necessary. Currently, cornea transplant surgery is performed at Kitwe Central Hospital and some private Eye hospitals. The corneal donor tissues are obtained from abroad as there is currently no donor tissue bank in Zambia nor do we have well-outlined policies on human organ/tissue transplantation in place.

Objectives

4.2.9.1 To establish an Eye tissue bank at UTHs-Eye Hospital 4.2.9.2 To establish corneal transplant services to UTHs-Eye Hospital and expand the Services at Kitwe Eye Centre

4.2.9.3 To establish Cornea and Refractive services at UTH-Eye Hospital

Strategies

1. Establish an eye bank at UTH-Eye Hospital 2. Sensitize the public regarding the importance of organ/tissue transplantation 3. Engage stakeholders to facilitate formulation of legal framework to allow for organ harvesting and donation from cadavers in Zambia 4. Create awareness within communities on harmful traditional practices and beliefs 5. Increase capacity of ophthalmologists in management of corneal diseases 6. Train Ophthalmologists with specialist training

4.3 Human Resources for Eye Health

The shortage of human resource for eye health (HReH) has seriously affected the efforts towards the prevention of avoidable blindness. Currently the eye health personnel operates at 20% capacity. Creation of adequate funded positions for eye health workers has not been adequately addressed and this plan will put in place strategies to ensure that workers are trained and recognised in the public service salary structure in order for them to be appropriately remunerated if they are to be retained in the public workforce.

Inadequate and mal-distribution of the workforce, “brain drain” of highly skilled manpower and staff turnover have for a long time characterized the Zambian health system. This has resulted in an increased workload for remaining staff, reducing staff motivation and the quality of service for patients.

Many of these issues are addressed in the Ministry of Health Human Resources for Health Plan whilst this plan will seek to address the specific challenges of eye health worker training, skills transfer and continuous medical education.11

4.3.1 Eye health worker training

Qualified eye health workers are crucial for enhanced quality eye health service delivery. Currently the country experiences a huge shortage of eye health personnel at all levels. To address the shortage of qualified eye health professionals, deliberate efforts have been made to scale up the training of various human resources for eye health. The Chainama College of Health Sciences has been training Registered Ophthalmic Nurses and Ophthalmic Clinical Officers for the last nine years. The college has also been training Optometry technologists since 2010. Furthermore, in 2011 the University of Zambia through government support introduced a Master of Medicine (M.Med) training program in Ophthalmology. The Chainama College of Health sciences in collaboration with University of Zambia intend to introduce Bachelor degrees in

To meet the “Vision 2020 – The Right to Sight,” goals in Human Resource, the following positions have been identified as essential: 1. Ophthalmologists  Paediatrics  Oculoplastic and orbital tumour surgery  Cornea and Refractive surgery  Glaucoma  Vitreous and Retina Surgery  Public Health for Eye Health 2. Optometrists 3. Orthoptist 4. Ophthalmic clinical officers To be upgraded to Bachelor’s degree in 5. Registered Ophthalmic Nurses clinical ophthalmology 6. Low Vision Therapists 7. Bio Medical Engineers 8. Ophthalmic Instrument Technicians

Below are the recommendations outlined by the WHO for the number of positions per population in Sub-Saharan Africa:

Table 4: WHO recommendations for the number of positions per population in Sub-Saharan Africa POSITION NUMBER OF POSITIONS / POPULATION Ophthalmologist 1/250,000 Ophthalmic clinical officer 1/100,000 Ophthalmic Nurses 1/100,000 Optometrist 1/250,000 PEC Nurses 1/10,000 CHWs 1/1,000

In order to fulfil the human resource needs the cost implications are given in the table below. Table 5: Duration of training according to type of eye health professionals

Type of Eye Worker Period of Cost of Training Location of Training Training Fellowship-trained 15 months USD 50,000 India ophthalmologist Ophthalmologist 48-60 USD 60,000 Kenya, Malawi, Tanzania months Zambia Ophthalmic Clinical Officer 24 months ZMW 34,000 Zambia

Registered Ophthalmic 24 months ZMW 30,000 Zambia Nurse Optometrist 48 months USD 26,000 India

Table 6: Outline of objectives for Development for Human Resources for Eye Health

HUMAN RESOURCE CURRENT EXPECTED SITUATION 2017 BY 2021 IN PUBLIC OPHTHALMOLOGISTS Central Province 2 3 Eastern Province 1 4 Copperbelt Province 7 16 Luapula Province 1 4 Lusaka Urban 1 1 UTH-Eye Hospital 8 16 Vitreous and Retina Surgery 0 2 Paediatrics 0 2 Oculoplastic and orbital tumour 0 2 Cornea and Refractive surgery 0 2 Glaucoma 0 2 Public Health for Eye Health 0 2

Muchinga Province 0 2 North/western Province 1 2 Northern Province 0 3 Southern Province 1 3 Western Province 1 2 TOTAL 24 87 Ophthalmic Clinical Officers 49 49

Optometrists 2 Optometry Technologists 30 68 UTH-Eye hospital 4

Orthoptist 0 5 Registered Ophthalmic Nurses 79 140 UTH-Eye hospital 9

Registered Nurses 30 300 UTH-Eye 33 Low vision therapists 1 11 Ophthalmic equipment technicians 1 11 BioMedical Engineers - Ophthalmic 0 10 Ophthalmic instrument technicians 0 11

4.3.1.1 To increase the number of trained eye health workers, in line with the WHO recommendations as shown in table 7 below

Table 7: Recommendations of eye health workers according to facility level

POSITION 4th LEVEL 3RD LEVEL 2ND LEVEL 1ST LEVEL Consultant 16 8 2 0 Ophthalmologist Senior Registrar 16 8 1 0 Chief Nursing Officer 1 0 0 Principal Nursing Officer 1 0 0 Optometrist 4 2 1 1 Senior Nursing Officer 4 1 1 0 Senior Night 2 0 0 Superintendent Senior Theatre 1 1 1 0 Superintendent Night Superintendent 4 2 0 0 Theatre Superintendent 1 1 1 0 Orthoptist 4 2 0 0 Public Health Nurse 4 2 2 1 Registered Ophthalmic 60 30 6 3 Nurse Ophthalmic Theatre 18 9 2 0 Nurses Optometry Technologists 3 3 1 1 Registered Nurses 40 21 5 1 Low vision therapists 4 2 1 0 Ophthalmic equipment 4 2 1 0 technicians Ophthalmic instrument 4 2 1 0 technicians

Table 7b Recommendations of Ophthalmologists according to Sub-specialities at UTH-Eye Hospital

Sub-specialities Current Situation Expected 2021 Paediatrics 0 2 Oculoplastic and Oncology 0 2 Cornea and refractive surgery 0 2 glaucoma 0 2 Vitreous and Retina Surgery 0 2 Public Health for Eye 2 3

Strategies

1. Focus and scale up subspecialisation training of ophthalmologists locally and abroad 2. Strengthen MMED Ophthalmology training at the UTH-Eye hospital/UNZA 3. Commence bachelor’s degree training in Optometry and clinical ophthalmology 4. Scale up the training of all eye health workers both in the country and abroad 5. To create and formalize practicum sites at three Established Eye centres Fully equip training facilities with essential appropriate equipment and consumables(medical & surgical) 6. Commence training programmes of all eye health personnel at institutions other than UNZA and Chianama Hills College Hospital

4.3.2 Continuous Medical Education (CME)

The MoH in collaboration with the Zambia Ophthalmological Society (ZOS) and cooperating partners shall organise CME for all eye health workers in the country. All eye health workers shall be encouraged to participate by way of attending, active engagement and paper presentations.

Transfer of special skills is effectively and continuing applying the knowledge, skills, and/or attitudes that were learned in a learning environment or through experience to the job environment and to others. This increases the speed of learning and promotes mentoring of junior staff.

Special skills transfer is encouraged through sponsored training of staff at highly specialised centres; for example low vision training to address the needs of people with visual impairment or phacoemulsification for cataract patients. Alternatively specialist skills in gained through the attachment of experts to specified centres such as spectacle dispensing and glazing or vitreo- retinal surgery. Such arrangements need to have clearly defined objectives and timelines for the skills to be transferred.

Objectives

4.3.2.1 Each eye health worker to attend at least 10 accredited CME course per year 4.3.2.2 All Eye Centres to provide for skills transfer Strategies

1. Provide structured CME to all levels of eye health workers 2. Support and/or Organise ZOS congress, workshops and symposia on eye health 3. Participate in international conferences and workshops on eye health 4. Develop staff certification process in accredited CME courses 5. Strengthen and develop existing links with local and international partners to enhance skills transfer 6. Promote tele-medicine and e-learning in eye health training institutions 7. Provide guidance to health professions council on the accreditation of eye health personnel and use of appropriate nomenclature

4.4 UTHs’ EYE HOSPITAL STRUCTURE

4.4.1 ORGANOGRAM OF THE SENIOR MANAGEMENT UTHs’ EYE HOSPITAL

Senior Medical Superintendent (SMS)

Head Clinical Care (HCC) National Eye Health Coordinator (NEHC)

Chief Hospital Senior Public Principal Heads of Chief Chief PROVINCIAL Administrator Human Relations Accountant departments Purchasing Nursing (CHA) Resources /INSTITUTIONAL Officer and Officer Manageme Supplies (CNO) nt/Develop Officer ment Officers

4.4.2 ORGANOGRAM OF CLINICAL CARE UTHs’ EYE HOSPITAL

Head Clinical Care

Head, Head, Head, Head, Head, Head, Head, Head Nursing Head, Eye Glaucoma Cornea Paediatric Oculoplastic Vitreous Optometry pharmacy Laboratory Services Health and Ophthalmology & & Retina and Vision and Eye Promotion anterior Orbital Centre Bank and segment tumour Services research

Counseling Services

6.4.3 ORGANOGRAM OF ADMINISTRATION UTHs’ EYE HOSPITAL

Chief Hospital Administrato r (CHA)

Procurement Laundry Human Audit Accounts Maintenance Administration Security Information House and Medical Resources and Keeping equipment Planning

Transport Catering Services

4.5 Infrastructure, Equipment and Medical and Surgical Consumables 4.5.1 Infrastructure Development

Provision of adequate and sustainable infrastructure for medical purposes is one of the six pillars of the NHSP. A standard building plan was developed and list of minimum equipment required for various levels of care, to include eco-compatible solar power back up systems. The University Teaching Hospitals –Eye Hospital is the national referral eye hospital bearing the responsibilities of service delivery, undergraduate/postgraduate training and coordinating all eye health services in the country. The current state of UTH-Eye hospital infrastructure is not adequate hence there is critical need for construction and modernization to enhance service delivery. In order to befit its status the structure needs to include but not limited to the following space:- in patient wing, operating theatre rooms, eye bank, administration, and other service blocks.

