Diabetic retinopathy service delivery and integration into the health system in Pakistan-Findings from a multicentre qualitative study.

This paper is based on qualitative research carried out in a diabetic retinopathy (DR) programme in three districts of Pakistan. It analyses the organisation and delivery of DR services and the extent to which the interventions resulted in a fully functioning integrated approach to DR care and treatment. Between January and April 2019, we conducted 14 focus group discussions and 37 in-depth interviews with 144 purposively selected participants: patients, lady health workers (LHWs) and health professionals. Findings suggest that integration of services was helpful in the prevention and management of DR. Through the efforts of LHWs and general practitioners, diabetic patients in the community became aware of the eye health issues related to uncontrolled diabetes. However, a number of systemic pressure points in the continuum of care seem to have limited the impact of the integration. Some components of the intervention, such as a patient tracking system and reinforced interdepartmental links, show great promise and need to be sustained. The results of this study point to the need for action to ensure inclusion of DR on the list of local health departments' priority conditions, greater provision of closer-to-community services, such as mobile clinics. Future interventions will need to consider the complexity of adding diabetic retinopathy to an already heavy workload for the LHWs.

Task-shifting eye care to ophthalmic community health officers (OCHO) in Sierra Leone: A qualitative study.

BACKGROUND: Preventing visual impairment due to avoidable causes has been a long-standing global priority. Of all blindness in Sierra Leone, 91.5% is estimated to be avoidable and 58.2% treatable, however there are only 6 ophthalmologists for the whole country. Task-shifting has been suggested as a strategy to address this issue and a training intervention was developed to create a cadre of community-based staff known as Ophthalmic Community Health Officers (OCHOs). This qualitative study aimed to explore the experiences of OCHOs, their relationship with other eye health workers, and how they interact with the wider health system, in order to provide recommendations for the design and delivery of future task shifting strategies. METHODS: Between April and May 2018, we conducted semi-structured interviews with 42 participants including: OCHOs (n = 13), traditional ophthalmic staff (n = 17) and other stakeholders from the districts (n = 6), training institution staff (n = 4) and MOH headquarters (n = 2). We identified participants using purposive sampling. Interviews were audio-recorded, transcribed, and thematically analysed. We draw largely on in-depth interviews but complement the analysis with evidence from a document review. RESULTS: In Sierra Leone, the roll-out of the OCHO programme presented a mixed picture. OCHOs participating in the study expressed a strong commitment to their new role. However, policy changes proposed to clearly demarcate roles and responsibilities and institutionalise the cadre in the civil service were not implemented, resulting in the posting of some staff at an inappropriate level, dissatisfaction with the OCHO certification, and lack of opportunities for advancement and training. These challenges reflect structural weaknesses in the health system that undermine a cohesive implementation of eye health initiatives at the primary health care level in Sierra Leone. CONCLUSIONS: Task-shifting has the potential to improve provision in under-resourced specialities such as eye health. However, the success of this approach will be contingent upon the development of a robust and supportive health policy environment.

Understanding the role of lady health workers in improving access to eye health services in rural Pakistan - findings from a qualitative study.

BACKGROUND: In 1994, the Lady Health Workers (LHWs) Programme was established in Pakistan to increase access to essential primary care services and support health systems at the household and community levels. In Khyber Pakhtunkhwa (KPK) province in northern Pakistan, eye care is among the many unmet needs that LHWs were trained to address, including screening and referral of people with eye conditions to health facilities. However, despite an increase in referrals by LHWs, compliance with referrals in KPK has been very low. We explored the role of LHWs in patient referral and the barriers to patient compliance with referrals. METHODS: Qualitative methodology was adopted. Between April and June 2019, we conducted eight focus group discussions and nine in-depth interviews with 73 participants including patients, LHWs and their supervisors, district managers and other stakeholders. Data were analysed thematically using NVivo software version 12. RESULTS: LHWs have a broad understanding of basic health care and are responsible for a wide range of activities at the community level. LHWs felt that the training in primary eye care had equipped them with the skills to identify and refer eye patients. However, they reported that access to care was hampered when referred patients reached hospitals, where disorganised services and poor quality of care discouraged uptake of referrals. LHWs felt that this had a negative impact on their credibility and on the trust and respect they received from the community, which, coupled with low eye health awareness, influenced patients' decisions about whether to comply with a referral. There was a lack of trust in the health care services provided by public sector hospitals. Poverty, deep-rooted gender inequities and transportation were the other reported main drivers of non-adherence to referrals. CONCLUSIONS: Results from this study have shown that the training of LHWs in eye care was well received. However, training alone is not enough and does not result in improved access for patients to specialist services if other parts of the health system are not strengthened. Pathways for referrals should be agreed and explicitly communicated to both the health care providers and the patients.

Methods for measuring health inequalities (part I)

Source: Originally published with the title gb sMétodos de medición de las desigualdades de salud gc s, in Pan American Journal of Public Health 12(6), 2002

Métodos de medición de las desigualdades de salud / Methods for measuring inequalities in health

Measuring health inequalities is indispensable for progress in improving the health situation in the Region of the Americas, where the analysis of average values is no longer sufficient. Analyzing health inequalities is a fundamental tool for action that seeks greater equity in health. There are various measurement methods, with differing levels of complexity, and choosing one rather than another depends on the objective of the study. The purpose of this article is to familiarize health professionals and decision-making institutions with methodological aspects of the measurement and simple analysis of health inequalities, utilizing basic data that are regularly reported by geopolitical unit. The calculation method and the advantages and disadvantages of the following indicators are presented: the rate ratio and the rate difference, the effect index, the population attributable risk, the index of dissimilarity, the slope index of inequality and the relative index of inequality, the Gini coefficient, and the concentration index. The methods presented are applicable to measuring various types of inequalities and at different levels of analysis.

La medición de las desigualdades en el campo de la salud es una condición indispensable para avanzar en la mejoría de la situación de salud de la Región, donde el análisis de los valores medios ha dejado de ser suficiente. Este tipo de análisis es una herramienta fundamental para la acción en busca de una mayor equidad en salud. Existen diferentes métodos de medición y niveles de complejidad cuya elección depende del objetivo del estudio. Este artículo tiene como objetivo familiarizar a los profesionales de la salud y a las instancias decisorias con los aspectos metodológicos de la medición y el análisis simple de las desigualdades en el campo de la salud, utilizando datos básicos registrados con regularidad y agregados por unidades geopolíticas. Se presenta la forma de calcular los siguientes indicadores y se comentan sus ventajas y desventajas: la razón y la diferencia de tasas, el índice de efecto, el riesgo atribuible poblacional, el índice de disimilitud, el índice de desigualdad de la pendiente y el índice relativo de desigualdad, el coeficiente de Gini y el índice de concentración. Los métodos presentados son aplicables a la medición de las desigualdades de diferentes tipos y a distintos niveles de análisis.