Brien Holden Vision Institute Partnership for Child Development Determining the most effective school eye health program A comparative analysis of a stand-alone versus an integrated school eye health model Implemented by: Brien Holden Vision Institute Partnership for Child Development Ministry of Health, Zanzibar Ministry of Education and Vocational Training, Zanzibar Funded by: USAID CHILD BLINDNESS PROGRAM

VS HR VI School Eye Health Program Integrated model Eye health + Feeding HR VI Vision impairment is high but human resources are scarce! VS Stand-alone model Eye health only Innovative approaches are needed to identify children with eye conditions early and refer them for management – School Eye Health Program Aim: To build the evidence base for an effective school eye health intervention in Zanzibar.

Objectives To compare the effectiveness and efficiency of a school eye health program integrated into the existing school feeding program (integrated model) versus a stand-alone school eye health program (stand-alone model) To compare the number of pupils referred for treatment, uptake of referrals for between the two models To compare the eye health cost per child between the two models To compare spectacle usage and compliance among the students between the two models To determine how the integrated program fits into the existing School Health Program in terms of system integration, training, budget allocation and human resource allocation

Flow of research Training of 6 master trainers Training of ~70 teachers Baseline survey Conduct screening and health promotion in schools Refer the children who need further check up to the vision centre Eye care personnel examine, treat or refer the children Wait for 6 months Follow up on number of children referred and went for treatment Interview with key personnel and children Endline survey Costing analysis

Coverage 11134 children screened 427 children failed screening 5992 integrated (96%) 5142 standalone (90%) 427 children failed screening 297 integrated (69.5%)   130 standalone (30.5%)   Effective and efficient in reaching high number in short time  high school attendance rate good coordination between the implementation partners of the program and schools and teachers

Follow up rate, spectacle usage and spectacle compliance A random selection of 234 children who failed screening included in the endline survey. Response rate- 94.5%, n=222 122 children integrated 77 (63.6%) went for follow up 100 children standalone 46 (46%) went for follow up Spectacle usage was low - 22 children integrated - 4children standalone Barriers for low follow up: Lack of financial means Unware the need for management Low spectacle usage- teasing by friends

Knowledge, attitude and practice of health and health survey 1000 Children at baseline KAP survey 498 children from integrated model 502 children from stand-alone KAP of eye health, nutrition and hygiene- Small changes and not significant between the groups Eye health is a new component needs longer intervention to see significant changes. Nutrition and hygiene- Baseline scores were already high

Total number of children 1.3 1.79 Cost category Stand-alone Integrated Training Of Trainers 786 1,833 Teachers training 1,650 3,341 M&E 1,114 2,599 Printing 504 755 Screening equipment for schools 2,684 2,196 Total Cost 6,738 10,724 Total number of children 5142 5992 Screening cost per child (6 months) 1.3 1.79 Integrated model used almost 1.4X the resources compared to stand-alone model per child. More resources on training (more days) Monitoring (more component and more days) One-off costs equipment have useful lives beyond one year- lowering the future costs. Training need only to be conducted at the beginning of the intervention.

Proportion of cost categories to total project cost Integrated option has greater opportunity of reducing resource training can be shared with other health programs. M&E conducted simultaneously between activities saving costs. Output (number of children screened) is as important for efficiency improvement as the input (resources used).

In-depth interviews with key personnel Foreseen challenges Proposed solutions Include implementers from all levels in the planning from National Ministries to schools, community and health faicility levels Coordination between the vision centres and school teachers so that arrangement/appointments can be made to avoid clogging up the health facilities Over burdening the health facilities due to high volume of patients following screening Mainstreaming school eye health into the Ministry of Health agenda to ensure budget is allocated for integration of eye health Using evidence from this study for advocacy Dialog with the Ministries to develop a roadmap for integrating eye health Identify institution which are able to provide resource or can serve as a resource Challenges in securing resources allocation Longer training time with careful teachers selection and deciding on number of teachers trained with possibility of incentives for teachers Refresher trainings for teachers to ensure high screening sensitivity and specificity Health education to improve service uptake and spectacle usage and compliance Sustaining effectiveness and efficiency

Conclusion Coverage of eye health screening was high in both models Follow up, spectacle usage and compliance was low in both models KAP of eye health, nutrition and hygiene did not differ in both models Even though integrated model used 1.4X the resources compared to standalone model per child, there are great opportunities for cost sharing and saving, and achieve long term sustainability