The country has only 3 Eye Centres of that have been built i.e. Kitwe Central, Lewanika General and St. Pauls’ Mission Hospitals whereas UTH, Livingstone Central and Ndola Central Hospitals underwent refurbishing. The construction, of two centres in Chipata and Kabwe is underway.

Objectives

4.5.1.1 To construct the Eye Hospital 4.5.1.2 To construct an Eye bank at UTH 4.5.1.3 To refurbish eye health facilities in need of a face lift

Strategies

1. To lobby for funding from MoH and CPs for the construction of UTH-Eye Hospital 2. To ensure the standards of NPBC’s guidelines for new infrastructures are implemented 3. Engage with partners around the construction and/or refurbishment of eye health facilities and vision centres 4. Build a suitable facility to house an eye bank 5. Maintain an annual infrastructure development plan 6. Closely monitor construction or renovation of the infrastructure 7. Ensure systems are put in place for the installation and maintenance of alternative sources of energy at all eye health facilities

4.5.2 Equipment

The Government has made tremendous progress in procuring and distributing ophthalmic equipment for the various hospitals in Zambia. At the moment, most district hospitals have one slit lamp as the minimum available eye equipment.

The standard list of consumables and equipment is available for reference and clearly shows the minimum required equipment for the various levels of eye health facilities.

Though much has been done, there are still gaps in the area of equipment provision and the newly established Eye hospital also needs to be equipped further.

Objectives

4.5.2.1 To ensure that all eye health facilities are equipped according to the standard list appropriate to the level of care

Strategies

1. Conduct periodic checks to identify the gaps in the area of equipment at all eye health facilities 2. Ensure that all equipment is in working condition and routine maintenance is conducted 3. Ensure inventory reports are submitted accordingly 4. Ensure appropriate and ongoing training for ophthalmic equipment technicians 5. Carry out an audit of all the equipment in vision centres to ascertain their needs and functional status 6. Procure Phacoemulsification equipment 7. Procure posterior segment vitrectomy equipment (Constellation machine) 4.5.3 Supplies for optical services

4.5.3 Vision Centres and Refractive Services

There are 12 fully functional vision centres in public health and 5 in faith-based health institutions. Vision centres are situated within the eye departments and provide eye tests, spectacle prescriptions and affordable spectacles. The challenge in all these vision centres is the procurement processes of lenses and frames.

Objectives

4.5.3.1 To set up a laboratory for production of optical devices at Chainama Hills College Hospital 4.5.3.2 To ensure all vision centres are well stocked with sufficient supplies for optical service

Strategies

1. Develop a list of equipment and supplies required for vision centres 2. Streamline the procurement process for optical service supplies

4.5.4 Medicines and surgical consumables

Medical Stores Ltd, in Lusaka, does not stock most medicines and surgical consumables required in eye units. Indeed, consumables are acquired through the support of the cooperating partners only in facilities where the partnership exists.

Objectives

4.5.4.1 To ensure that all eye health facilities are stocked with essential medical and surgical consumables Strategies

1. Implement the already establish an essential medical and surgical consumables list for eye health services 2. Prioritise continued procurement of essential medical and surgical consumables for eye health by the Ministry of Health 3. Work in partnership with all eye health stakeholder on essential medical and surgical consumables

4.6 Health Management Information Systems (HMIS)

The HMIS is a routine electronic data-capturing tool, which is critical in gathering health information. Quality, timely and disaggregated data collection is key to improving health service delivery and in setting national health priorities. The MoH shall develop and maintain a database of all eye health activities in the country. This will be achieved through submissions and consolidation of reports from the district to national level and capture essential data for disease monitoring and control according to the WHO. The database shall be designed to interface with the National HMIS.

Objectives

4.6.1 To integrate an improved list of eye health indicators into the National HMIS 4.6.2 Disaggregate data by key demographic indices (age, sex, urban/rural and disability)

Strategies

1. Establish facility level data collection tools for patients and disease information for eye health 2. Develop a list of eye health indicators for integration in the National HMIS 3. Promote use of electronic data-capturing systems at all the eye health facilities 4. Implement an agreed methodology to disaggregate data by disability 5. Train personnel to ensure data is captured well and adequately monitored

4.7 Leadership and Governance

4.7.1 National Prevention of Blindness Committee (NPBC)

The NPBC formulates, coordinates, evaluates and monitors eye health programmes, in the Ministry of Health. The NPBC is comprised of the Technical Working Group and Expanded Committee. The Technical Working Group, comprising ophthalmologists, is the core-working group for policy direction. The Expanded Committee comprises the Technical Working Group, which may determine the composition of cooperating partners and other members.

The Director of Clinical Care and Diagnostic Services of the Ministry of Health is the chairperson for the NPBC,and the Senior Medical Superintendent of the UTH-Eye Hospital provides the Secretariat for the NPBC.

Objectives

4.7.1.1 Strengthen eye health governance

Strategies

1. Develop other eye programmes as need may arise during the implementation of the NEHSP 2017 to 2021 2. Hold quarterly NPBC meetings 3. Ensure the performance assessment is carried out at all eye health facilities in the country at least once per year or as need may arise and audits and/or carry out inventories of equipment and manage a database of human resources in eye health facilities 4. Set up a fully functional National Eye Health Coordination programme through UTHs’ Eye Hospital, with sufficient staffing to support monitoring and evaluation, research and clinical care 5. Ensure an implementation plan is developed for the NEHSP 6. Carry out a midterm progress review of the NEHSP in September 2018 7. Ensure legal framework in place for the delivery of the NEHSP, including the development of the eye bank 8. Promote tele-medicine and e-learning 9. Coordinate information and communication in eye health and ensure that there is free flow of information to the centre from the periphery and partners and vice versa 10. Work on integrating the NEHSP into the National Health Plan and budget, and incorporate it further into relevant poverty-reduction strategies, initiatives and wider socioeconomic policies.

4.8Finances and Resource Mobilisation

The estimated total cost for the five – year programme implementation is Sixty six million three hundred eighty one thousand seven hundred and seventy four United States Dollars and eight cents (USD 66,381,774.08). At the present value of ZMW10.0 per 1.00 USD, this will translate to Six hundred sixty three million eight hundred and seventeen thousand seven hundred and fourty kwacha eighty ngwee (ZMW 663,817,740.80)). The expected sources of funding are the Government of the Republic of Zambia (GRZ) through the Ministry of Health (65%) and the rest from the cooperating partners.

Objectives

4.8.1 To ensure sufficient financial resources are available for eye health 4.8.2 To construct the UTH-Eye Hospital and Eye bank 4.8.3To ensure efficient use of financial resources for eye health

Strategies

1. To lobby for funding to construct the UTH-Eye hospital 2. Ensure there is accountability for all the resources dedicate to eye health 3. Enhance financial record keeping for efficient and effective monitoring of the financial flow of the various programmes 4. Conduct audits on eye health resources 5. Strengthen partnerships with cooperating partners 6. Prioritise efficient disbursement of the eye health budget

Table 8: Summary budget to implement the NEHSP 2017 – 2021

YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 TOTAL ITEM (2017) (2018) (2019) (2020) (2021) (USD) Training 2,471,000.00 2,641,100.00 2,905,210.00 4,080,846.00 4,488,930.60 16,587,086.60 Infrastructure(A) 3,400,000.00 3,740,000.00 4,114,000.00 4,525,400.00 4,977,940.00 4,977,940.00 UTH-Eye hospital Infrastructure(B) 3,690,000.00 4,059,000.00 4,404,400.00 4,844,840.00 5,329,324.00 22,327,564.00 Others Equipment 4,034,700.00 1,578,170.00 1,735,987.00 1,909,585.70 2,100,544.27 11,358,986.97

Medicines, Supplies & 1,023,000.00 1,125,300.00 1,237,830.00 1,361,613.00 1,497,774.30 6,245,517.30 Consumables

Health Promotion 90,000.00 99,000.00 108,900.00 119,790.00 131,769.00 549,459.00

Eye health Outreach 120,000.00 132,000.00 145,200.00 159,720.00 219,615.00 776,535.00 Services

Community engage in 24,850.00 27,335.00 30,068.50 33,075.35 36,382.89 151,711.74 primary eye health

Governance, Partnerships, 116,000.00 71,500.00 78,650.00 86,515.00 95,166.50 447,831.50 collaborations, links HMIS 52,000.00 57,200.00 62,920.00 69,212.00 76,133.20 317,465.20

Eye health Research 100,000.00 110,000.00 121,000.00 133,100.00 146,410.00 610,510.00 and Publications Monitoring & 7,700.00 8,470.00 9,317.00 10,248.70 11,273.57 47,009.27 Evaluation Transport 325,000.00 357,500.00 393,250.00 432,575.00 475,832.50 1,984,157.50

GRAND TOTAL 15,454,250.00 14,006,575.00 15,346,732.50 17,766,520.75 19,587,095.83 66,381,774.08

**Note: The budget for the construction of the UTH-Eye Hospital is estimated at USD 3,400,000.0 in 2017 but will increase by 10% each year due to inflation

5.0 INTEGRATION WITH THE WIDER HEALTH SYSTEM

5.1 The role of non-eye health workers in eye health

The contribution of non-eye health workers will be essential in the delivery of the NEHSP 2017- 2021. Their active participation will include improving the referral system, improved early diagnosis and treatment and overall better eye health outcomes. General health workers are often the first point of contact for eye health patients, and their ability to identify and make timely referrals is critical to the effectiveness of the eye health system. This is complementary to the strengthening of human resources for eye health, and will lead to better integration of the eye health system with the wider health system.

