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Journal of the New Zealand Medical Association, 13-March-2009, Vol 122 No 1291

Mid-level cadre providing eye care in the context of Vision 2020

Rènée du Toit, Garry Brian

Abstract

The contribution of the mid-level cadre of eye care providers is an essential component of the Vision 2020: The Right To Sight initiative, to eliminate avoidable blindness by 2020. However, for the past 20 years the functions of this cadre have not been definitively outlined, or universally accepted. Consequently, the competencies they require to provide high quality comprehensive eye care have not been established. This has had implications for both training programmes and the subsequent deployment of the graduates of these programmes.

This paper examines, mainly through a review of World Health Organization (WHO) documentation, the progress that has been made in defining the role and outlining appropriately enabling training of this cadre of mid-level personnel. As a result of this analysis, recommendations are made concerning the development of this cadre to provide eye care in the context of Vision 2020:

• Develop consistent and widely applicable nomenclature

• Outline workplace functions and job descriptions, so that personnel can be categorised by their competencies and functions.

• Develop curricula based on the competency requirements of job descriptions and that will prepare personnel for those jobs.

• Establish and/or develop training centres, including those capable of training trainers.

• Establish government recognition, resources, support, and evaluation and feedback systems to ensure that this mid-level cadre can implement their training, and have the opportunity of providing high quality eye care.

The concept of deploying eye care personnel educated to an appropriate level to meet the needs of communities has been advocated for more than a quarter of a century.1 The enduring relevance of a primary health care approach as a basis for this was recently confirmed.2 Forming teams of complementary cadres of eye care providers, working in one location or geographically spread, these personnel should provide accessible and timely eye care, either as a carer where training and facilities allow, or as a referrer in a chain of escalating care. This concept has crystallised as one of the key strategies underpinning the Vision 2020: The Right to Sight initiative to eliminate avoidable blindness.3

The eye care team is generally thought of as an integrated working unit consisting of ophthalmologists, a mid-level cadre of eye care personnel, primary eye care providers, and support personnel, such as managers.4–6 While the roles of ophthalmologists, primary eye care providers,5 and support personnel are relatively well defined, exactly who comprises the mid-level cadre, the functions they undertake, the education they require, and the circumstances in which they work remain largely unresolved. The only consensus is about the vital role this cadre has to play in the eye team, and the contribution it can make towards achieving the goal of Vision 2020.

An optimally functioning workforce is essential: attaining the Millennium Development Goals is dependent on skilled, supported and motivated health care personnel.7,8 The 2006 World Health Report’s attempt to add to the limited information about enhancing workforce performance7–10 was criticised for erroneously considering health care personnel as an artificially homogeneous group.11

Eye care, along with other disciplines, needs to contribute specific detailed planning and recommendations for different cadres of workers. These include workforce planning, differences in emphases in education and setting standards to ensure quality, responsive and professional practice. Some of these issues are considered in this paper.

Further, this paper reviews the expectations of and recommendations made by the broader eye care community about the roles of the mid-level cadre, as documented in World Health Organization (WHO) publications and elsewhere. The need for a mid-level eye care cadre, the confusion surrounding its role and nomenclature, and the training required are discussed. Based on this analysis, recommendations are made on how this cadre may be supported to contribute optimally to eliminating avoidable blindness.

The need for a mid-level cadre of eye care providers

Avoidable vision impairment will not be eliminated by 2020 using just the current global eye care workforce. Its capacity—both in numbers and effectiveness—must be increased.12,13 While increasing the number and skill of ophthalmologists in low resource countries should be a priority, this strategy by itself will not be sufficient to overcome the need for increased human resources.12

Optometry, with its non-medical history, has defined an independent position for itself, but its role is underdeveloped and uncertain in most low resource countries. Training for ophthalmologists and other more highly skilled eye care personnel takes a long time and is expensive. Further, these professionals tend to stay in urban centres, leaving the rural population, who are often poor, largely deprived of eye care.14

The emphasis has shifted away from hospital-based acute care with an ophthalmologist at the peak and helm, and nurses in mostly ancillary roles, generally directed by medical staff. The old systems are being supplanted by new paradigms encompassing comprehensive patient-centred care and district-based eye care for the community that require team-driven systems, new competencies, skill substitution, interdisciplinary collaboration, and continuity of care (Figure 1).9,12

Figure 1. Characteristics and contributions of different cadres to providing eye care. The mid-level cadre could provide the bulk of eye care

