School eye health services in Sri Lanka: An innovative way of approaching eye health in children
The country has achieved remarkable progress in health sector domains of the millennium development goals compared to the peers in the South Asian region.
Sri Lanka, historically known as the “Pearl of the Indian Ocean,” is home to a population of 20.27 million in the year 2012 and comprised of 25 districts and nine provinces. Sri Lanka is a lower middle income country which has transitioned from an agriculture based economy towards a more urbanised economy of industry and service delivery. The country has achieved remarkable progress in health sector domains of the millennium development goals compared to its peers in the South Asian region. Further it has a unique free education and health system in the public sector, established for decades. The high literacy rate [overall 92.6% (Male 93.6% and Female 91.7%)] reflects universal access to free education system in the country. Sri Lanka provides free education, starting from primary school up to the level of post graduate higher education under public sector institutions.
School Medical Inspection (SMI)
School children’s well-being is a cornerstone of development of a country. There are 4.14 million school children in 10,162 schools in Sri Lanka. The Government of Sri Lanka spends 2.2% of GDP on education,1 management of human resources and development of infrastructure, centrally and, school uniforms through local governments. In addition there is a successful sponsorship programme for pupils who come from the families below poverty line. The “School Medical Inspection” (SMI) programme began in Sri Lanka in the year 19182 with the objective of identifying infectious diseases among children.3 This has been recorded as one of the earliest such programmes, initiated globally. The SMI is a collaboration between the Ministry of Education (MOE) and Ministry of Health (MOH) through the Family Health Bureau. As part of this programme, every child entering the government school system is examined periodically for health conditions, including visual problems.
Structure of the SMI programme
The main cadres involved in SMIs are medical officers of health (identified as MOH – a medically qualified and a registered practitioner from the public sector), public health inspectors (PHI) and public health midwives (PHM) in the local government. Based on the size of population, geographical regions have been divided among medical officers of health who work under a regional director of health services (MOH). The MOHs are responsible for conducting SMIs in their assigned areas. In the school based programme, children are examined in grade 1, 4, 7 and 10 by the SMI team. In the conventional programme, visual acuity is checked by a trained Public Health Inspector (PHI). Children who have been identified as having any visual impairment are referred to the nearest hospital with an eye clinic. At the eye clinic, children undergo refraction and prescriptions are given for spectacles. Parents have the choice of buying spectacles of their choice from private stores. It has been observed that the cost of a pair of glasses was unaffordable for most parents, especially those below the poverty line. Often at the end of the SMI process many children ended up not having appropriate vision correction with spectacles. Many limitations were observed in achieving satisfactory screening and spectacle usage under the conventional approach.
Innovative SMI approach under the Vision 2020 programme
Having observed this scenario, the Vision 2020 Programme of the Ministry of Health – Sri Lanka initiated an action plan to to correct refractive errors in children. In this programme spectacles are issued free of charge to school children with significant refractive errors. The Vision 2020 initiative has adopted strategies locally to supply good quality spectacles, in bulk, to such children in a cost effective manner, at no cost to their parents. The results have been encouraging. The school eye health initiative is a collaboration between the Ministries of Health and Education and this programme has been successfully replicated using varied sources of non-governmental funds.
Steps followed in the innovative approach were as follows:
- Initial planning including identification of logistics involved, budgeting, and scheduling.
- Signing agreements with local stakeholders, meeting regional stakeholders to schedule the project and discuss probable issues and challenges.
- School teachers’ training: Pre-screening was taught to teachers with practical illustrations in order to make them familiar with identifying children with visual impairment. A batch of approximately 50 school teachers was selected. Each teacher has the capacity to screen up to 500-1,000 children. Trained teachers were assigned to transfer skills gained to the rest of the teachers at their institution. The number of teachers to be trained was decided based on the need and if it was inadequate, higher secondary level school prefects were trained.