Objectives

5.1.1 To ensure non-eye health workers have a better understanding of eye health conditions and are able to take appropriate actions

Strategies 1. Deliver training to ensure community health workers are aware of key eye health conditions and when and how to refer 2. Support and provide training for primary non-eye health worker in order for them to work an integrated manner with eye health workers and have a basic understanding of eye conditions and treatments 3. Delivery training for general nurses, in order that they have a basic understanding about eye care and post-surgical care 4. Strengthen the eye health component in the general medical training curriculum 5. Work with the Child Health Programme to include a basic eye examination, with appropriate referrals when necessary 6. Conduct a KAP study with non-eye health workers to better understand perceptions of eye health

5.2 Referral system

A robust referral system is vital in increasing the quality of eye health service delivery, through prompt referral leading to early diagnosis and treatment. The NEHSP 2017-2021 aims to strengthen the referral system for eye health and enhancing the feedback system between eye health facilities and the referring centre.

Objectives

5.2.1 To increase the number of eye health referrals that receive treatment in eye health facilities by 20%

Strategies

1. Develop a system for monitoring the referral system for eye health conditions 2. Improve the understanding of health workers of the referral system 3. Work with other Ministry of Health departments on a strategy for improving the referral system

5.3 Integration in schools

Early diagnosis and treatment of eye health conditions in school children is very important for their educational performance. It also has an impact on the awareness of eye health in the wider community, especially within the family. Therefore it is important to integrate eye health education into the school programme, so that teachers are able to identify when a child is struggling to see and take appropriate action.

Objectives

5.3.1 Children with eye conditions are identified through a school vision screening programme

Strategies

1. Develop a school vision screening programme to be integrated within the School Health Programme 2. Work with the School Health Programme to include eye health screening is a standard 3. Work with the Ministry of Education on the development and implementation of the school vision screening programme 4. Introduce eye health talks in school and communities to address stigma associated with spectacles and low-vision devises

6.0 EQUITY AND UNIVERSALITY OF ACCESS TO EYE HEALTH SERVICES 6.1 Equity of access

In line with Government policy, and with the recommendations of the WHO, it is important for people to know the eye health services offered and where they can access them. These services must be affordable and easily accessible by everyone irrespective of ability to pay, age, sex, disability or geographical location. It is also clear that there is a need for a strengthened monitoring system to track progress in equity of access.

Objectives

6.1.1 People in rural areas access basic eye health services in district hospitals 6.1.2 Gender disparities in eye health conditions are reflected in those accessing services 6.1.3 Data on access to services for people with disabilities, older people and marginalised groups is available

Strategies

1. Develop a system for monitoring equity of access to eye health services, with effective metrics 2. Work with the HMIS to improve disaggregation of data by age and sex and implement an agreed methodology to disaggregate data by disability 3. Conduct research to greater understand barriers faced by vulnerable and marginalised groups 4. Improve public awareness for eye health

6.2 Information, education and communication (IEC) material development

Greater public awareness of eye health conditions and services that are available will lead to improved health seeking behaviour, early diagnosis and referral, and therefore eye health outcomes. IEC materials on eye diseases are limited in number and will need to be developed and made available in order to raise awareness on eye conditions and related issues. The HMIS should be used to inform the development of effective IEC materials.

Objectives

6.2.1 To create greater public demand for eye health services

Strategies

1. Review and reproduce existing IEC materials 2. Develop appropriate IEC materials on major blinding eye conditions collaboration with the Health Education Unit of Ministry of Health 3. Utilise information from research on barriers to accessing eye health and the HMIS in order to better target IEC materials and activities 4. Develop and broadcast eye health programmes through the print media, radio and television 5. Participate in World Sight Week 6. Work with cooperating partners on the development of IEC materials

7.0 STRONG AND EFFECTIVE PARTNERSHIPS

Strong partnerships with key stakeholders have been an integral part of eye health services in the country. These include other government line-ministries and departments, local communities, the private sector, faith-based institutions, the civil society and cooperating partners. These partnerships significantly contribute to eye health sector development through the leveraging of financial, technical, material and logistical support. International partnerships and local alliances are instrumental in developing and strengthening effective public health responses for the prevention of avoidable blindness. Sustained and coordinated local action with adequate funding has resulted in impressive achievements, and we need to build on these successes in the NEHSP 2017-2021.

Objectives

7.1 To enhance partnership between government and all cooperating partners in eye health sector

Strategies

1. Work with cooperating partners to finance the implementation of the NEHSP 2. Engage cooperating partners in the implementation of the NEHSP 3. Work with training institutions to incorporate and improve eye health modules within core health training curricula 4. Foster greater interaction with private sector eye health providers in the implementation of the NEHSP 5. Provide guidance and leadership in the operations of cooperating partners in order to ensure greater equity in resource distribution throughout the country 6. Provide guidance and leadership in the operations of cooperating partners in order to ensure quality standards are met for all eye health resources 7. Facilitate statutory obligations through signing of MOUs between the Ministry of Health and cooperating partners 8. Ensure that all MOUs include well-defined exit strategies for programmes supported by cooperating partners 9. Work with other line-ministries in the implementation of the NEHSP

10. Engage with relevant Ministry of Health departments to ensure that interaction with traditional healers and birth attendants includes sensitisation on eye health and appropriate actions 11. Establish new cross-sectorial international partnerships in research, innovation, data disaggregation and capacity building

Table 8: Scope of engagement of Government Departments in the NEHSP Ministry Scope of engagement Key responsibilities Ministry of Lead stakeholder to provide policy, To establish and support the NEHC Health (MoH) implementation guidelines and To support the NEHC coordination for eye Health To coordinate and lead the full roll out Services in Zambia. of the National Eye Strategic Plan To ensure collaboration with other To ensure that surgeries for cataracts line Ministries, cooperating are incorporated into the existing partners, and the corporate sector. service delivery structures To enhance collaboration with other To coordinate eye screening divisions of the Ministry of Health, To conduct monitoring, evaluation and district leadership, and the broader reporting on all eye health activities in health system. the country. Is the main driver of promoting To host NEHC meetings community participation and To engage cooperating partners to engagement towards the NEHSP. Vital in making the community support the eye health strategy actively participate in the eye implementation screenings and outreach activities. To lobby for political will in the roll out of eye health services To integrate eye screening in other programmes aimed at preventing avoidable blindness To mobilize and allocate resources (human, financial and logistical) for eye screenings and outreach activities To inspire and mobilise positive behavioural change at community level tailored towards preservation of vision, e.g. wearing of protective eye wear by industrial workers, improved health seeking behaviour. Work with communities to encourage face and hand washing, general health education, sanitation and increased safe water supply. Engage communities in fundraising for drilling of boreholes and constructing VIP latrines. Establishment and support of the NEHC

Integration of eye health strategy at primary health care level through their planning and service delivery To play a leading role in community and schools screening for eye conditions To integrate visual screening in other programmes aimed at preventing avoidable diseases. To play a community influential role in eye health services at community level Ministry of Local Is the lead ministry for WASHE Vital in enforcing and strengthening laws Government and activities and regulations with regard to community Housing (MLGH) Promoting and protecting the public’s behaviour towards safe human waste health in addressing public health disposal, water safety, general community factors at a localised level. hygiene and sanitation Protection and enhancement of the Where there may be no legislation, there health and wellbeing of the community may be need to introduce some form of As such, it will be the key partner in bylaws to strengthen the above the scale-up of environmental change To enhance the activities of Community activities Led Total Sanitation (CLTS) Will work through the National Rural To engage local government leadership and Urban Water and Sanitation such as councillors to take a leading role Programmes to improve the in noise reduction enforcement availability of safe water points Enhance provision and efficient MLGH will upgrade the messaging management of safe & clean water at and subsequent dissemination to all community level districts programmed for accelerated sanitation efforts

Ministry of Will play an important role in the To introduce mandatory eye screening in Education development and execution of the schools’ health programme called (MoE) visual screenings education school health and nutrition (SHN) initiatives. Efforts to integrate eye To work closely with the SHN screening into the national school coordinators School coordinators to be equipped with health curriculum should be a relevant skills and knowledge on eye priority. In addition, advocacy with conditions, placing high priority on visual district education officers would be disorders. included in district strategies to Give regular talks to learners on health encourage and support the matters in collaboration with Ministry of development of teacher capabilities Health officials in delivering these lessons. Work with child to child clubs in schools MoE is the key institution ensuring as a platform to promote good health inclusion blind children into the practices mainstream school system Strengthen existing clubs to make them more active in the dissemination of visual disorders information among the children

Work with health workers to give health talks in schools Ministry of Is an important vehicle through Work hand in hand with the Chiefs to Chiefs and which rural development can be disseminate information on eye health Traditional delivered to the Chiefdoms. Will conditions to all the chiefdoms Affairs play an important role in ensuring To ensure that the subjects in various (MoCTA) that the traditional leadership across chiefdoms are sensitized on the country is sensitized about eye community based approaches to health conditions. combating eye health conditions Use traditional ceremonies as a platform for disseminating information on effects of harmful traditional practices and beliefs To ensure enhanced community adherence basic personal hygiene and sanitation Ministry of To ensure that Safety Health and To supplement efforts of MLGH Mines, Energy Environment (SHE) regulations are To work with the SHE coordinator and Water adhered to for the wellbeing of the Development national workforce. (MMEWD):

8.0 RESEARCH Although data exists regarding prevalence of eye conditions throughout Sub-Saharan Africa, which have been extrapolated from the WHO to apply to Zambia, not many prevalence studies have been done within Zambia itself. As part of continuous medical education, evidence-based policy formulation and decision making, more eye health research needs to be conducted.

