BMJ Open · 5 authors, 6 centres
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This mixed-methods study found that child eye health (CEH) is insufficiently addressed in Ethiopian health policy documents, with limited funding, workforce shortages, and a poor referral system. Key informants highlighted a lack of dedicated ownership and coordination across ministries, leading to over-reliance on donor support. The findings underscore the need for stronger policy integration, dedicated budgets, and improved health information systems to advance CEH in Ethiopia.
**Background:** Child eye health is a critical public health issue in Ethiopia, where children under 15 constitute over half the population. Childhood blindness contributes significantly to the global economic burden of blindness, with up to 60% of blind children in low- and middle-income countries dying within a year of becoming blind. Ethiopia has a high burden of blindness (prevalence 1.6%) and childhood blindness (0.1%, accounting for over 6% of total blindness). Despite signing international commitments like VISION 2020 and developing national child health policies, it was unclear how comprehensively child eye health (CEH) is addressed in government policies.
**Methods:** This mixed-methods situational analysis comprised documentary analysis and key informant interviews. Government publications (from the Ministries of Health and Education) touching on any element of CEH and published after 2000 were included. Key informants were leaders, authorities, researchers, or clinicians involved in child health, selected purposively. Data were analyzed using narrative synthesis, guided by an adaptation of the WHO Eye Care Situation Analysis Tool (ECSAT), covering six domains: leadership/governance, workforce/infrastructure, service delivery-access, service delivery-quality, health financing, and health information systems.
**Key Results:** Eleven documents were included (10 from MOH, 1 from MOE). Only one document (National Strategic Action Plan for Eye Health) covered all six ECSAT domains; 7 of 11 (63%) covered only one domain. The most common domains were Health Information Systems and Service Delivery-Access (each in 5/11, 45%). Fourteen key informants participated (13 male, 1 female; 6 from academia, 4 from government, 4 from civil society). Key findings across domains: - **Leadership/governance:** Only 3/11 (27%) documents had CEH indicators. The National Health Policy made no mention of eye health. Coordination between MOH departments was poor; the eye care system is largely dependent on NGOs. - **Workforce/infrastructure:** Only 3/11 (27%) documents outlined workforce plans. The National Human Resource for Health Strategic Plan targets increasing paediatric ophthalmologists from 20 (2020) to 33 (2025), ophthalmic nurses from 820 to 1457 at primary hospitals, and optometrists from 68 to 117 at general hospitals. However, inequitable distribution persists, with 62.4% of ophthalmologists working in the capital. - **Service delivery-access:** 5/11 (45%) documents discussed access. Five public tertiary eye care units (TECUs) exist, but primary eye care is neglected; CEH is not included in the Health Extension Programme. No regular nationwide school health programme exists. - **Service delivery-quality:** Only 3/11 (27%) documents discussed quality. The referral system remains poor despite policy focus. No national guidelines or standard operating procedures for CEH were found. - **Health financing:** 4/11 (36%) documents included financing. The Health Sector Transformation Plan II estimated a budget of USD$21.89–27.55 billion over 5 years, but no proportion for CEH was noted. The National Strategic Action Plan for Eye Health had a total budget of USD$13 million (2016) and USD$21 million (2020), with only USD$48,000–87,000 for school vision screening. Only 13.2% of the total government budget was allocated to health (2013), with unclear CEH allocation. - **Health information systems:** 5/11 (45%) documents discussed HIS. The Health Management Information System includes 169 indicators, only 3 related to eye care (cataract, trachomatous trichiasis, glaucoma), none specific to CEH. The Demographic Health Information System 2 includes 12 eye health indicators disaggregated by age, but lacks data on outcomes and quality.
**Clinical Implications:** The study reveals critical gaps in policy and practice for CEH in Ethiopia. Without dedicated leadership, funding, workforce planning, and integration into existing child health services, CEH remains underprioritized. The lack of comprehensive data hampers evidence-based planning. Strengthening ownership, improving coordination between MOH and MOE, mandating dedicated budgets, integrating CEH into primary care (including training health extension workers), and incorporating CEH indicators into health information systems are essential steps. These findings are relevant for other low- and middle-income countries facing similar challenges in child eye health.