Mid-level health personnel can, and do, perform some of the functions of the more traditional health professionals with specialist qualifications, with the advantages of lower entry educational qualifications and a shorter period of training than ophthalmologists.15 Also, this cadre can be more readily deployed across remote and sparsely populated areas, such as the outer islands in the Pacific,16 to provide accessible and much needed care. By managing minor eye conditions, referring appropriately and assisting more specialist staff, they can also help lower the costs of health care.15,16

This is not a new suggestion. For many years the eye care community and attendees at WHO meetings have discussed the need for optimally trained and functioning eye care personnel in general, and a mid-level cadre specifically (Table 1).1,4,14,17–20 Despite this, the mid-level cadre remains an underutilised resource, hampering the development of sustainable eye care programmes in areas of high need and priority.9

Table 1. The mid-level cadre of eye care personnel:
Observations from WHO meetings and reports

1979	Trained “auxiliary health personnel” working at both the primary care and intermediate level, would be essential to deliver eye care and prevent blindness 1
1988–90	Five cadres of eye workers in Africa were defined by function 17,18 community (preventive and first aid) integrated eye worker (any level of medical staff but providing eye care full-time), at the primary level* ophthalmic assistant (full-time eye diagnosis and treatment but not cataract surgery) cataract surgeon# (role of ophthalmic assistant, but with cataract surgery) at the intermediate level* ophthalmologist at tertiary eye care level*.
1989	In the Western Pacific Region, medical officers, nurses and medical assistants should be provided with in-country training to manage eye conditions. A nursing shortage might make this difficult20
1992	Issues concerning Mid-level Eye Care Personnel (MLEP) were a priority in the South East Asia Region (SEAR)19
1993–96	A regional model of a standard curriculum for MLEP training was produced 19,21,22
2000	Review of the strategies and current situation in MLEP training, and development of the subtasks and core competencies for training of MLEP in the SEAR 23 Recommendation: “Immediate steps should be taken to increase the number of mid-level eye care workers” in the SEAR16
2001	Report containing information about the availability; production, distribution and utilisation of Mid-level Ophthalmic Personnel (MLOP) in the SEAR14 to be used: as an advocacy tool, as a guide for regional and national level actions, for discussion during a workshop in December 2001 Workshop to provide guidelines for comprehensive planning of human resources for eye care for Vision 2020, sensitive to the needs of the population 4 The recommendations the workshop made included: Establish taskforces to: Recommend uniform generic nomenclature, define roles and job descriptions for MLOP Investigate the options for training programmes for MLOP Provide advocacy, role clarification/job descriptions Participate in a planning workshop to iron out critical issues Establish a working group to review existing policies, curricula and training manuals Determine equivalence of degrees and diplomas of comparable educational programmes Explore and utilise avenues for professional development and continuing education Distance education as an alternative strategy for training Determine how training programmes can be designed to create opportunities that will provide avenues for career advancement, professional and academic development. Recommendation that the WHO and Regional International Agency for the prevention of Blindness (IAPB) should provide: Advocacy at meetings of Health Ministers and Health Secretaries of Member Countries Assistance in planning workshops for human resources in eye care within the context of Vision 2020 to determine the long-term goals for the country. Consider in future planning the prevailing weak licensing system, absence of accreditation system and variations across training institutions Support and strengthen training institutions, designate Regional Training Centres and facilitate and support networking of these institutions for sharing information, resources and expertise4,14

* Note the level at which the cadres work was also included in this definition, illustrating a source of confusion: the title of mid-level personnel is interchangeably used to mean either the level of service at which they work, or the level of skills they perform; # Since the role of cataract surgeons is similar to that of an "ophthalmic assistant", except for the addition of the well-defined function of cataract surgery, it will not be discussed separately to mid-level cadre of eye care personnel.

Defining the role of mid-level personnel in eye care services

A significant impediment to establishing the role of mid-level eye care workers is the confusion concerning the terminology and definitions used to describe this cadre. It has been suggested that this is due to the involvement of non-government organisations in eye care, resulting in a proliferation of training programmes, and of worker categories, each with differing levels of competency, that have been trained and deployed.14

Over the years there has been considerable discussion of and great variation in nomenclature, with terms used interchangeably and in parallel, even within single documents (Table 2).

