RW Final Research Report

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Increasing utilization of sight restoration services offered at Sabona Eye Centre from service providers perspectives: a case for shared governance

Rodah Wangondu, PharmD Candidate, Northeastern University

Fall 2014

Increasing utilization of SEC from service providers perspectives

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Table of Contents ACKNOWLEDGEMENTS ...................................................................................................................................... 3

ABSTRACT ...................................................................................................................................................... 4

INTRODUCTION……………………………………………………………………………………………………………………………………….5

METHODOLOGY ............................................................................................................................................ 6

RESULTS ........................................................................................................................................................ 7

GOVERNANCE ........................................................................................................................................... 7

HUMAN RESOURCES ................................................................................................................................. 7

FINANCING ................................................................................................................................................ 8

PHARMACEUTICALS/CONSUMABLES ........................................................................................................ 9

SERVICE DELIVERY ..................................................................................................................................... 9

MONITORING SYSTEMS ............................................................................................................................ 9

RELATIONSHIPS ....................................................................................................................................... 10

Sabona Eye Centre .............................................................................................................................. 10

Clients .................................................................................................................................................. 10

DISCUSSION & REFLECTION ........................................................................................................................ 10

REFERENCES ................................................................................................................................................ 14


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ACKNOWLEDGEMENTS

With regard to my time in South Africa, I am grateful to Elmer Freeman, Director of the Center for

Community, Health, Education, and Research (CCHERS) for facilitating my experience in such a

beautiful country. I also owe much thanks to Dr.Hlalele of the Sabona Sonke Foundation and Dr.

Kaseje of Great Lakes University of Kisumu for theirguidance and mentorship in the development of

the research study. The willingness of the service providers to create time for the interviews was also

critical to the success of this study.


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ABSTRACT

Background:With the year 2020 steadfastly approaching, the WHO global initiative of eliminating

avoidable blindnessneeds to be fully supported by the start of the new decade. Considering that Sabona

Eye Centre (SEC) was built in 2009 to support this initiative by catering for high volume cataract

operations in the Eastern Cape of South Africa, the sub-optimal utilization of the institution is alarming

and needs to be effectively addressed.

Objectives: This study sought to understand how the utilization of SEC can be increased by determining

the health system issues that affect the three aforementioned districts and by examining the

relationship of the PHC centres with SEC and with the communities in their catchment areas.

Methods:Semi-structured interviews were conducted with fifteen service providers (8 ophthalmic

nurses, 2 operational managers, and 5 NCD managers) representing the three districts.

Results:The main challenges that were identified such as deployment, training, and patient mobilization

concerned thehealth system issues of human resources, financing and service delivery. The

management of transport for service delivery and the maintenance of pharmaceutical supplies were

more complex issues that surfaced during the course of the study.

Conclusions:With regard to possible solutions to these issues, shared governance was proposed as a

model that would enable ophthalmic nurses to make decisions on their own behalf in order to improve

the delivery of eye health services in their respective institutions. Effective monitoring was also

recommended in order to better understand the more complex issues such that evidence-based

interventions can be proposed.


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INTRODUCTION

Preventable blindness has been identified as a global public health issue in terms of the economic and

social impact of blindness in communities In South Africa’s Eastern Cape Province, a rapid assessment of

avoidable blindness (RAAB) was conducted to determine the rates of blindness and to evaluate the main

causes of blindness in the area. From the RAAB data, it was determined that “untreated age-related

cataracts” accounted for 62.2% of bilateral blindness in the province (Shamanna, 2012).

In 2009, the Eastern Cape Department of Health partnered with the Fred Hollows Foundation (now

known as the Sabona Sonke Foundation) to open the Sabona Eye Centre (SEC) at Frontier Hospital in

Queenstown. The SEC was established such that it could be effective in reducing the burden of blindness

in the province with special focus on cataracts. The SEC is centrally located in the Eastern Cape Province

in the Lukhanji sub district where there is the greatest cataract surgical load in the Chris Haani district

and receives referrals from surrounding districts. Based on South Africa’s health structure which relies

heavily on a tiered referral system starting at the sub-district level, Sabona Eye Centre which is attached

to a regional facilityis expected to receive thousands of patients referred from PHCs , CHCs, and district

hospitals in Chris Haani and surrounding districts. However, it has been noted that the facility has not

been meeting the proposed targets in terms of the number of services utilized by the communities it

seeks to serve.