- A single optotype E card was introduced to the system in order to make the pre-screening procedure easy and simple. Only a few seconds of time was spent per child for vision screening. This optotype was piloted and validated to prove its accuracy. Teachers were requested to reproduce copies of the card in similar size and quality and share with others. A Vision 2020 toll free telephone number was opened to tackle the queries they have about screening. Teachers were screening children with great success and they were listing children who had impaired vision as they were instructed. In the practical setup, it took less than half a minute to screen a child in contrast to two to three minutes with Snellen chart. Schools with lesser number of children could be screened rapidly and the schools with larger populations could be screened within two weeks.
- Lists of children who were unable to pass through the vision test were referred to regional health authorities. Later, further examination and refraction were organised in close proximity to the MOH office or school. Mass refraction programmes were organised with participation of several optometrists and prescriptions were issued to children who had significant refractive errors (myopia or myopic astigmatism > -0.50 D sphere or cylinder or hyperopia > +0.75).
- Children were given the choice of type, design and colour of the spectacle frame. Each child was given the best suited spectacle, which was custom made according to the prescription.
- Eye glasses were given free of cost to those in need, with funds available from the Vision 2020 Programme of the Ministry of Health. These funds were sourced from different donor organisations. Vision 2020 programme coordinators monitored the production of good quality spectacles at a low cost. The cost of a complete pair of spectacles was around 600 LKR (4 USD), which consisted of a custom-made CR 39 lens, metal frame in the desired colour, a plastic box and a cleaning cloth.
- Selection of suppliers for eye glasses took place annually according to tender procedures and regulations about instrument procurement under the Ministry of Health. A technical evaluation committee, comprised of eye health professionals, decided the minimum specifications of spectacles. Terms and conditions were made and an agreement was signed in order to supply spectacles as per specifications and provision of after sales services with a warranty for defects.
- Once manufactured, spectacles were received at the head office of Vision 2020 in the capital city, a random sample was checked with an automatic lens metre prior to dispatch. The spectacles were securely sent to different regions across the country via local courier services.
- At the district level spectacles were handed over to students through the local health and education officials with an instruction sheet to the parents on usage and care of glasses.
- Trained teachers in each school were assigned to follow up on children who received spectacles. This included periodic checks to see whether they were using them in the correct way and to report back to the health officials with details of follow up.
- Follow up programmes were organised in each area to replace broken and misplaced glasses and to provide new spectacles to those who needed a change in prescription.
By adapting a conventional programme in the health system and using new innovations to control avoidable blindness, the school eye health programme is a success story in Sri Lanka. This programme illustrates the possibility of achieving complete screening coverage of a targeted population using cost effective interventions. Sri Lanka could screen the entire student population and provide eye care free of charge, by integrating an eye care programme into the existing system through public-private partnerships and a multi- disciplinary approach. Several case studies from the country showed improvements in the quality of life of spectacle recipients, with many regaining better sight. Lessons learned from Sri Lanka could be useful to other neighbouring countries and the rest of the world to develop strategies to control childhood blindness.
Highlights of Sri Lanka School Eye Screening Programme
- Totally free of cost for school children
- Pre-screened by trained teachers
- Funded by non-governmental organisations
- Total student population covered
- Government mediated, credibility ensured
1 The World Bank.Government expenses on education https://data.worldbank.org/indicator/SE.XPD.TOTL.GD.ZS (accessed June 24, 2017).
2 Family Health Bureau,Sri Lanka.A short history of school health programme http://medicine.kln.ac.lk/depts/publichealth/Fixed_Learning/PHI%20manual/PHI%20New%20Documents%20Including%20full%20PHI%20Manual%20$%20Office%20Documents/PHI%20Manual%20Full/11%20Chapter%209%20-%20SCHOOL%20HEALTH%20PROGRAMME%20-(285-294).pdf (accessed June 24, 2017).
3 Family Health Bureau, Ministry of Health, Sri Lanka. School Health Promotion Programme, Mid Term Plan 2008-2012. (accessed June 24, 2017).