Objectives

8.1 To generate an evidence base for eye health specific to the Zambian context

Strategies 1. Develop a list of research priorities 2. Build the research capacity of the Zambia Ophthalmological Society 3. Support and encourage Eye Centres to produce research and publish in peer reviewed journal per year 4. Promote research presentations at the annual conferences of the Zambia Ophthalmological Society and College of Ophthalmology of Eastern ,Central and Southern Africa (COECSA) 5. Ensure ethical approval is granted by the Ethics Committee before any research is conducted 6. Ensure all research done in hospitals has appropriate permission from the Ministry of Health

9.0 MONITORING AND EVALUATION 9.1 Measurement

Tools have been developed (Appendix 1) for monitoring and evaluation of the quality and quantity of eye health services being offered in the country. The MoH will carry out biannual monitoring and evaluation of the implementation plan and later conduct an end-term evaluation.

Objectives

6.1. To strengthen the monitoring and evaluation in the delivery of the NEHSP, 2017-2021

Strategies

1. Establish standards for eye health practice 2. Conduct comprehensive annual audits of eye health service delivery 3. Establish system for regular drug, equipment, instruments, medical and surgical consumables replenishment which is integrated within national drug requisition system 4. Ensure regular facility reporting

Table 9: Monitoring and evaluation objectives and indicators

Objective Measurable Baseline Targets Means of Verification Indicator Eye Health System Strengthening 4.1.1 - To promote Percentage of Eye 35% 100% Report from MoH/UTH good eye health and Health Promotion Eye hosp prevention of eye programmes diseases by 100% 4.2.1.1 - To increase Cataract Surgical 743 (2015) 1,500 Annual facility reports the Cataract Surgical Rate Rate by 100% 4.2.1.2 - To reduce Prevalence of 10% 5% Impact Assessment the prevalence of active trachoma in active trachoma by children 1-9 years Biennial surveillance 50% in children 1-9 of age report years of age 4.2.2.2 - To reduce Prevalence of TT 1.3% 0.6% Impact Assessment the prevalence of trichiasis by 50% among those 15 years and above 4.2.3.1 - Provide Percentage of - 50% Report from MoH/UTH refractive services in districts with Eye Hospital more than 50% of the vision centres

36 districts in the country 4.2.4.1 - Develop low Number of Eye 1 3 Report from MoH/UTH vision units at UTH- Centres with low Eye Hosp Eye hospital and two vision unit other Eye Centres 4.2.5.1 - To establish Number of trained 0 2 Training reports a glaucoma glaucoma department at UTH- specialists Facility reports Eye Hospital with working in Eye trained specialists Centres 4.2.5.2 - To screen all Percentage of 77% 100% Patient records adults visiting UTHs’ adults visiting eye Eye Hospital and all departments other eye departments screened for for glaucoma glaucoma 4.2.6.1 - To establish Number of trained 1 2 Facility reports Paediatric and paediatric Strabismus services ophthalmologists with trained 0 specialists at UTH- Number of trained 5 Eye Hospital anaesthesiologists working with eye departments 1 Number of Eye 2 Centres with all equipment found on paediatric equipment list 4.2.6.2 - To enhance Number of 1 2 Facility reports Paediatric and paediatric Strabismus services ophthalmologist with trained specialists at Kitwe Number of Eye central Hospital Centres with all 1 2 equipment found on paediatric equipment list 4.2.7.1 - To establish Number of 0 100% Report from UTHs’ Oculoplastic surgery surgeries Eye Hospital and Orbital tumour Number of 0 2 services with trained surgeons specialists at UTH- Eye Hospital 4.2.7.2 - To train Percentage of 0% 100% Training reports

100% of mid-level mid-level eye eye health workers on health workers retinoblastoma trained on retinoblastoma 4.2.8.1 - To establish Number of 0 100% Report from UTHs’ Vitreous and Retina vitreous and retina Eye Hospital services with trained surgeries done specialists at UTH- Eye Hospital Number of active surgeons 0 2 4.2.8.3 - To establish Number of laser 30% 100% Facility reports comprehensive DR procedures services at 5 Eye Monitoring visit reports Centres 4.2.8.4 - To establish Percentage of 35% 100% Facility reports DR screening in all general hospitals general hospitals with DR screening Monitoring visit reports 4.2.9.1 - To establish Number of 0 1 Facility reports an eye bank at UTH- operational eye Eye Hospital banks 4.2.9.2 - To expand Number of Eye 1 2 Facility reports corneal transplant Centres offering services at UTH-Eye corneal transplant Hospital and Kitwe services Eye Centre 4.2.9.3 - To establish Number of cornea 0 2 Facility reports cornea and refractive and refractive surgery services surgeons 4.3.1.1 - To increase Reference table 6 Reference Reference Training reports the number of trained above table 6 above table 6 above eye health workers, in line with the WHO recommendations 4.3.1.2 - To have eye Reference table 6 Reference Reference Facility reports health workers above table 6 above table 6 above deployed in accordance with the agreed recommendations 4.3.2.1 - Each eye Percentage of eye - 100% Facility reports health worker to health workers attend at least 10 attending 10 Attendance certificates accredited CME accredited CME courses per year courses 4.3.2.2 –UTH-Eye Percentage of Eye 100% 100% Facility reports

Hospital and all Eye Centres Centres to provide for conducting skills transfer activities 4.5.1.1 - To Number of 1 1 Report from MoH/UTH modernize and operational eye Eye hospital construct a state of hospital the art eye hospital at UTH befitting that of a national referral centre

4.5.1.2-To support Number of Eye 2 2 Report from MoH/UTH and equip the two eye Centres currently Eye hospitals centres that are under under construction construction Monitoring visit reports 4.5.1.3 - To set up Percentage of 51% 85% Report from MoH/UTH functional eye units in district hospitals Eye hospital district hospitals with function eye units Monitoring visit reports 4.5.2.4 - To ensure Percentage of eye 51% 100% Report from MoH/UTH that all eye health health facilities Eye hospital facilities are equipped that are fully according to the equipped Monitoring visit reports standard list according to the appropriate to the standard list level of care appropriate to the level of care 4.5.3.1 - To set up a Number of 0 1 Report from MoH/UTH laboratory for operational optical Eye hospital production of optical devices laboratory devices at UTH-Eye Hospital 4.5.3.1 - To ensure all Percentage of 72% 100% Facility reports vision centres are vision centres that well stocked with are fully stocked Monitoring visit reports sufficient supplies for according to the optical services standard list for optical services 4.5.4.1 - Ensure that Percentage of eye 5% 100% Facility reports all eye health health facilities facilities stock that are fully Monitoring visit reports essential medical and stocked according surgical consumables to the standard list appropriate for the for medical and level of care surgical consumables

4.5.4.2 - To integrate Number of eye 7 30 National HMIS an improved list of health indicators eye health indicators in National HMIS into the National HMIS 4.7.1 -Strengthen eye Percentage of 50% 100% Minutes of NPBC health governance quarterly NPBC meetings and leadership meetings held

Percentage of eye 100% 100% Monitoring visit reports health facilities inspected annually 4.8.1 - To ensure Percentage of the 84% 100% Ministry of Health sufficient financial NEHSP 2017- Accounts Department resources are 2021 budget records available for eye funded health Reports from cooperating partners 4.8.2 - To ensure Number of - 5 Report from Auditor efficient use of “Good” external General financial resources for audit reports into eye health eye health resources Integration with the wider health system 5.1.1 - To ensure non- Percentage of TBC through TBC after KAP study eye health workers non-eye health 2016/17 KAP baseline have a better workers with an study understanding of eye improved health conditions and understanding of are able to take eye health appropriate actions 5.2.1 - To increase the Number of 10% 30% Facility reports number of eye health patients treated referrals that receive who have been treatment in eye referred health facilities by 20% 5.3.1 - Children with Number of 11% 11% School screening eye conditions are children identified reports identified through a with eye health school vision conditions screening programme through school screening programmes Equity of Access to Eye Health Services 6.1.1 - People in rural Number of eye 0.5 1 Facility reports

40 areas access basic eye health facilities health services in per/100,000 Monitoring visit reports district hospitals population 6.1.2 - Gender Percentage 7% 0% RAAB reports disparities in eye difference in health conditions are Cataract Surgical reflected in those Coverage between accessing services men and women 6.1.3 - Data on access Number of eye 0 5 National HMIS to services for people health HMIS with disabilities, older indicators that are people and disaggregated by marginalised groups disability is available

6.1.4 - To increase Percentage 20% 80% Facility reports greater demand for increase in eye health services outpatient visits in eye health facilities

CSR 732 1,500 Strong and Effective Partnerships 7.1 - To enhance Percentage of eye 30% 35% Ministry of Health partnership between health budget Accounts Department government, private funded by reports institutions and cooperating cooperating partners partners Training reports in eye health sector Number of 0 2 ophthalmologists trained by partners

Number of eye 0 20 health training programmes run by partners Research and Evidence 8.1 - To generate Number of 0 11 Peer reviewed journals evidence based data publications in for eye health specific peer-reviewed Conference to the Zambian journals per year programmes and context reports Number of 3 11 presentations made at annual

conferences of ZOS and COECSA Monitoring and Evaluation 9.1 - To strengthen Number of 0 43 Report from MoH/UTH the monitoring and successful Eye hospital evaluation in the indicators delivery of the NEHSP, 2017-2021