In 2009,PrashasaHealth Consultants reported that the SEC can perform 3,600 cataract operations per

year considering that its two theatres and thirty beds; however, the centre has been functioning at a

30% utilization rate with approximately 1,100 operations conducted per year (Saravanan, S. 2009). This

sub-optimal utilization is alarming as it was also identified in 2009 that the Chris Haani district should be

accounting for at least 7,000 cataract surgeries per year if the VISION 2020 goal of eradicating avoidable

blindness is to be met.

A recent previousstudy was conducted by Dr. Hlalele, the Director of the Sabona Sonke Foundation, to

determine the community’s awareness of the services available at SEC and the patients’ barriers to

utilizing those services. From this study, it was determined that the eight communities evaluated were

aware of SEC and 62% of the sample population desired that primary eye care (PEC) be more available at

local facilities (i.e. clinics) in order to increase their access to service (2013). Therefore, an intervention

was proposed to enhance service delivery and utilization by expanding the referral system to target

patients at the household level through eye screening by community health workers (CHWs) who would

serve as cataract case finders. However, despite the implementation of this intervention through eye

care training of primary health care workers and structured outreach, the utilization of Sabona Eye

Centre has not significantly increased as expected.

In order to bridge the gap of understanding the reasons for sub-optimal utilization at SEC, perspectives

of service providers at primary health care level should also be considered.

As such, this study will assess the perspectives of primary level service providers who refer patients from

their institutions to Sabona Eye Centre for specialized eye care in order to determine the challenges of

the health system in their districts. Chris Haani district and the neighbouring districts that refer to SEC,


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namely Amathole and Joe Gqabi district, will be surveyed in the study. Such an evaluation will,

therefore, help to identify how the provision of sight restoration services can be increased with focus on

the primary health care level.

Study Aims:

1. Determine the health system issues that are affecting the districts referring patients to Sabona Eye

Centre.

2. Investigate the relationship of the primary health care institutions with both Sabona Eye Centre and

the communities these facilities seek to serve.

METHODOLOGY

Qualitative cross-sectional assessment was utilized in the study as interviews were conducted with

targeted participants. The targeted participants were ophthalmic nurses and non-communicable disease

(NCD) managers in the respective districts that are referring patients for eye restoration services to

Sabona Eye Centre as these service providers are representative of the primary health care level.

The study employed criterion based purposive sampling accounting for the participants’ geographic

location, institution, and job designation. As previously discussed, the study focused on service providers

in the Chris Haani, Amathole, and Joe Gqabi districts. Therefore, convenience sampling was also utilized

as the specific institutions selected were based on the accessibility of their location. Among the 3

districts, 10 ophthalmic nurses (with 2 deployed as operational managers) and 5 NCD

managers/supervisors were identified for participation in the study. Authorization to conduct the

interviews was obtained from the service providers and their respective district offices that served as

the institutional review board..The service providers participated in the study voluntarily and were able

to withdraw if they no longer wished to continue. Informed consent was regulated by discussing the

objectives, possible complications, and benefits of the research study before obtaining consent.

Information collected that could be used to identify the participants was maintained in a manner that

guaranteed confidentiality.

An open-ended questionnaire with self-administered questions to collect relevant personal information

and structured questions for facilitating the interview was utilized. The structured questions designed to

evaluate the health system of the participants’ institution covered the following topics:

governance/stewardship, human resources, financing, pharmaceuticals and consumables, service

delivery/disease control, health and management information systems, and the institutions’ relationship

with Sabona Eye Centre and with clients. During the interviews, the researcher recorded the subjects’

answers on the questionnaire form so that summary documents could be produced for analysis.

Thematic analysis was utilized to review the summary documents such that data was segmented and

categorized based on the topics discussed in the interviews. Such an analysis was useful in identifying

the internal and external barriers that service providers encounter within the health system. Cross


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48%

28%

24%

Human Resource Issues that are affecting service providers

Inadequate Training

Inadequate Staffing

Lack of Knowledge

tabulation was also conducted utilizing SPSS in order to evaluate the service providers’ responses based

on their designation as ophthalmic nurse, operational manager or NCD manager.

RESULTS

GOVERNANCE

In Joe Gqabi district, all the

service providers (4/4) spoke

positively about governance and

displayed an understanding of

the nature of meetings held.

However, their responses on the

frequency of meetings held by

the governing board were

inconsistent. In Amathole district,

the responses varied as three

service providers stated that they

were negatively affected by the

decisions made by the governing

body while the other three

indicated that they were

positively affected by those

decisions. It is interesting to note

that the ophthalmic nurses who

served as operational manages and the NCD managers were more critical of the governance structures

than the other service providers.