Table 2. The mid-level cadre of eye care personnel: nomenclature/designations from WHO meetings and reports

Mid-level Ophthalmic Personnel (MLOP)(7)	Mid-level Eye Worker (non-physician) (25)	Mid-level Eye Care Personnel (MLEP) (28)	Middle Level Eye Care worker(38)	Mid-level Eye Care Personnel (4)
Ophthalmic nurse	Nurse		Ophthalmic nurse
Ophthalmic technician	Ophthalmic medical officer	Ophthalmologist substitute	Nurse practitioner
Ophthalmic assistant (outreach)	Ophthalmic assistant Assistant medical officer	Ophthalmologist assistant	Ophthalmic assistant
Paramedical worker	Auxiliary			Allied eye health personnel
Optometrist, Refractionist, Optician, Orthoptist	Technician		Optometrist Optician
Eye care worker (outreach) Primary eye care worker

The most recent and comprehensive definition of mid-level ophthalmic personnel (MLOP) specifies their workplace (facility-based or on outreach), training (not doctors; not provide health services other than eye care), and provision of eye care on a full-time basis:

“...all categories of professionals who work full time in eye care, except qualified doctors / ophthalmologists. Broadly, MLOPs have so far been grouped in two categories: (1) those working in regular facilities (clinics/hospitals), which include ophthalmic nurses, ophthalmic technicians, optometrists, refractionists, opticians, orthoptists; and, (2) those with outreach/field functions, which would include primary eye care workers and ophthalmic assistants. Health care workers who perform eye care as an additional task to other key responsibilities (e.g. village health workers, midwives, and auxiliary nurses) are not included in the group of MLOPs, because their deployment and training would be entirely different.”14

Defining the mid-level cadre according to the infrastructure level where they provide eye care (e.g. secondary or intermediate facility), or according to the level of assumed skill (e.g. “not a community worker, and not a doctor”), is problematic. It is possible for a person to perform mid-level functions (e.g. treatment of uncomplicated anterior eye problems) in a primary care capacity (i.e. first level of contact for patient), whilst working at a secondary level facility (e.g. a district hospital) or providing outreach to a community centre (i.e. community level).

One of the reasons for confusion surrounding nomenclature and role is that the middle level cadre of eye care worker is not of uniform skill or deployment, for which a single training course or workplace arrangement is applicable. These depend on local needs and perceptions, legislative constraints, finances, and health systems.24

It was recommended that a taskforce suggest uniform generic nomenclature, define roles and job descriptions for all MLOP in the South-East Asia Region (SEAR).14 Thereafter, it was proposed that closely related categories should be merged to minimise the current plethora of categories.4 While this may alleviate some confusion, the different functions and roles that necessitated the creation of the separate categories in the first place must be considered.

In the same way that optometry25, ophthalmology,26 and ophthalmic nursing are defined by their legal scope of practice as well as by competencies, so too should the mid-level cadre be defined by the tasks required of them and the skills required for these. The mid-level cadre should be populated by workers united by their membership of an integrated eye care team, and their complementary overlapping competencies (Figure 1).

Defining a cadre based on function is not a new concept: five categories of eye workers were defined almost 20 years ago (Table 1).17,18,24 Defining members of the mid-level cadre by what they do, and not by whom they are or where they work, clearly differentiates these personnel from the other team members. Additionally, this information will be useful for compiling job descriptions,24 making decisions about what should be included in curricula; in workplace policies and planning.

The tasks required from mid-level eye care providers for the delivery of comprehensive eye care have been identified in various reports (Table 3). There is some overlap in the tasks of the mid-level and primary-level workers, and also with the tasks fulfilled by ophthalmologists, at different times and in different places.

These tasks should, therefore, be divided amongst the available workforce in such a way that the relatively few capable of high end tasks are freed to deliver those. So, if competencies for the mid-level cadre are defined, then relevant competencies can be selected from these as required for a particular team setting.

For recognition, this may mean that the individual worker will be a member of a particular mid-level cadre with a subdivision, such as a refractionist. For service provision, this means that a given task can be fulfilled at different levels, depending on local circumstances and their reflection in the competency-set of the local workers.

Table 3. The mid-level cadre of eye care personnel: Suggested topics for training from WHO meetings and reports