10.0 SWOT ANALYSIS

This section presents an analysis of the Strengths, Weaknesses, Opportunities and Threats (SWOT) of the National Eye Health Strategic Plan

SERVICE DELIVERY

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

Active patient attendance Political will No guarantee of at all hospitals including Inadequate In continued Partner the eye centres in patient,out patient and Partner support support Mongu, Livingstone, theatre space at UTH- Lusaka, Ndola , Kitwe Eye Hospital Government support Change in policy and the OPD in Senanga. direction Available state of the art Poor maintanance of Full government support No guarantee of Ophthamic equipment at equipment. continued Patner all eye centres and some Available Partner support support first level hospitals Replacement parts not readily available Change in policy locally. direction Modern method of cataract surgery not available at UTH-Eye Hospital(phacoemulsif ication) Approved and availbale Inadquate drugs Available government and Inconsistence in document on enssential procured under the Partner support procuring and drugs list for eye health essential drug. distribution of by MoH essential drugs from Poor distribution of the centre and procured drugs institution

HUMAN RESOURCE

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

Availability of training Lack of Availability of Limited space available for institutions and programs subspecialization specialized training foreign students with providing Ophthalmic institutions abroad lengthy entry requirements training

Available Ophthalmic Limited local Availability of training Inadequate funding for personnel to specialize Ophthalmic training programs abroad training programs available Staff ready to undertake training CPD courses are available CME requirements Potential for Uncertainty of funding for are not specific to collaboration with PPP training program cadre’s scope of and CPs to improve practice. training and CPD

INFRASTRUCTURE

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS We have five eye centres Lack of a state of the Declaration of UTH- Lack of building across the country in, art infrastracture to Eye Hospital maintanance Livingstone, Lusaka, befit a 4th level hospital Ndola , Kitwe, Mongu . status at the University Good partner support Two Out Patient Teaching Hospitals- and political will. Departments in Senanga Eye Hospital and Nchelenge Two eye centres are under construction in Kabwe and Chipata Not well designed to Political will to build Newly constructed suit eye health service appropriate sturctures Competing with other district hospitals have delivery standards departments designated OPD space for eye services

HEALTH INFORMATION AND RESEARCH

OPPORTUNITI STRENGTHS WEAKNESSES THREATS ES HMIS available Gives inadequate Availability of Unassured support from information on eye disease government and partners pattern pattern support to strengthen HMIS Quality improvement Poor data utilization by Quality Failure to adopt and adapt to initiatives available in quality improvement teams improvement Zambia hospitals systems have been successful in other settings Information officers Information officers not Institutions Accessibility to training not available trained in eye health already offering assured specifics training in Zambia

HEALTH INFORMATION AND RESEARCH CONTINUED

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

Expertise in research Inadequate expertise for Advocate for policy to ensure Accessibility available research protected research time not assured

Lack of protected time to do research Research institutions insufficient resources Peer review journals available Cost of doing available available to research conductresearch in ophthalmology

HEALTH FINANCING

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS General resource No specific funding Partners willing to support Sustainability not assured allocation criteria allocation towards outreach services and from partners available and there is eye health in all training programmes Change in policy direction government institutions including Available Politcal will commitment to the UTH-Eye increase health sector Hospital funding Well-developed eye health services Global sources of support Weak coordination of sector coordination not prioritized available, e.g. Internatinal external sources of funding structures with health Trachoma Initiative, sector financing Sightsavers, Lions Aid technical working Norway, CBM and group ORBIS Public Private Lack of awareness Private inverstors and Sustainability not assured Partnership (PPP) act among ophthalmic Institutions available from partners available providers

LEADERSHIP AND GOVERNANCE STRENGTHS WEAKNESSES OPPORTUNITIES THREATS Strong and consistent Inadequate Strong political will Changing political landscape leadership of the sector awareness and & Lack of existing NSOAP from MoH prioritization of framework Ophthalmic services

Existence of public Delayed replacement Existence of WHA Failure to take advantage of the health acts and health of the repealed 68.15, DCP3 to help potential of this opportunity policies, National National Health organize the Health Care Package Services Act of 1995 government systems with the Vision 2030 Vision 2020,”The lack of sensitzation Strong government No guaranteed sustainability Right to Sight” at institutinal level partnerships with NGO’s in eye health i.e Sightsavers, Lions Aid Norway, Operation Eye Sight, CBM

11. 0 REFERENCES

1. Lindﬁeld, R; Griﬃths, U; Bozzani, F; Mumba, M; Munsanje, J (2012) A rapid assessment of avoidable blindness in southern Zambia. PLoS One, 7 (6). e38483. ISSN 1932-6203 DOI: 10.1371/journal.pone.0038483 2. Fiammetta Maria Bozzani, Ulla Kou Griffiths, Karl Blanchet and Elena Schmidt,Health systems analysis of eye care services in Zambia: evaluating progress towards VISION 2020 goals, BMC Health Services Research 2014, 14:94 doi:10.1186/1472-6963-14-94 3. National Eye Health Strategic Plan 2012 to 2016 4. Population and Demographic Projections, 2011-2035, United Nations Department of Economic and Social Affairs: Population Division, 2016 5. National Health Strategic Plan 2011 to 2016 6. Universal eye health: a global action plan 2014–2019, WHO 7. Hubley J, Gilbert C, Eye health promotion and the prevention of blindness in developing countries: critical issues, Br J Ophthalmol 2006; 90: 279–284. doi: 10.1136/bjo.2005.078451 8. Integrated Health Services, WHO, 2007 9. Ministry of Health Trachoma Survey report; 2012 10. Ministry of Health Trachoma Survey report; 2016 11. Yau JW, et al., Global prevalence and major risk factors of diabetic retinopathy, Diabetes Care. 2012 12. National Human Resources for Health Strategic Plan 2011 – 2015

12.0 APPENDICES 12.1 APPENDIX 1: Tools for Monitoring and Evaluation

INFORMATION ON EYE CARE UNITS AND SERVICES IN ZAMBIA - № OF SURGERIES

Name of District Province № of days Total № Total № Total № of № of № of № of Other Eye Unit allocated OPD of Cataracts Glaucoma Trichiasis Paediatric Surgeries Surgeries for patients Cataracts with IOL Surgeries Surgeries Surgeries due to Specify Surgery in seen Surgeries (Specify) trauma a week Annually (specify)

DATE FORM FILLED IN: ......

INFORMATION ON EYE CARE UNITS AND SERVICES IN ZAMBIA - № OF PERSONNEL

Name of District Province Ophthalmologists Orthoptist Optometrists OCO ON Optician Cataract Low Specialized Centre or Surgeon Vision Theatre and Hospital Therapist OPD Nurses

DATE FORM FILLED IN: ......

INFORMATION ON EYE CARE UNITS AND SERVICES IN ZAMBIA - № OF EQUIPMENT

Name of District Province Schiotz Direct Indirect Slit lamp Operating Visual Yag Green OCT Centre or Tonometer Ophthalmoscope Ophthalmoscope with microscope Field Laser Laser Hospital Tonometer

DATE FORM FILLED IN: ......

INFORMATION ON EYE CARE UNITS AND SERVICES IN ZAMBIA - CONSUMABLES

Name District Province Cataract PHACO Vitrectomy Visco Antibiotic Steroid Glaucoma Anaesthetic Dilating Others of Kits Kits Kits – Eye Drops Eye Eye Drops Eye Drops + Eye (Specify) Centre elastic Drops Injectables Drops

DATE FORM FILLED IN: ......

INFORMATION ON EYE CARE UNITS AND SERVICES IN ZAMBIA - INFRASTRUCTURE

Name District Province Eye Offices OPD OPD Female Male Paeds Laser Visual OCT Optical Theatre(s) of Unit Adult Paeds Wards Wards Wards Room Field Room Workshop Centre + + + Room and №Bed №Bed №Bed Dispensary Space Space Space

DATE FORM FILLED IN: ......

INFORMATION ON EYE CARE UNITS AND SERVICES IN ZAMBIA – SURGICAL INSTRUMENT SETS

Name of District Province Cataract Lid DCR PHACO Squint Glaucoma Probing Orbitotomy Plastic Vitrectomy Centre Surgery Surgery Set Surgery Surgery Surgery Set and Set Surgery Surgery Set Set Sets Set Syringing Sets Sets Set

DATE FORM FILLED IN: ......

INFORMATION ON EYE CARE UNITS AND SERVICES IN ZAMBIA - TRANSPORT

Name of District Province № of Type of № of № of Non - If non-runner, № of vehicles What type of Centre or Vehicles Vehicles Runner Runner are they required vehicles required Hospital Available Available Vehicles Vehicles repairable

DATE FORM FILLED IN: ......

ANNUAL INFORMATION CAPTURE SHEET ON EYE DISEASES AT PRIMARY, SECONDARY AND TERIARY LEVELS

NAME OF CENTRE: DISTRICT: PROVINCE: EYE CONDITION FIRST QUARTER SECOND QUARTER THIRD QUARTER FOURTH QUARTER ANNUAL TOTALS ADULTS CHILDREN ADULTS CHILDREN ADULTS CHILDREN ADULTS CHILDREN ADULTS CHILDREN REFRACTIVE ERROR № of people screened № of people prescribed spectacles № of people dispensed spectacles

CATARACTS № of people screened № of people operated № of IOLs used

GLAUCOMA № of people screened № of people operated

TRACHOMA № of people screened № of people operated № of people dispensed Zithromax Estimated № communities endemic trachoma № communities implementing SAFE strategy

RETINAL DISEASES № of people screened № of people operated

№ of people treated with Laser

IRREVERSIBLE VISUAL IMPAIRMENT № of people screened № of people clinically diagnosed irreversibly blind or VI № of people received clinical LV assessment № of clients entering education № of blind people registered with the Zambia Federation for the blind (ZFB)

OTHER EYE DISEASES № of people screened № of people treated № of people not treated

DATE FORM FILLED IN: ......