HUMAN RESOURCES

There was a unanimous response

(15/15) that the service providers are

negatively affected by the level of

human resources available for eye

health. The majority of responses

(10/15) indicated that further training is

needed for CHWs, ONs, and especially

PEC trained nurses. Despite their current

training, PEC trained nurses were

identified by service providers (both

ophthalmic nurses and managers) as


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lacking or incompetent in basic skills such as visual acuity testing. The possible implication of their level

of incompetence is best captured by an ophthalmic nurse serving as an operational manager who stated

that she is not feeling “the presence or support of the PEC trained nurses”.

Staffing also presented itself as an issue as (6/15) responses identified inadequate levels of human

resources in their institutions.

With regard to staffing, (10/15) service providers identified deployment as the main factor affecting

their institution’s capacity to provide quality eye health services. Due to deployment such as when ONs

are promoted to managerial positions or even switched to night duty where eye health services are not

conducted, service providers stated that the ophthalmic nurses are not able to fully focus on eyes.

FINANCING

Responses on financing differed based on

designation as all the NCD managers (5/5)

indicated that they were involved in the

mechanisms of financing institutions in their

districts.On the other hand, the majority of

ophthalmic nurses (8/10) indicated that they

were not involved in financing mechanisms

and claimed to be negatively affected by this

lack of involvement. Both NCD managers

and ophthalmic nurses cited bureaucratic

issues as a source of frustration in the

financing of institutions. Four NCD managers

revealed their dissatisfaction with the

allocation of budgets by provincial managers.

Similarly, ONs stated that they must rely on

NCD managers to request funds for

44%

17%

26%

9%

4%

Factors affecting institutions' capacity to provide quality eye health services

Deployment

Lack of Recognition

Infrastructure

Retention

Referral


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institution needs but the “eye program is undermined”. One ophthalmic nurse deployed to the post of

operational manager went even as far as stating that “it is de-motivating to not get the things that I

need”.

PHARMACEUTICALS/CONSUMABLES

The majority of service providers (13/15) stated that pharmaceutical supplies were both unavailable and

inadequate in their facilities. Stock outs were greatly experienced in their institutions and claims were

made that depot shortages were the cause of the stock outs. Five service providers also mentioned that

the Essential Drug List provided by the government limits procurement of drugs that are considered out

of scope for the clinic level.

SERVICE DELIVERY

Eight service providers identified patient mobilization as a limitation of their institution that affects their

capacity for disease control. Service providers linked their limitations on patient mobilization to lack of

transport for ophthalmic nurses to conduct outreach for community based screening. Three NCD

managers also mentioned that the lack of transport is affecting the patients’ ability to fulfill their

booking dates for cataract extraction operations.

MONITORING SYSTEMS

A slight majority of eight service providers regarded the service delivery monitoring systems in place at

their facilities as needing improvement. A common theme of their critiques was that the District Health

Information System (DHIS) data collection tool is not loaded with data elements for eye care at the

Primary Health Care (PHC) level. As such, service providers have to improvise in capturing data on eye

health services. One operational manager shared that she uses a notebook to serve as a “tick register”.

In theSenqu sub-district of Joe Gqabi district, service providers also identified a weakness in the

monitoring system with regard to the lack of feedback provided after submitting data to management.

53%33%

14%

Factors affecting institution's capacity for disease control

Screening

Mobilization

Referral


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RELATIONSHIPS

Sabona Eye Centre

With regard to the relationship between their facilities and SEC, testimonies praised SEC’s provision of

refractions and cataract eye operations but the majority of service providers (9/15) indicated that

improvement is needed. Five of these nine service providers cited that communication is ineffective as

dates for booking and feedback about the cataract operations should be provided more often.

Clients

Nine service providers believed that the mechanisms in place for linking communities in their catchment

areas to eye health services are effective. Awareness talks were cited as a common method of

promoting eye screening in communities. From the six service providers that perceived that

improvements are needed, four mentioned that transport should be available for ONs to conduct

outreach so that eye health services can be more accessible to communities in their catchment area.

DISCUSSION & REFLECTION

In seeking to understand the health system issues that are affecting the districts referring patients to

Sabona Eye Centre, the results of the study indicate that human resources, financing mechanisms,

pharmaceuticals, service delivery, and monitoring systems need to be addressed. Surprisingly, the

majority of service providers interviewed did not directly relate these health system issues to the

governance of their respective institutions.