"Sri Lanka: ""Njia ya ubunifu ya kukabiliana na afya ya macho kwa watoto"" Nchi hiyo imepata maendeleo makubwa katika sekta ya afya ya malengo ya maendeleo ya milenia ikilinganishwa na wenzao katika mkoa wa Asia Kusini." Sri Lanka, ambayo kwa kihistoria inajulikana kama 'Pearl of the Indian Ocean', ina idadi ya watu milioni 20.27 na inajumuisha wilaya 25 na mikoa tisa. Sri Lanka ni nchi ya chini ya mapato ya kati ambayo imebadilika kutoka uchumi wa kilimo kuelekea uchumi wa mijini zaidi wa viwanda na utoaji wa huduma. Nchi hiyo imepata maendeleo makubwa katika sekta ya afya katika malengo ya maendeleo ya milenia ikilinganishwa na wenzao katika eneo la Asia Kusini. Zaidi ya hayo ina elimu ya kipekee ya bure na mfumo wa afya katika sekta ya umma, imeanzishwa kwa miongo kadhaa. Kiwango cha juu cha kusoma na kuandika (kwa jumla 92.6% (Wanaume 93.6% na Wanawake 91.7%)) huonyesha upatikanaji wa jumla wa mfumo wa elimu ya bure nchini. Sri Lanka hutoa elimu ya bure, kuanzia shule ya msingi hadi kiwango cha elimu ya juu ya kuhitimu chini ya taasisi za sekta ya umma. Utafiti wa Matibabu ya Shule (SMI) Ustawi wa watoto wa shule ni jiwe la msingi la maendeleo ya nchi. Kuna watoto milioni 4.14 katika shule 10,162 nchini Sri Lanka. Serikali ya Sri Lanka hutumia asilimia 2.2 ya Pato la Taifa kwa elimu, usimamizi wa rasilimali za binadamu na maendeleo ya miundombinu, kwa njia ya serikali kuu na serikali za mitaa. Kwa kuongezea kuna mpango wa udhamini uliofanikiwa kwa wanafunzi ambao wanatoka kwa familia zilizo chini ya kiwango cha umaskini. Programu ya uchunguzi wa matibabu ya shule ilianzishwa nchini Sri Lanka mwaka 1918 na lengo lake lilikuwa kugundua magonjwa ya kuambukiza miongoni mwa watoto. Mfumo huu ni ushirikiano kati ya Wizara ya Elimu na Wizara ya Afya kupitia Ofisi ya Afya ya Familia. Kama sehemu ya mpango huu, kila mtoto anayeingia katika mfumo wa shule ya serikali huchunguzwa mara kwa mara kwa hali za afya, ikiwa ni pamoja na matatizo ya kuona. Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo wa Mfumo. Kwa kuzingatia idadi ya watu, mikoa ya kijiografia imegawanywa kati ya maafisa wa afya ambao hufanya kazi chini ya mkurugenzi wa mkoa wa huduma za afya (MOH). Wizara ya Afya ina jukumu la kuendesha SMEs katika maeneo yao ya kupewa. Katika programu ya shule, watoto huchunguzwa katika darasa la 1, 4, 7 na 10 na timu ya SMI. Katika programu ya kawaida, uwazi wa kuona ni checked na mafunzo ya Afya ya Umma Inspector (PHI). Watoto ambao wamegunduliwa kuwa na kasoro yoyote ya kuona huelekezwa kwenye hospitali ya karibu zaidi yenye kliniki ya macho. Katika kliniki ya macho, watoto hupitia refraction na dawa hutolewa kwa ajili ya miwani. Wazazi wanaweza kuchagua kununua miwani ya kuchagua kutoka maduka ya kibinafsi. Kwa mfano, gharama ya miwani ya macho ilikuwa kubwa sana kwa wazazi wengi, hasa wale waliokuwa chini ya kiwango cha umaskini. Mara nyingi mwishoni mwa mchakato wa SMI watoto wengi walimaliza bila kuwa na marekebisho sahihi ya maono na miwani. Mapungufu mengi yalionekana katika kufikia uchunguzi wa kuridhisha na matumizi ya miwani chini