12.2 APPENDIX 2: List of equipment and surgical instruments recommended according to the level of facility

A. Type of Equipment and instruments B. A.1 First Level (District Hospital) 1. Visual acuity charts (Distance and near charts) 5 2. Trial set and trial frame 2 3. Torch with batteries 2 4. Direct Ophthalmoscope 2 5. Retinoscope 2 6. Magnifying operating loupes 2 7. Schiotz Tonometer 2 8. Slit lamp with applanation tonometer 1 9. 90D lens 1 10. Ishihara colour vision test plates 2 11. SICS (Cataract) surgery sets 8 12. Eyelid Surgery sets 10 13. Operating microscope 1

A.2 Secondary level (General Hospitals) I. Outpatient Department (OPD) Slit lamp with applanation tonometer 4 Refraction set with trial frames (2 paediatric and 2 adult) 4 Non-Contact Tonometer 4 Visual Acuity Charts (Projector – Drum) 2 Near Vision Chart 8 Sheridan Gardner Children reading charts 4 Distance Snellen’s Visual Acuity Chart 6 Torch with extra batteries 8 Direct Ophthalmoscope (2 rechargeable, 2 battery) 4 Binocular Indirect Ophthalmoscope with teaching mirror 3 Retinoscope (2 rechargeable, 2 battery) 5 Examination lenses: 90D 2 78D 2 20D 2 2.2 panretinal 2 Gonio lens 2 3 mirror lens 2 Lenses for laser Laser high resolution Centralis lens 1 Laser high resolution wide field lens 1 Laser capsulotomy lens 1 Laser iridectomy lens 1 a. Laser suture lysis lens 1 58

9. Magnifying operating loupes 2 10. Ishihara colour vision test plates 4 11. Prism Bar (single x 2and 2racks 1horizontal, 1vertical) 3 12. Yag Laser 1 13. Green Laser 1 14. Ultra Sound Scan A & B 1 15. Fundus Camera 1 16. Autorefractometer with Keratometor 1 17. Manual lensometer 1 18. Visual Field Analyser (Humphrey) 1 19. Stereopsis Test 1 20. Amsler grid charts 2 21. Spare bulbs for all equipment a. operating microscopes 10 b. direct ophthalmoscopes 10 c. retinoscopes 10 d. slit lamps 10 22. UPS 10 23. Biometer (IOL Master) 1 24. CORNEA PRODUCTS: a. Cornea cross-linking machine 1 b. Ocular Cornea Topographer 1 c. Specular Microscope 1 d. Placcido disc

II. Theatre Equipment and Instruments 1. Operating microscope (1 stationary, 2 portable) 3 2. Anterior vitrector 1 3. Bipolar cautery 2 4. Ophthalmic operating tables 2 5. SICS (Cataract) sets 15 6. Squint sets 4 7. Evisceration and enucleation sets plus periostium elevator 4 8. Eyelid surgery sets 4 9. DCR sets 2 10. GLAUCOMA PRODUCTS a. Tabeculectomy set 5 b. Trabeculotomy set 4 c. Goniotomy set 4 d. Kelly punch 5 10. Surgical stools 12. CORNEAL SET  DMEK SET  DSAEK SET

 DALK SET  PRK SET  Fixation ring and trephine 5  Artificial eyes 200  PMMA eye conformers 100 2. Orbital implants 200 11. Instrument trolleys 4 12. Mayo stands and trays 6 13. Drip stands 4 14. Operating light 4 15. Autoclave portable 1 16. Ultrasound cleaner for instruments 2 17. Surge protectors for equipment 10 18. Theatre cabinets 5 19. Orbital implants 50 20. Phacoemulsification machine(AMO Sovereign Compact) 1

II. Paediatric OPD 1. Lea Chart, Sheridan G Chart 4 2. Preferential Looking Chart 2 3. Handheld Slit lamp 1 4. Handheld Rebound Tonometer (i-Care) 1 5. Handheld Refractometer 1 6. Prisms Rods or Single 3 7. Toys several 8. The R.A.F. near point rule 1 9. Catford Drum 1 10. Major Amblyoscope 1 12. Placido Disc 1 13. Examination lenses a. 28D 2 b. 30D 2 14. Trial frames 5 15. Synoptophore 1

III. Optical Shop 1. Basic requirements for setting up a Vision Centre ITEM QTY REMARKS

MAIN ITEMS Glazing machine - TakuboEcom 1 Ecom 6v Former Edger "Basic Edger" 6v (with standard wear parts and Takubo fitted with Glass cutting wheels service tools) not plastic Wheel dressing stones coarse 2 Coarse for roughing wheel (100) Wheel dressing stones medium 2 Fine/medium for bevelling wheel (400) Former cutter PM8 1 PM8 Pattern Maker Takubo. Stock of formers (£11.00 per 20 Takubo Formers 2000 100) Marking up focimeter Topcon 1 LM8 Lensmeter LM8 Spare ink cartridges for LM8 1 Spare ink cartridges for LM8 Centring device 1 LS-3 Layout Marker Takubo Chuck rubber - large 4 Chuck rubber - small 6 Lens suction cups 4 Adhesive lens block - large 6 Adhesive lens block - small 20 Stick on pads (Surefix) 1xlarge 4 1 x large full eye and 3 x small/half eye 3xsmall - suitable for Takubo adhesive blocks (as above) Hand edger 1 Takubo NH-32WV 100dia by 12 wide rough 20 wide finish V wheel radius of 2 on edge Auto Lens Groover 1 Frame heater 1 NorvilleAutoflow standard File 1 x rough, 1 x smooth 2 Flat file with handle 1 xmedium, 1 x smooth Bumper box, screws, pads, tips 1 box of assorted screws (srew set P70) ref BBXS Plano safety glasses 2 Basic eye protection Pliers: Holding Nylon Ref PP161 1 Side Cutters 1 Pull up pliers 1 old style claw type Screwdrivers 2 SM6 Spare blades for SM6 1 spare blades for SM6 Reamer set 1

Permanent ink marker pens 10 (medium) UniPosca Markers (white) 12 Job Trays Ref WE/181 30 Snap'n'Tap screws (assorted 1 sizes) Pd rule 4 Plastic RR Large Lab cloths 4 Tint tank/hot plate (4 to 6 pot) 1 UV test Unit 1 Heat transfer Fluid (for BPI 6 pot 1 tank) UV Lens Holder (white) ref 1 WE/230 Adjustable Lens Holder ref 3 WE/229 Digital Thermometer 1

1. Optical consumables ITEM REMARKS Takubo Formers 2000 Spare ink cartridges for LM8 Chuck rubber - large Chuck rubber - small Lens suction cups Adhesive lens block - large Adhesive lens block - small Stick on pads (Surefix) 1 x large full eye and 3 x small/half eye - suitable 1xlarge 3xsmall for Takubo adhesive blocks (as above) Assorted screws For spectacle repairs Nose pads For spectacle repairs Permanent ink marker pens For marking up lenses (medium) UniPosca Markers (white) For marking up lenses Range of tints For tinting lenses One minute UV block To provide UV protection Neutraliser To bleach lenses Plus Lenses Plano to +8.00 in quarter dioptres with cylinders up to -3.00 in quarter dioptres Minus Lenses -0.25 to -8.00 in quarter dioptres with cylinders up to -3.00 in quarter dioptres Frames Plastic and metal for men, women and children/babies Ready-made spectacles Reading glasses in a range from +1.00 to +4.00 in half dioptres (spheres only)

Minus glasses in a range from -1.00 to -4.00 in half dioptres (spheres only)

III. Low Vision Services 1. Assessment kits for low vision 15 2. Low vision house 1 3. Blackboard 1 4. Low vision aids e.g. a. magnifiers 100 b. binoculars 100 5. Monitor 1 6. Streak retinoscope 1 7. Direct ophalmoscope 1 8. Halberg clip 1 9. Long handle ocluder with pinholes 1 10. Pen torch 1 11. Measuring tape 1

A.3 Tertiary Level Hospitals

I. General Outpatient Department (OPD) 1. Slit lamp and applanation tonometer 6 2. Digital slit lamp 1 3. Refraction sets with trial frames 6 4. Prism Bars (single and rack horizontal / vertical) 4 5. Visual Acuity Charts (Projector/Drum) 6 6. Near Vision charts 10 7. Ishihara colour vision test plates 6 8. Torches with extra batteries 6 9. Direct Ophthalmoscope 6 10. Binocular indirect ophthalmoscope 6 11. Examination Lenses a. 90D 6 b. 78D 6 c. 60D 6 d. 20D 6 e. 2.2D 6 f. Gonio lens 6 g. 3 mirror lens 6 3. Lenses for laser a. Laser high resolution Centralis lens 2 b. Laser high resolution wide field lens 2 c. Laser capsulotomy lens 2 d. Laser iridectomy lens 2 e. Laser suture lysis lens 2

12. Ultra Sound Scan A & B Scan 1 13. CORNEA PRODUCTS: e. Cornea cross-linking machine 1 f. Ocular Cornea Topographer 1 g. Specular Microscope 1 h. Placcido disc 14. Autorefractometer with Keratometer 2 15. Phoropter 16. Retinoscope 6 17. Fundus Camera with Fluorescein Angiogram (FA) 1 18. Fundus camera 1 19. Slit lamp camera 1 20. Yag Laser 1 21. Green/Diode Laser 2 22. Optical Coherence Tomogram (OCT) 1 23. HumphreyVisual Field Analyser 1 24. Stereopsis Test 6 25. Amsler grid charts 6 26. Maddox wing 1 27. Maddox Rod 1 28. Spare bulbs for all equipment a. operating microscopes 10 b. direct ophthalmoscopes 10 c. retinoscopes 10 d. slit lamps 10 29. UPS 20 30. Biometer (IOL Master) 1

