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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