1. Introduction

These Terms of Reference (TOR) outline the requirements of the completion of surveys to determine (i) the Cataract Surgical Rate in Zambia for 2022 and 2023 covering all 10 provinces

(ii) mapping of all ophthalmic Human Resource and coverage of eye care service delivery.

2. Background

The Ministry of Health 4th National Eye Health Strategic Plan (2022-26) provides a framework for the planning, delivery and management of quality eye health care services at all levels of eye health delivery systems in Zambia. It aims to address the many eye problems that Zambians face through a strategic approach to eye health systems strengthening, integration with the wider health system, improving equity of access and strengthening partnerships.

Progress has been made to strengthen eye health systems in Zambia through efforts by the Ministry of Health and public/private partnerships. Working with partners such as Orbis, the national programme for prevention and control of blindness has improved infrastructure, human resources and outreach of eye care services. The approach has included setting up district hospitals as a unit of implementation for cataract surgery, while establishing the link between primary, secondary and tertiary health care. According to the strategic plan, comprehensive eye health services are offered from primary to tertiary levels in all the ten provinces of Zambia, giving coverage of 80% mainly along the line of rail in Copperbelt, Southern and Lusaka provinces. To compliment the public eye health services, there are a number of private health facilities offering eye care services, including five private hospitals.

The prevalence of blindness in Zambia is estimated at 2% giving approximately 389,000 blind people. The major causes of blindness include cataract, glaucoma, trachoma, refractive errors, corneal opacity and diabetic eye disease; Cataract alone accounts for 53% of the blindness.  A number of Ophthalmologist and Cataract Surgeons are dotted around the country, conducting cataract surgery in both private and public hospitals.

Data collection, management, reporting and use remain a challenge in eye health, and the Ministry of Health with support from partners has taken steps to improve data management and reporting at all levels of care. Within the MOH Health Management Information System (HMIS), the ministry has expanded the DHIS2 to capture more information on eye health activities in the country in accordance with the International Classification of Diseases – 11 (ICD 11). This is being done through submission of reports from levels of service delivery to district, provincial and national levels in order to capture data essential for disease monitoring and control according to the WHO.

Cataract accounts for 53% of the causes of reversible blindness (RAAB 2017) in Zambia. There are no known ways of preventing cataract due to aging, thus treatment involves surgical removal of the natural lens, and implantation of an artificial intraocular lens (IOL). This procedure results in the restoration of sight to individuals who would have remained blind for life. It improves the quality of life and allows individuals to live full lives socially and economically.

Cataract Surgical Rate (CSR) is the number of cataract operations performed in one year, per million population. It is a measure of the quantity and availability of cataract services. According to the 4th National Eye Health Strategic Plan (NEHSP 2022-24), CSR in Zambia is at 258 per million population per year (the recommended minimum for Africa is 2,000). While the CSR only measures quantity of services, the quality of the surgical outcomes also need to be measured.

Objectives of the NEHSP 2022-2024 on cataract include to:

i. increase the Cataract Surgical Rate from the current 258 per one million population to 750

ii. perform cataract surgeries with IOL implantation rate of 90% and

iii. attain visual outcome of 6/18 or better in 65% at day one post operation, and 85% at six weeks.

The ministry will achieve this by establishing a national cataract task force and the following strategies:

1. Provide comprehensive static and outreach cataract surgical services in all the districts

2. Ensure that biometry equipment is available at all the institutions conducting cataract surgeries so that 90% cataract patients have biometry done prior to surgery

3. Strengthen phacoemulsification surgery at all tertiary eye health facilities

4. Conduct capacity building training for community-based volunteers and health workers to assist with identification of cataract and provide follow-up services

5. Conduct awareness campaigns and eye health education on cataract

6. Ensure availability of transport for outreach services

7. Ensure availability of equipment, consumables and surgical instruments

Orbis International (OI) is a non-aligned, non-profit, global development organization on a mission to transform lives through access to quality eye health. To achieve its mission, it builds the capabilities of its partners through education and training, eye care management systems development, technical and financial support, and research. OI manages four global programs – a Flying Eye Hospital, Hospital Based Programs, Fellowships, and Cybersight – and has country programs in Asia, Africa, Latin America, and the Caribbean.

In Zambia, Orbis International partners with the Ministry of Health in supporting prevention and treatment of blindness, scaling up of universal eye health services to ensure equitable access to quality, affordable and inclusive eye health for everyone.

Orbis International Zambia (OIZ/ Orbis Zambia) has been working in partnership with the Ministry of Health since 2010. OIZ’s mission is to transform lives through the prevention and treatment of blindness and a vision of networking with partners to mentor, train and inspire local teams so that they can save sight in their communities. OIZ has implemented programs in all the 11 districts of North- Western province for the past 9 years, including a targeted cataract project to serve the elderly population in the province that are not able to afford cataract surgery. In Lusaka, our support for the past 7 years focused on training for Human Resource for Eye Health as well as systems strengthening at the University Teaching Hospitals Eye Hospital. The work in Lusaka district has been scaled up to include Lusaka province to support eye health services from primary to tertiary level across all the districts. The scale up now includes UTH Eye Hospital, Levy Mwanawasa Teaching Hospital, 4 first level hospitals, district hospitals and selected health facilities. OIZ implemented projects with restricted grants in Lusaka, Copperbelt and North- Western provinces. The projects covered areas such as Pediatric Eye Health, Cataract surgery, Human Resource for Eye Health, including support for residency training, faculty training and fellowships, set up of specialist clinics as well as the use of mobile phone technology to enhance primary eye care and improve cataract surgical outcomes through use of the Better Outcomes Operating Software Tool (BOOST) application.