II. Paediatric OPD 1. Lea Chart, Sheridan G Chart 4 2. Preferential Looking Chart 2 3. Handheld Slit lamp 1 4. Handheld Tonometer 1 5. Handheld Refractometer 1 6. Prisms Rods or Single 3 7. Toys several 8. The R.A.F. near point rule 1 9. Catford Drum 1 10. Major Amblyoscope 1 11. Hess Screen 1 12. Placido Disc 1 13. Examination lenses a. 28D 2 b. 30D 2 14. Trial frames 5

15. Synoptophore 1 III. Low Vision Services 1. Assessment kits for low vision 15 2. Low vision house 1 3. Blackboard 1 4. Low vision aids e.g. a. magnifiers 100 b. binoculars 100 5. Monitor 1 6. Streak retinoscope 1 7. Direct ophalmoscope 1 8. Halberg clip 1 9. Long handle ocluder with pinholes 1 10. Pen torch 1 11. Measuring tape 1

IV. Theatre Equipment and instruments 1. XY Operating Microscope with teaching pieces 4 a. Camera 4 b. LCD monitor 4 2. Portable Operating Microscope 2 3. Vitrectomy (Posterior andAnterior Vitrectomy) 2

4. Phacoemulsification machine (AMO Sovereign Compact) 1 5. Cryo unit 2 6. SICS (Cataract) sets 30 7. Cataract phaco set 8. LASIK set 9. ECCE set 10. Squint sets 4 11. Evisceration and Enucleation sets plus periostium elevator 4 12. Minor surgery sets 6 13. DCR sets 14. Lid Set 15. GLAUCOMA PRODUCTS a. Tabeculectomy set 5 b. Trabeculotomy set 4 c. Goniotomy set 4 d. Kelly punch 5 16. Retinal set 17. DMEK SET 18. DSAEK SET 19. DALK SET 20. PRK SET 21. CORNEAL SET

22. Fixation ring and trephine 5 23. Artificial eyes 200 24. PMMA eye conformers 100 25. Orbita implants 200 26. Operating light 4 27. Ophthalmic Operating table 4 28. Drip stands 6 29. Autoclave portable 4 30. Electrocautery - Bipolar diathermy 5 - Unipolar 2 31. Ultrasonic cleaner 8 19. Retcam 1 20. Aneasthetic machine units 2 21. STERILIZING EQUIPMENT a. Autoclave1 b. Portable autoclave 1 c. Sterilizing drums 20 d. Instrument sterilizing boxes/Trays 50 e. Distilled Water unit for sterilizers 1 f. Spirit Lamp with Wick 3 h. Instrument Soaking Tray 210 x 130mm 5 i. Chittle Forceps (big forceps to handle sterilize materials) 6

V. Theatre Furniture 1. Instrument cabinet 4 2. Surgical stools 10 3. Step Ladders 4 4. Instrument Trolleys 16 5. Mayo Stands and Trays 10

12.3 APPENDIX 3: List and amounts of essential eye medicines according to level of facility

B.1 First Level (District Hospital)

I. Antibiotics eye drops and ointments 1. Tetracycline 1% ointment 400/year 2. Chloramphenicol drops 0.5% 400/year 3. Chloramphenicol ointment 400/year 4. Ciprofloxacin drops 300/year 5. Gentamycin drops 300/year 6. Tobramycin drops 500/year

II. Steroid and antibiotic combinations; 1. Dexamethasone + Neomycin eye drops 300/year 2. Dexamethasone +Neomycin Occ 300/year 3. Dexa/chloramphicol eye drops 500/year 4. Tobra/Dexa eye drops 500/year

III. Anti-allergy drops and ointment 1. Sodium Chromoglycate 6000/year 2. Naphazolidine 1000/year 3. Olopatadine 500/year

IV. Mydriatics 1. Cyclopentolate 1% 100/year 2. Tropicamide 1% 100/year 3. Tropicamide + Phenylephrine 100/year

V. Glaucoma 1. Timolol 0.5% 1000/year 2. Latanoprost 500/year

V. Miscellaneous 1. Eye shields 100/year 2. Acetazolamide 250mg tabs 1000/year 3. Amethocaine eye drops 200/year 4. Flurorescein strips 100 x 30 boxes/year 5. Acyclovir eye ointment 200/year 6. Povidone iodine 5 -10% 500mls x 50/year 7. Natamycin5% eye drop 100/year 8. Methylated spirit 2.5litres x 24/year 9. Ethanol 95 – 99% 2.5litres x 24/year 10. Distilled water 2.5litres x52/year 11. Hand sanitizers 200ml x 1500/year 12. Alcohol wipes 52 x 5boxes/year 13. Surgical gloves 50x5boxes/year 14. Examination gloves 100x5boxes

B.2 Secondary level and Tertiary Level Hospitals b. Secondary and Tertiary level Hospitals I. Antibiotics eye drops and ointments 1. Tetracycline 1 % ointment 500/year 2. Chloramphenical drops 0.5% 2,000/year 3. Chloramphenical ointment 900/year 4. Ciprofloxacin drops(Ofloxacin) 1,500/year 5. Gentamycin drops (Tobramycin) 1,500/year

II. Steroids eye drops and ointments 1. Dexamethasone drops 3,000/year 2. Betamethasone drops 2,500/year 3. Prednisolone drops 2,500/year 4. Hydrocortisone ointment 1,500/year 5. Fluoromethalone eye drops 1,300/year

III. Steroid and antibiotic combinations (Ointments and eyedrops) 1. Dexamethasone + Neomycin 1,500/year 2. Dexamethasone + Chloramphencol 4,500/year

IV. Anti allergy drops and ointment 1. Sodium Chromoglycate eye drops 2,400/year 2. Naphazolidine eye drops 2,300/year 3. Alomide eye drops 2,200/year 4. Olopatadine 2,200/year

V. Mydriatics 1. Cyclopentolate 1% 300/year 2. Phenylephrine + Tropicamide 1000/year 3. Atropine 1% 100/year 4. Tropicamide 100/year

VI. Miotics 1. Miochol intracameral 200/year 2. Pilocarpine eye drops 300/year

VII. Beta- blockers 1. Timolol 0.5% 4,000/year 2. Betaxolol 2,500/year

VIII. Alpha agonist 1. Apraclonidine 20/year 2. Brimonidine 30/year 3.

IX. Prostaglandin analogues 1. Latanoprost (Xalatan) 100/year 2. Travoprost (Travatan) 50/year

X. Carbonic anihydrase inhibitors 1. Topical a. Brizolamide10% 5mls 100/year b. Dorzolamide 50/year

2. Oral c. Acetazolamide (250mg Diamox) 5000/year

3. Combination drops d. Combigan 30/year e. Cosopt 20/year f. Lacoma-T 150/year

XI. Hyperosmotic agents a) Mannitol 50/year b) Glycerol c) 5% Sodium chloride eye drops 50/year

XII. Anti Virals 1. Acyclovir eye ointment 200/year 2. Ganciclovir injection 50/year

XIII. Anti Fungals 1. Econazole 50/year 2. Natamycin 150/year

XIV. Ocular Surface lubricants 1. Artificial tear gel 500/year 3. Artificial tears 1,000/year

Anti-metabolites 4. 5-fluorouracil 1,000/year 5. Mitomycin C 500/year

XV. Anaesthetic Eye Drops 1. Amethocainedrops 600/year 2. Tetracaine drops 500/year 3. Lignocaine drops 400/year 4. Proparacaine 600/year

XVI.TOPICAL NSAIDs 1. Ketorolac 200/year 2. Nepafenac 200/year 3. Diclofenac 200/year

XVII. Stains 1. Fluorescein strips 100 x 150 boxes/year 2. Rose Bengal strips 10 x 3 boxes/year 3. Fluorescein sodium 10%5 mL injection 50/year

4. Schirmer Tear Strips 12 x 100 boxes/year

XVIII. TOPICAL MISCELLANEOUS 1. Cyclosporine eye drop

XVIII. INTRAVENOUS DRUGS 1. ANTIBIOTICS a. Ceftazidime 500 vials/year

b. Ceftriaxone 300vials/year c. Cefotaxime 300vilas/year d. Vancomycin 100vials/year e. Metronidazole 200/year f. Ciprofloxacin 200/year g. Amikacin 50/year h. Gentamycin 500/year

2. ANALGESICS a. Paracetamol 200/year b. Diclofenac IM 1000/year c. Pethidine 200/year d. Morphine 100/year

3. ANTIFUNGALS a. Amphotericin 500/year b. Fluconazole 100/year

4. ANTIVIRALS a. Ganciclovir 50/year b. Acyclovir 100/year

5. ANAESTHETICS a. Lignocaine 5000/year b. Bupivacaine 2000/year c. Propofol d. Thiopental e. Isoflurane/Halothane f. Atropine g. Adrenaline h. Fentanyl i. Morpine j. Suxamethonium k. Pancuronium l. Atracurium m. Vancuronium

6. STEROIDS a. Methylprednisolone 50/year b. Triamcinolone 500/year c. Dexamethasone 4mg/ml 15,000/year

7. ANTIHYPERTENSIVES a. Frusemide 100/year b. Hydralazine 100/year

8. SEDATIVES a. Diazepam 100/year

9. ANTIEMETICS 1. Metochlopromide 50/year 2. Promethazine 50/year

10. IVF a. Balanced Salt Solution 500mls x 10,000/year b. Ringer’s Lactate 500mls x10,000/year c. Normal Saline 0.9% 500mlsx10,000/year

11. HAEMATINICS 1. Ferrous sulphate 1000x5tins/year 2. Folic Acid 1000x5tins/year

12. ANT-VGEF a. Avastin 50bottles/year

13. MISCELLANEUOS a. Hyaluronidase 5000/year b. Chlorpromazine 50/year c. Manitol 20% 20mls bottle x 500/year d. Botulinum injection 10bottles/year

