1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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).

10. 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

11. 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