ya mbinu ya kawaida. "Kutokana na hali hii, ""Vision 2020"" ya Wizara ya Afya ya Sri Lanka ilianzisha mpango wa hatua ya kurekebisha makosa ya refractive kwa watoto." Katika mpango huu miwani hutolewa bila malipo kwa watoto wa shule wenye makosa makubwa ya refractive. "Mtazamo wa 2020 umepitisha mikakati ya ndani ya nchi ya kutoa miwani ya ubora wa hali ya juu kwa watoto hao kwa njia ya gharama nafuu, bila gharama kwa wazazi wao.""" Matokeo yamekuwa yenye kutia moyo. Mpango wa afya ya macho ya shule ni ushirikiano kati ya Wizara ya Afya na Elimu na programu hii imefanikiwa kuiga kwa kutumia vyanzo mbalimbali vya fedha zisizo za serikali. Hatua zilizofuatwa katika mbinu ya ubunifu zilikuwa kama ifuatavyo: - Mipango ya awali ikiwa ni pamoja na utambulisho wa vifaa vinavyohusika, bajeti, na ratiba. - Kutia saini makubaliano na wadau wa ndani, kukutana na wadau wa kikanda kupanga mradi na kujadili masuala na changamoto zinazowezekana. - Mafunzo ya walimu wa shule: Uchunguzi wa awali ulifundishwa kwa walimu na vielelezo vya vitendo ili kuwafanya wajue kutambua watoto wenye ulemavu wa kuona. Kikundi cha walimu wa shule 50 hivi kilichaguliwa. Kila mwalimu ana uwezo wa kuwahudumia watoto 500 hadi 1000. Walimu waliozoezwa walipewa mgawo wa kuhamisha ujuzi waliopata kwa walimu wengine katika taasisi yao. Idadi ya walimu waliopaswa kufundishwa iliamuliwa kulingana na uhitaji na ikiwa haikuwa ya kutosha, wasimamizi wa shule za sekondari za juu walifundishwa. - kadi moja optotype E ilianzishwa kwa mfumo ili kufanya utaratibu wa kabla ya uchunguzi rahisi na rahisi. Ni sekunde chache tu za wakati zilizotumiwa kwa kila mtoto kwa ajili ya uchunguzi wa macho. Optotype hii ilijaribiwa na kuthibitishwa ili kuthibitisha usahihi wake. Walimu waliombwa wachapishe nakala za kadi hiyo kwa ukubwa na ubora kama huo na kuigawanya na wengine. Nambari ya simu ya bure ya Vision 2020 imefunguliwa ili kushughulikia maswali yao kuhusu uchunguzi. Walimu walifanya uchunguzi wa watoto kwa mafanikio makubwa na walikuwa wakiorodhesha watoto waliokuwa na matatizo ya kuona kama walivyoagizwa. Katika hali ya kawaida, ilichukua chini ya nusu dakika kuchunguza mtoto, kinyume na dakika mbili hadi tatu na chati ya Snellen. Shule zenye idadi ndogo ya watoto zinaweza kuchunguzwa haraka na shule zenye idadi kubwa ya watu zinaweza kuchunguzwa ndani ya wiki mbili. - Orodha za watoto ambao hawakuweza kupita kupitia mtihani wa kuona zilipelekwa kwa mamlaka za afya za kikanda. Baadaye, uchunguzi zaidi na refraction ziliandaliwa karibu na ofisi ya MOH au shule. Katika kipindi cha miaka ya tisa, madaktari wa macho walifanya uchunguzi wa jumla wa refractive astigmatism (myoopia au astigmatism ya myopia) na kugundua kwamba watoto walikuwa na matatizo makubwa ya refractive (myoopia au astigmatism ya myopia) na walikuwa na uwezo wa kuona mbali zaidi. - Watoto walipewa uchaguzi wa aina, kubuni na rangi ya sura ya miwani. Kila mtoto alipewa kioo kilichofaa zaidi, ambacho kilitengenezwa kulingana na maagizo. - Miwani ya macho ilitolewa bila malipo kwa wale wanaohitaji, na fedha zilizopatikana kutoka