XIX. ORAL DRUGS 1. ANTIBIOTICS a. Ciprofloxacin 10,000 tablets/year b. Amoxyl 20,000 tablets/year c. Amoxyllin + Clavunic Acid 5,000 tablets/year d. Azithromycin 1000 tablets/year e. Metronidazole 10,000/tablets/year f. Doxycycline 20,000 capsules/year g. Cephalexin 1000 bottles/year

2. ANTIVIRALS

a. Acyclovir 5000 tabs/year 3. ANTIFUNGALS a. Fluconazole 500 capsules/year 4. ANALGESICS a. Paracetamol 20,000 tabs/year b. Ibuprofen 5000tabs/year c. Diclofenac 5000tabs/year 5. STEROIDS a. Predinisolone 5mg tabs 10,000/year 6. ANTIGLAUCOMA a. Acetazolomide 250mg tabs 10,000tabs/year 7. ANTIHYPERTENSIVES a. Frusemide 1000tabs/year b. Nifedipine 1000 tabs/year 8. MISCELLANEOUS a. Chlopheniramine 50 tabs/year b. Cetrizine 1000 tabs/year

XX. EMERGENCY DRUGS 1. Vitamin K 2. Hydrocortisone Injectable 3. Adrenaline Ampoule 4. 50% dextrose 5. Sodium bicarbonate 6. Atropine Sulphate injectable 7. Potassium chloride 8. Frusimide 9. Aminophylline

C. List of Medical and Surgical Consumables C.1 First Level (District Hospital) 1. Cataract kits 100/year 2. Viscoelastic 350/year 3. Sutures i. 10.0 nylon 25 boxes/year ii. 9.0 nylon 25 boxes/year iv. 7.0 vicryl 10 boxes/year v. 5.0vicryl 100 boxes/year vii. 4.0 silk 50 boxes/year

V. Miscellaneous 1. Eye shields 100/year 2. Acetazolamide 250mg tabs 1000/year 3. Amethocaine eye drops 200/year 4. Flurorescein strips 100 x 30 boxes/year

5. Acyclovir eye ointment 200/year 6. Povidone iodine 5 -10% 500mls x 50/year 7. Natamycin 5% eye drop 100/year 8. Methylated spirit 2.5litres x 5/year 9. Ethanol 95 – 99% 2.5litres x 5/year 10. Distilled water 2.5litres x5/year 11. Hand sanitizers 200ml x 500/year 12. Alcohol wipes 52 x 5boxes/year 13. Surgical gloves 50x100boxes/year 14. Examination gloves 100x100boxes

C.2 Secondary level (General Hospitals) 1. Cataract kits 500/year 2. Viscoelastic 1,500/year 3. Sutures i. 10.0 nylon 100 boxes/year ii10.0Prolene 25 boxes/year ii. 9.0 nylon 100 boxes/year iii. 8.0 vicryl 50 boxes/year iv. 7.0 vicryl 50 boxes/year v. 6.0 vicryl 50 boxes/year v. 5.0vicryl 50 boxes/year vi. 5.0 prolene 50 boxes/year vii. 4.0 silk 50 boxes/year 4. Phaco kits with cassettes 255/year 5. Anterior vitrectomy kits 100/year 6. Posterior vitrectomy kits 245/year 7. Cataract Phaco set 8. CORNEAL AND REFRACTIVE SURGERY a. Bandage contact Lens b. Cyanoacrylic glue c. Intraocular lenses (IOL) 8. VITREO-RETINALPRODUCTS a. Gases b. Silicon oil c. Vision blue d. Perfluorocarbon liquids e. Scleral buckles

9. GLAUCOMA PRODUCTS a. Glaucoma Drainage Devices b. German Swabs

10. OCULOMPLASTIC PRODUCTS a. Silicon frontalis sling V. Miscellaneous 1. Eye shields 100/year 2. Acetazolamide 250mg tabs 1000/year 3. Amethocaine eye drops 200/year 4. Flurorescein strips 100 x 30 boxes/year 5. Acyclovir eye ointment 200/year 6. Povidone iodine 5 -10% 500mls x 50/year 7. Natamycin 5% eye drop 100/year 8. Methylated spirit 2.5litres x 24/year 9. Ethanol 95 – 99% 2.5litres x 24/year 10. Distilled water 2.5litres x52/year 11. Hand sanitizers 200ml x 1500/year 12. Alcohol wipes 52 x 5boxes/year

C.3 Tertiary Level Hospitals 1. Cataract kits 700/year 2. Viscoelastic 2000/year 3. Sutures i. 10.0 nylon 100 boxes/year ii 10.0 Prolene 25 boxes/year ii. 9.0 nylon 100 boxes/year iii. 8.0 vicryl 50 boxes/year iv. 7.0 vicryl 50 boxes/year v. 6.0 vicryl 50 boxes/year v. 5.0vicryl 50 boxes/year vi. 5.0 prolene 50 boxes/year vii. 4.0 silk 50 boxes/year

4. Phaco kits with cassettes 255/year 5. Anterior vitrectomy kits 100/year 6. Posterior vitrectomy kits 245/year 7. Cataract Phaco set

8. VITREO-RETINALPRODUCTS f. Gases g. Silicon oil h. Vision blue i. Perfluorocarbon liquids j. Scleral buckles

10. CORNEAL AND REFRACTIVE SURGERY a. Bandage contact Lens b. Cyanoacrylic glue

c. Intraocular lenses (IOL)

11. GLAUCOMA PRODUCTS a. Glaucoma Drainage Devices b. German Swabs 12. OCULOPLASTIC PRODUCTS a. Silicon frontalis sling V. Miscellaneous 1. Eye shields 100/year 2. Acetazolamide 250mg tabs 1000/year 3. Amethocaine eye drops 200/year 4. Flurorescein strips 100 x 30 boxes/year 5. Acyclovir eye ointment 200/year 6. Povidone iodine 5 -10% 500mls x 50/year 7. Natamycin 5% eye drop 100/year 8. Methylated spirit 2.5litres x 24/year 9. Ethanol 95 – 99% 2.5litres x 24/year 10. Distilled water 2.5litres x52/year 11. Hand sanitizers 200ml x 1500/year 12. Alcohol wipes 52 x 5boxes/year

12.4 APPENDIX 4: Terms of Reference of the NPBC

1. Recommend eye care policy to the Ministry of Health so as to be in line with overall Government priorities and programmes in the National Health Strategic Plan 2. Develop the National Eye Health Strategic Plan (NEHSP) for every five year period to run concurrently with the NHSP 3. Coordinate and supervise all eye care activities being carried out by Governmental and Non-Governmental Organisations in Zambia 4. Advocate and lobby for support for Eye Health programmes, within and outside Zambia 5. In liaison with the Research and Ethics Committee, sanction research work on eye health so as to be in line with government policy on research 6. Supervise and monitor all eye health facilities and optical centres in Zambia to ensure that maximum standards are maintained 7. Approve training curricula and provide technical guidance on training in various eye health training programmes and supervise all eye care training conducted in Zambia 8. Appoint subcommittees in eye care as need may arise 9. Advise MoH on implementation, information management, monitoring and evaluation of the eye health activities 10. Formulate policy for publicity and sensitization of the NPBC and its work 11. Maintain a database on all eye health services in Zambia such as Human Resources, Infrastructure, Equipment, Optometry, Cooperating Partners, Visual Impairment and Blindness 12. Devise the tools for monitoring and evaluation of eye care services 13. Monitor and evaluate the performance of eye care services in both public and private facilities 14. Conduct ophthalmic CMEs through MoH and ZOS 15. Make recommendations to MoH on how coordination can proceed in delivering eye care services 16. To work with Road Traffic and Safety Agency (RTSA) to regulate the issuance of driving licences. 17. Maintain Register for the blind and the visually impaired

Composition of the NPBC

 The Technical Committee of the NPBC shall be comprised of the following members:  Ministry of Health Director Clinical Care and Diagnostic Services as Chairperson  Senior Medical Superintendent of the UTH-Eye Hospital as Secretary  A representative from a teaching college (e.g. Chainama College)  An ophthalmologist from each tertiary institution  An ophthalmologist from each province  Three (3) ophthalmologists from private eye health institutions

The Expanded Committee of the NPBC shall be comprised of the following members:

 All of the above  Representatives from other government departments

 Representatives from all the eye health Cooperating Partners (CPs)

NPBC CALENDAR AND ACTIVITIES In this NEHSP 2017 to 2021, the following ophthalmic annual events shall be observed as part of CME and interaction of the eye health structure with the international ophthalmic community. NPBC should work in collaboration with National Health Research Authority (NHRA) to fund research.

The following annual ophthalmic calendar has been adopted – not sure if the word adopted is appropriate. It’s better to say recommended.

February World Ophthalmology Congress (WOC) March Ophthalmological Society of Southern Africa (OSSA) April WHO GET 2020 May International Agency for the Prevention of Blindness (IAPB) August College of Ophthalmology of Eastern, Central, and Southern Africa (COECSA) October Zambia Ophthalmological Society (ZOS), World Sight Day

The NPBC meeting shall be held on the first week of the last month of the quarter.

12.5 APPENDIX 5: Dispute Settlement

For CPs signing a MoU or agreement with MoH the following dispute settlement shall apply if need be.

Any misunderstanding or disagreement arising out of the MoU or agreement shall be settled in the first instance through mutual consultations and negotiations. In event the parties are unable to resolve the misunderstanding or disagreement the dispute shall be referred to an agreed arbitration process before a single arbitrator in Zambia (with the government and the CP agreement on such appointment) for final determination under provisions of the Arbitration Act of Zambia No.19 of 2000 or any statutory modification thereof.

12.6 APPENDIX 6: Detailed Budget for the NEHSP 2017 to 2021