With regard to the question on governance, the reliability of the responses from the ophthalmic nurses

is questionable as only one nurse spoke negatively when asked about the effectiveness of the governing

structure. This unreliability was observed when discussions concerning other issues such as human

resources, financing, and monitoring indicated that these service providers were dissatisfied with the

management of their respective facilities. For example, ONs in Joe Gqabi district claimed that their work

was positively affected by the decisions made by the governing body which they perceived to address

hospital issues such as the improvement of eye care services. However, in following questions the same

ONs stated that staffing is inadequate and that issues such as deployment affected their institution’s

capacity to provide quality eye health services. Considering that the governance question was the first

to be answered in the questionnaire, it is possible that the ONs were reluctant to share their honest

views due to initial cautiousness. The construct of the question might also have been the problem as the

ONs seemed to be confused by the term governance and further probing was required to obtain a

response. The NCD and operational managers, who better understood the concept of governance and

did not require much probing on the question, displayed more knowledge and exhibited more criticism

of the governance structure. This suggests that the managerial designation of the NCD and operational

managers enables them to have a greater understanding of governance than the ONs.

The implication of the ONs’ lack of involvement in management was identified during discussions about

the financing mechanisms of their institutions. During the majority of these discussions, the ONs shared

their frustration with the financing of eye services and lamented about their lack of involvement as it

undermined the eye program. This sentiment was best captured by an ON who ranted that she “should


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be involved as the eye clinic has specific needs” andthe other who stated that it was “de-motivating to

not get the things that I need”. As such, these rants make a case for the management strategy known as

“shared governance”. According to Doherty and Hope (2000), “shared governance is a method of

devolving organizational structures to ensure that clinically based nurses are involved in decisions that

affect their clinical practice”. Therefore, through a model of shared governance ONs can be empowered

to help address issues that are related to their provision of eye care services.

In 1995, Relf proposed a shared governance model that utilizes “a unit-based committee structure”

which allows nurses to “influence patient care and govern themselves”. In a unit-based committee

structure, nurses voluntarily organize themselves in committees depending on their interests and

strengths such as education, quality improvement, clinical practice, peer review, and scheduling. In the

current governance structures, either hospital boards or clinic committees composed of members of the

community have little if any representation of nurses. However, this study makes a case for their

representation as nurses displayed great understanding of the problems affecting the provision of eye

care services and proposed possible solutions when interviewed about different factors concerning the

health system.

With regard to human resources, the service providers and especially the ONs were vocal about the

need for further training, especially for primary eye care (PEC) trained nurses. They criticized the limited

competency of primary eye care trained nurses particularly in conducting visual acuity testing and

recommended that PEC training should be more practical in order to improve screening. These criticisms

and propositions are valid and are actually supported by an evaluation conducted by PrashasaHealth

Consultants in 2012. During the evaluation, the Prashasaconsultant found that “PEC training was a good

capacity building exercise” but “lacked, in most cases, hands on experience or demonstration aspects”.

Therefore, the consultant recommended that an audit on the facilities and the skills of eye care service

providers should be conducted to identify the gaps. Drawing from the concept of shared governance, it

can be argued that ONs are in a position to help address such issues; for example, if they formed a peer

review committee that monitored the clinical skills of eye health service providers. Furthermore,

another committee could be formed to regulate staffing and scheduling in order to prevent

mismanagement such as the cases of ONs being deployed to night duty where they are not able to

provide eye care. Consequently, the work satisfaction of the ONs would increase as Relf states that “the

end result [of shared governance] is a highly motivated staff dedicated to the institution” and therefore,

enhanced service delivery (1995).

Based on the study results, the challenges with patient mobilization and screening must also be resolved

if service delivery is to improve. However, the service providers indicated that these challenges are due

to lack of transport which is a management issue outside of their control. This is due to the fact that the

provision of transport for service delivery depends on a local management team within the local service

area (LSA) as demarcated by the provincial government (Hall et al, 2006). According to the study

conducted by Hall et al of the Health Systems Trust, “all LSA management teams say that service

delivery takes precedence, but in reality administrative trips are honored first” (2006). This has serious

implications for patients’ utilization of eye health services as “it is upon being transported by means of

government vehicles that they imply they are fine to travel to Sabona Eye Centre where the miracle of


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sight restoration awaits them” (Hlalele, 2013). Therefore, it is recommended that a monitoring tool for

transport be developed and included in the District Health Information System in order to effectively

evaluate the provision of transport for delivery of health services.

During the study, a case was also made for the improvement of monitoring systems with regard to the

delivery of eye health services. Data collection is currently a challenge considering that the District

Health Information System (DHIS) is not loaded with elements of eye care at the primary health care

level and ONs have to improvise with simple tools like notebooks. This exclusion of eye care elements is

a serious limitation as the Standard Operating Procedures approved by the National Department of

Health state that data collected using the DHIS is to be analyzed and statistically validated by the District

Health Information officer (2013). After data review, the DHI officer is to provide feedback to the

program manager at the sub-district office who then communicates with the facility managers (2013).