MID-LEVEL CADRE OF EYE CARE WORKERS	PRIMARY LEVEL OF EYE CARE WORKERS
+Overview on Blindness / Community Eye Care
Blindness and visual impairment with its implications, social, economic and quality of life22 * Structure of National Program for PBL^22 Concept of avoidable and unavoidable blindness22 Necessary actions for blindness elimination/control-based on understanding magnitude and distribution22	Identify those with visual impairment or blindness in the community1,4,17 Assessment of visual acuity 88 Blind Register in villages4 Record severe visual impairment1
+Clinical Functions
Knowledge of ocular function and eye examination22 Recognition of eye conditions (external examination)1,17,20	Identify nutritional disorders 4 Recognition of normal eyes17
Manage common eye conditions and emergencies, eye medications96 Manage (treatment or referral) common eye conditions, including vitamin A deficiency1,17,20 Recognise cataract, manage glaucoma1,20 Recognise, refer conditions requiring more sophisticated care, direct ophthalmoscopy17 Measure IOP1,17 Rehabilitation of visually impaired people22	Diagnosis, treatment and/or referral of common causes of red eye and injuries17 Manage common eye infections1 Referral of cataract and corneal scar 17 Identify common external diseases, cataract, treat red eye, remove foreign bodies, provide emergency care, postoperative follow-up4 Manage eye injuries1 remove foreign body, epilation, apply ointment, eye pads 17 Immediately refer serious eye problems after first aid17
Effective communication with patients, colleagues and the community (public education) 22 Education: primary eye care (health promotion, prevention)17 Initiate and collaborate in community development activities, especially related to eyes1 Health education20	Provide eye health education1,17,4 prevent injuries1,17 Ensure treatment has been taken4 Ensure newborn babies’ eyes cleaned, Crede’s or similar 17 Promote immunisation17 Give Vitamin A to children with measles or malnutrition17
*Refraction, orthoptics, low vision,22 testing vision1 Providing spectacles for presbyopia and postcataract1 Refraction work20	Refraction, prescription of glasses4
*Minor surgery, eye bank management22 Remove foreign bodies, chalazion surgery, in trachoma areas: eyelid surgery, evisceration17 Select, prepare patients for surgery, assist with surgery 17,20 arrange surgery1 provide postoperative care 1,17
+Eye Health Management Functions
Epidemiological approaches: application to programme management22	Have knowledge of common eye conditions that occur in the community 17
Collect and report data on visual status1,20 Competence in programme planning, management, monitoring and evaluation22	Accurate recording and reporting maintained for monitoring17 Basic recording and reporting as designated by supervisor 17
Manage an eye clinic, including record and stock keeping17 Provide frontline workers with administrative, logistic, and organisational support1 Manage an outpatient unit20
Identify and mobilise community resources22
*Screening methodology22 Organise and run outreach clinics and school screening 17	Eye screening 4
+Training Function
Train primary level health personnel and the community22 Take part in training frontline workers1,20 responsible for the training, supervision and support of personnel at lower levels 17 * Training of trainers 22	Eye health promotion 4 Advise on how to prevent harmful local practices and beliefs17
+Technical Functions
Maintenance of instruments and equipment22 *Local preparations/ dispensing, produce spectacles22

+ Headings from South East Asian Region (SEAR): proposed curriculum for training MLOP (1995,1996).

Training for a cadre of mid-level eye care personnel

Just as the definition and promulgation of an agreed role for a mid-level cadre has been vexed, so too has devising and delivering their training. A workshop on training materials27 considered job descriptions for mid-level personnel to be “fairly well defined”, and dependent on their geographic region. Although the job descriptions did not include management tasks, the meeting recommended the development of training materials for a management module. This illustrates the disparity that often exists between job requirements, the expected competency, and the training offered.

Consideration of training seems to have been in isolation, without continuum or progress. For example, a 2001 workshop recommended that “top priority should be accorded to the training and/or retraining of mid-level eye care personnel, of whom there was an acute shortage”. It was recognised that “in the present context of poorly defined training of mid-level eye care personnel, WHO should constitute a working group...to review existing policies, curricula and training manuals”.4 This was surprising, given that these issues had previously been addressed by WHO meetings and had produced a standard curriculum.21,23

Five modules had been proposed (Table 3) to encompass the necessary basic functions of mid-level eye care workers. Broad outlines were provided with the expectation that contents of subtopics would be developed at a national level because these were country-specific.21 Subsequently, a taskforce met to finalise and prepare the curriculum for field-testing.22

Thereafter “...recognition and adaptation of these modules for MLEP [Mid-Level Eye Care Personnel] training should be officially distributed...” “...to the national trainers should be implemented as early as possible for them to train other MLEP in each country of the region”.23 No mention, however, was made of this curriculum either in the 2001 report14 or at the subsequent workshop,4 and no further progress on the implementation of a standard curriculum has been documented.

Currently, there are several training courses, each with its own curriculum, for mid-level low vision and rehabilitation professionals and those involved in management.19,28

As result of this review, recommendations are made to facilitate the development of a mid-level cadre to provide eye care in the context of Vision 2020 (Table 4).

Table 4. The mid-level cadre of eye care personnel:
Author recommendations

A consistent and widely applicable nomenclature should be determined.

Although confusion has surrounded this terminology in the past, the "mid-level" terminology is so widely used, it would be difficult to replace. This cadre of eye care workers could still be known as MLEP.
Within this group, and defined by the particular subset of competencies possessed, there should be specialised workers (e.g. MLEP Refractionist, MLEP Cataract Surgeon). This subdivision would be analogous to the subspecialisation that occurs in ophthalmology (e.g. Paediatric Ophthalmologist).