kwa Programu ya Maono ya 2020 ya Wizara ya Afya. Fedha hizo zilitoka kwa mashirika mbalimbali ya wafadhili. Mratibu wa Vision 2020 ametoa ushauri wa kuandaa miwani ya hali ya juu kwa gharama nafuu. Kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo cha kioo. - Uchaguzi wa wauzaji wa miwani ya macho ulifanyika kila mwaka kulingana na taratibu za zabuni na kanuni kuhusu ununuzi wa vyombo chini ya Wizara ya Afya. Halmashauri ya kiufundi ya tathmini, iliyofanyizwa na wataalamu wa afya ya macho, iliamua vipimo vya chini vya miwani. Masharti na masharti yalifanywa na makubaliano yaliandikwa ili kutoa miwani kulingana na vipimo na utoaji wa huduma za baada ya mauzo na dhamana ya kasoro. Baada ya kutengenezwa, miwani ilipokelewa katika ofisi kuu ya Vision 2020 katika mji mkuu, sampuli ya nasibu ilichunguzwa na mita ya lensi ya moja kwa moja kabla ya kutumwa. Miwani hiyo ilitumwa kwa usalama katika maeneo mbalimbali kotekote nchini kupitia huduma za kupeleka barua za mahali hapo. Katika wilaya za mitaa, miwani ilitolewa kwa wanafunzi kupitia maafisa wa afya na elimu ya mitaa na karatasi ya maagizo kwa wazazi juu ya matumizi na utunzaji wa miwani. - Walimu waliozoezwa katika kila shule walipewa mgawo wa kufuatilia watoto waliopokea miwani. Hii ilijumuisha ukaguzi wa mara kwa mara ili kuona ikiwa walikuwa wakitumia kwa njia sahihi na kuripoti nyuma kwa maafisa wa afya na maelezo ya ufuatiliaji. - Programu za ufuatiliaji ziliandaliwa katika kila eneo ili kubadilisha miwani iliyovunjika na iliyopotea na kutoa miwani mpya kwa wale ambao walihitaji mabadiliko ya dawa. Kwa kubadilisha programu ya kawaida katika mfumo wa afya na kutumia uvumbuzi mpya kudhibiti upofu unaoweza kuepukwa, programu ya afya ya macho ya shule ni hadithi ya mafanikio nchini Sri Lanka. Programu hii inaonyesha uwezekano wa kufikia chanjo kamili ya uchunguzi wa idadi ya watu waliolengwa kwa kutumia hatua za gharama nafuu. Sri Lanka inaweza kuchunguza idadi nzima ya wanafunzi na kutoa huduma ya macho bila malipo, kwa kuunganisha mpango wa huduma ya macho katika mfumo uliopo kupitia ushirikiano wa umma na binafsi na mbinu ya taaluma nyingi. Uchunguzi kadhaa wa kesi kutoka nchi hiyo ulionyesha maboresho katika ubora wa maisha ya wapokeaji wa miwani, na wengi wakipata tena maono bora. Mafunzo yaliyopatikana kutoka Sri Lanka yanaweza kuwa na manufaa kwa nchi nyingine jirani na sehemu nyingine za ulimwengu kuendeleza mikakati ya kudhibiti upofu wa watoto. Programu ya uchunguzi wa macho ya shule ya Sri Lanka - bure kabisa kwa watoto wa shule - Imechunguzwa mapema na walimu waliozoezwa - Imefadhiliwa na mashirika yasiyo ya kiserikali - Jumla ya idadi ya wanafunzi iliyofunikwa - Serikali ilisuluhishwa, uaminifu ulihakikishwa. "Kama ilivyoelezwa katika makala ya ""Mafunzo ya Usalama wa Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo ya Shule"" ya ""Mafunzo"" ya Shule"" ya ""Mafunzo"" ya Shule"" ya Shule ya Shule." 3 Ofisi ya Afya ya Familia, Wizara ya Afya, Sri Lanka. Programu ya Uendelezaji wa Afya ya Shule, Mpango wa Kipindi cha Kati wa 2008-2012 (Ilichukuliwa Juni 24, 2017).