Therefore, monitoring of eye health services could be more systematic if eye care elements were

included in the DHIS.

There should also be monitoring of stock outs with regard to pharmaceuticals and consumables as the

source of the problem was not clearly identified. Although some service providers indicated that the

provincial depots were at fault, no mechanism of monitoring stock outs is in place to evaluate these

statements. If stock-outs across the province were monitored effectively, it would be possible to

determine if the depots are the source of the stock-outs or if poor practices in ordering and stock-

maintenance at the facility level are to blame. With regard to the complaints that the Essential

Medicines List limits the procurement of drugs considered out of scope for the clinic, it was noted that

the EML “guidelines are based on the assumption that prescribers are competent to handle patients’

health conditions presented at their facilities” (NDOH, 2008). Furthermore, the EML states that “where

the professional expertise at certain PHC centres exceeds that of an average clinic” service providers can

“tailor the availability of medicines at these centres by using their initiative and creative insight” (NDOH,

2008). Considering that ONs have specialized skills that are not available in an average clinic, it can be

interpreted that their facilities can still manage to procure drugs regarded as “out of scope”.

In their efforts to work around this system and care for patients, some service providers mentioned that

they requested Sabona Eye Centre to provide patients with medications that were unavailable in their

institutions. With such support in mind, these service providers generally regarded their relationship

with SEC as good. However, the majority also insisted that the relationship between their facilities and

SEC could be improved especially with regard to communication. Suggestions were made that

communication of booking dates for cataract eye operations could be conducted more effectively such

as through a yearly calendar that SEC would provide to the clinics. With a yearly calendar, perhaps the

issue of waiting time could also be addressed as ONs could be able to plan more effectively. According

to a study conducted by Dr.Hlalele of the Sabona Sonke Foundation, 54% of patients needing an

operation had waited for at least a year before seeking assistance whereas the maximum waiting time

should be 3 months considering a patient’s development of coping mechanisms (2013). Therefore,

mechanisms of linking communities to eye health services also need to be strengthened.


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Based on interview responses, the majority of service providers perceived awareness talks and health

education conducted by community health workers (CHWs) as effective in promoting the utilization of

eye health services. This mechanism draws upon the referral system proposed from Dr. Hlalele’s study in

which community eye health is taken to the household level utilizing community level workers as health

promoters. However, there is more integration of care in the proposed referral system as the CHWs are

to conduct basic eye screening and refer patients to the PEC trained nurses in clinics or health centres

for secondary level screening (Hlalele, 2013). In order for this system to be effective, the competency of

the PEC trained nurses must be improved with the consideration and involvement of ONs.

CONCLUSION

The study provided great insight into the challenges that service providers face with regard to the

delivery of eye health services in their institutions. Key issues that were identified are the training of

PEC nurses, deployment, patient mobilization, data collection, and financing. The provision of

government transport for service delivery and pharmaceutical stock-outs are more complex issues that

surfaced and therefore, efficient monitoring is recommended in order to better understand them. In

discussing the key issues, the concept of shared governance was highlighted as a method of

empowering ophthalmic nurses to address these problems which they best understand. Therefore, a

study that investigates this concept in the stewardship of primary health care centres would be useful

for future research.


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REFERENCES

1. Doherty c. & Hope w. (2000). Shared governance—nurses making a difference. Journal of

Nursing Management,8, 77–81

2. Hlalele, M. (2013). Increasingthe uptake of sight restoration services offered at Sabona Eye

Centre. University of Pretoria. (not published)

3. National Department of Health. (2013). Standard Operating Procedures: Sub-District Level. District Health Management Information System (DHMIS).

4. National Department of Health. (2008). Standard Treatment Guidelines and Essential Medicines

List. Essential Drug Programme South Africa.

5. PRASHASA Health Consultants. (2012). External Evaluation of Primary Eye care Training for

Primary health care workers in Eastern Cape Province of South Africa. (not published)

6. Relf, M. (1995), Increasing job satisfaction and motivation while reducing nursing turnover

through the implementation of shared governance, CriticalCare Nursing Quarterly 18, 3, 7-13.

7. Saravanan, S. (2009). Workshop Report: Establishing Effective Eye Care Service Delivery at

Sabona Eye Centre, Queenstown in the Eastern Cape Province, South Africa. PRASHASA Health

Consultants. (not published)

8. Shamanna, BR. (2009). Survey Report: Rapid Assessment for Avoidable Blindness, Eastern Cape

Province, South Africa. PRASHSA Health Consultants. (not published)

9. World Health Organisation. World Health Report 2000. Geneva: World Health Organisation; 2000.


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RW Final Research Report