With this background, Orbis would like to engage a consultant to support the Ministry of Health through the Directorate of Clinical Care and Diagnostic Services office (and the National Eye Health Coordination office) to conduct a survey on (i) the Cataract Surgical Rate in Zambia for 2022 and 2023 covering all 10 provinces, (ii) mapping of all ophthalmic Human Resource and coverage of eye care service delivery.

3. TASK 1 – Cataract Surgical Rate (CSR) Survey

Orbis in collaboration with the Ministry of Health wishes to establish a baseline Cataract Surgical Rate (CSR) for 2022 and 2023 against which progress will be measured for the objectives stated about. The survey will document the number of cataract surgeries being conducted for the population in both public and private institutions in order to plan cataract surgical services and document the national cataract surgical rate for 2022 and 2023. Planning eye health programs in the sustainable development goal (SDG) era requires recent data about burden of disease to inform service development to achieve universal eye health coverage. CSR (cataract surgeries performed per million population) is an eye health indicator that helps assess the state of eye care services.

While the CSR only measures quantity of services, the quality of the surgical outcomes also needs to be measured. The survey will therefore further collect data on surgical outcomes as well as documentation practices of post-operative outcomes.

The main objectives of the survey are to:

1. Determine the volume of cataract surgery being performed at national, provincial and district levels in both public and private institutions

2. Estimate the annual cataract surgical output and the CSR for each district, province, and a national CSR

3. Identify priority districts that have low CSRs.

4. Estimate the number/proportion of phacoemulsification surgeries being performed presently.

5. Chart the progress in CSR over the last 2 years and make projections for the next 3 years.

4. TASK 2 – Mapping of Human Resources and services for Eye Health

The MOH continues to recognize the role qualified eye health personnel play in health service delivery. However, the limited establishment for human resource for eye health (HReH) affects the efforts toward the prevention of avoidable blindness and provision of quality eye health services across the continuum of care. The ministry continues to address the aforementioned issues relating to the HReH through the national human resource plan on which this plan will anchor in implementing specific challenges of eye health work training, skills transfer and continuous medical education (National HR for Health Plan 2017 – 2021). To make eye health services more equitable and affordable for achieving universal health coverage; ‘integrated people-centered eye care’ approaches (as proposed by the World Report on Vision) should be adopted in all districts.

Therefore, the Ministry would further want to understand the gaps in Human Resources for Eye Health in both private and public institutions by taking stock of all Ophthalmic staff and their placement.

The main objectives of the mapping are to:

1. Determine the number of trained Human Resource for eye health working in health facilities across the provinces

2. Mapping of Ophthalmic Human Resource and their location and qualifications in public and private practice

5. Methodology

The consultant will design an appropriate methodology to complete the assignment in line with the outlined outputs. They will design appropriate methodology for both tasks and develop data collection tools which will be finalized in consultation with Orbis Zambia. The methodology used for the surveys should include identification and mapping of all service providers by district and category and data collection from all districts in the country through the Provincial Health Offices. The methodology should include:

• Preparatory phase – A consultative/planning meeting with Orbis Zambia, the National Eye Health Coordinator and other partners working in eye health. Other preparatory meetings to be held with other key stakeholders as identified.
• Development of a master checklist of key informant contact data by province and district which will be used to build a profile of prospective respondents for data collection.
• A formal approval for the cataract mapping survey will be provided by the Ministry of Health and will be conveyed to the provincial and district health authorities, as well as private health facilities and requesting their cooperation and facilitation in the survey
• Generate primary data and review secondary data – Develop and pilot data collection tools for cataract surgical data collection and mapping of service providers. The tools will be reviewed and approved by Orbis and NEHC at the Ministry of Health. The consultant will engage respective Senior and District Health information Officers and other relevant officers to obtain secondary data on cataract surgeries and human resource for eye health as needed.
• Data validation, analysis and report writing

6. Outputs of the assignment

1. Report including all findings submitted to Orbis and the Ministry of Health through the Director Clinical Care and Diagnostic Services and the National Eye Health Coordinator for review and approval before its finalized. This will include a calculated CSR, Effective Cataract Surgical Coverage (eCSC, surgical outcomes data) and overview of HReH across the 10 provinces.

2. Data on cataract surgeries (disaggregated by age and sex) conducted in both the public and private institutions in their respective districts, in 2022 and 2023.

3. Mapping of service providers by district and category – public and private service providers.

4. A database of Ophthalmic Human Resources by cadre for each province according to each district and including the name of the facility, type of facility, and names and contacts of ophthalmic staff.  The database should include all ophthalmic staff working in the public and private sector.

7. Expected competencies of the Consultant

The consultant should have:

1. At least a master’s degree in the field of public health/medicine/development studies/social science or other relevant discipline.

2. Experience working with the Ministry of Health at levels

3. At least 10 years’ experience in research and evaluation in health systems, public health, and eye health care services

4. Strong methodological skills in the development and implementation of data collection tools, data management, and analysis (including use of statistical packages)

5. Excellent written English and report writing skills

6. Availability during the period of the assignment

Closing Date: 29th May 2024