Personnel should be categorised by their competencies and functions.

Eye care personnel, including those in the mid-level group, should be categorised by their competencies, required for the functions they perform. This will permit setting of job descriptions,24 scope of practise and standards of care.9
A comprehensive set of competencies for the mid-level cadre should be agreed upon.
The roles and specific tasks that particular personnel may be required to perform, in particular eye care systems, locations or circumstances, should then be defined (e.g. refraction, cataract surgery or service management).

Training curricula should be based on the competency requirements of job descriptions and that will prepare personnel for those jobs.1,24

With the required competencies agreed, appropriate training for MLEP could be sought or designed.
A review of existing training manuals and curricula, including the existing standard curriculum, could inform the development of these curricula, and ensure equivalence of qualifications from comparable educational programmes. 4,21,22 This should be accomplished through participatory planning, with input from both medical education and medical services experts.4
In addition to the skills listed in Table 3, WHO core competencies for chronic care 29 should be included in competency based curricula, assessment methods9 and evidence-based learning. Graduates should competently deliver high quality, acceptable and comprehensive eye care, including preventative and promotive eye care in teams or partnerships with the community.30 This would include personal and professional development with an emphasis on quality improvement.
Evaluations of the extent to which objectives have been reached, and effectiveness of programme and teachers,1,14,21 will allow ongoing improvement in training.

Training centres, including those capable of training trainers, should be established or developed.

The establishment of accredited, standardised, well-resourced training centres will encourage maintenance of training standards and MLEP of uniform experience and competency.
Networking of training institutions will permit sharing of information, resources and expertise.24
Distance education, can be explored as an alternative strategy,9 but may have more application to continuing education.

Government recognition, resources, support and evaluation and feedback systems should be established to ensure that this mid-level cadre can implement their training, and have the opportunity of providing high quality eye care.

Establishing professional credibility is important so that the contribution that could be made by the mid-level cadre is recognised and respected by other health professionals or administrators.15 Standardised training, uniform competency attainment, with appropriate well-resourced and supported workforce deployment, incorporating avenues for professional and academic development and career advancement, all within an environment of policy and legislative support, will facilitate this credibility.
Demarcation of professional boundaries between mid-level and other cadres will assist regulatory and professional bodies. These boundaries are not only important for a sense of professional identity, but will also help secure status31 upon which community acceptance is based.
Planning for human resources, including those of the mid-level cadre, should be done within the overall context of Human Resource for Health planning, and according to national policies on training, deployment and utilisation of personnel and within the scope of national eye care plans.4

Conclusion

Recommendations concerning a mid-level eye care cadre have been made repeatedly over the past 20 years. Why then, if there is general agreement on the urgent need for MLEP, and the issues identified and deliberated, has seemingly little progress been made to facilitate either their training or implementation of training?

Although essential, defining roles, competencies and training is not sufficient to ensure the mid-level cadre can provide high quality eye care. Careful selection of candidates for training, fair and reliable compensation, resources, infrastructure, supportive supervision and evaluation, and feedback systems must be in place to allow graduates to implement their training. There must be opportunities for career advancement in tandem with professional and academic development. Lifelong learning must be inculcated and accessible to ensure continued quality of care.4,9,14,24,32These can be achieved.

Information on creative strategies, success stories, and lessons learnt should be assembled and dispersed.10,11 Evaluation and research about improving workforce effectiveness, planning, policy, and programmes is needed. An international collaborative research agenda, coordinated, and aligned with other initiatives on health systems research, will avoid wasting time and resources and can also provide opportunities to develop capability of new scientists.

Ministries of Health and international organisations should be encouraged to help translate research results into action.32 A link across training and education, health care systems, and labour markets will assist in developing a system that will address these synergistically.10 What an eye care provider is called, what their education will be, how they fit into an eye care team, and if and how much they are paid by government will vary from country to country.

Effective workforce strategies must, therefore, be context-specific and be matched to a country’s unique history and situation by working in partnership with all stakeholders in both problem diagnosis and problem solving.9

Competing interests: None known.

Author information: Rènée du Toit, Education Director, Garry Brian, Medical Director, The Fred Hollows Foundation New Zealand, Auckland

Acknowledgements: We thank Allen Foster, Hugh R Taylor, and Jill Keeffe for helpful comments on the first draft of this manuscript.

Correspondence: Rènée du Toit, The Fred Hollows Foundation New Zealand, Private Bag 99909, Auckland 1149, New Zealand. Email: rdutoit@hollows.org.nz

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