Core Competencies for the Eye Health Workforce in the WHO African Region WHO African Region | I CORE COMPETENCIES FOR THE Eye Health Workforce IN THE WHO African Region II | Core Competencies for the Eye Health Workforce in the WHO African Region Core competencies for the eye health workforce in the WHO African Region ISBN: 978-929023418-0 © WHO Regional Office for Africa 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc- sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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Design and layout by Rail Graphic Design & Print, Republic of South Africa WHO African Region | i Contents Contents ................................................................................................................................................ i Acknowledgements .......................................................................................................................... ii Foreword ............................................................................................................................................. iv Abbreviations and acronyms .......................................................................................................... v Working definitions .......................................................................................................................... vi Chapter 1: Introduction .............................................................................................................................................1 Chapter 2: Classification of the Eye Health Workforce .............................................................................................5 Chapter 3: Roles of the Eye Health Workforce .........................................................................................................9 Chapter 4: Competencies for Ophthalmologists ....................................................................................................13 Chapter 5: Competencies for Optometrists ...........................................................................................................19 Chapter 6: Core Competencies for Allied Ophthalmic Personnel ..........................................................................27 Chapter 7: Common Non-Clinical Core Competencies for the Eye Health Workforce .........................................35 Chapter 8: Implementation .....................................................................................................................................41 References .........................................................................................................................................43 Annexes ..............................................................................................................................................44 ii | Core Competencies for the Eye Health Workforce in the WHO African Region Acknowledgements The Core Competencies for the Eye Health Workforce in the African Region have been developed in collaboration with a network of national, regional and international experts who provided guidance throughout the development process participating in the review of drafts at every stage of its preparation and development. The participation included the two rounds of the modified Delphi for consensus on the competencies (the list of individual contributors is in Annex VII) which involved a wider participation in addition to the face building or attending the two expert meetings held in Nairobi (September 2017 and February 2018). WHO secretariat therefore would like give special thanks to the following experts: James Amoo Addy (Head of Eye Unit, National Coordinator, Prevention of Blindness, MoH Ghana); Mouctar D Badiane (Coordinator of the national Eye Health Promotion Program, Senegal); Komi Matiklu Balo (Professor of Ophthalmology, University of Lomé); Grace Chipalo-Mutati (Senior Medical Superintendent, University Teaching Eye Hospital Zambia); Ellen A. Clegg (Former Principal, Ophthalmic Nursing School, Korle Bu); André Omgbwa Eballe (Deputy Coordinator, Prevention of Blindness Programme, Cameroon); Richard Ganga-Limando (WHO Collaborating Centre for Postgraduate Nursing & Midwifery Distance Education, University of South Africa); Dunera Ilako (Consultant Ophthalmologist, University of Nairobi); Godfrey Kaggwa (SiB Project Coordinator, Brien Holden Vision Institute, Uganda); Jefitha Karimurio (Chair, Department of Ophthalmology, University of Nairobi); Abigail Kazembe (Associate Professor & Deputy Dean, Kamuzu College of Nursing, Malawi University); Annette Kobusingye (Program Manager, the Fred Hollows Foundation, African Region, Uganda); Aaron T. Magava (Chair, IAPB Africa, Zimbabwe); Fikile Ntombi Mtshali (WHO Collaborating Centre - School of Nursing & Public Health, University of Kwazulu-Natal, South Africa); Peter Mwangi Kirigwi (Optometry Technologist Trainer, Kenya Medical Training College); Kolawole Ogundimu (Senior Global Technical Lead, Eye Health, Sightsavers, Nigeria); Mollent Okech (Senior Technical Advisor for HRH, Management Sciences for Health, Kenya); Joseph Enyegue Oye (Country Director, Sightsavers, Cameroon); Senanu K Quacoe- Wossinu (Francophone & Lusophone West Africa, Co-Chair, IAPB-Africa); Zahra Rashid (Optometrist, Kenya); Bernadetha Robert Shilio (National Eye Care Program Manager, Ministry of Health, Tanzania); Kassa Tsehaynesh Tiruneh (acting National Eye Health Coordinator FMoH, Ethiopia); Linda Visser (Academy Head, Dep. of Ophthalmology,Vice-President OSSA, President, College of Ophthalmology, South Africa). WHO would like to acknowledge the IAPB HReH task development teams who did preliminary groundwork. This Regional policy document has been drafted by the consultant services of Dr Michael Gichangi (Head of Ophthalmic Services Unit – MoH Kenya) at the various stages. Simona Minchiotti, Renee du Toit and Mwansa Nkowane contributed to the technical content of the document and provided technical feedback to the consultant. The steering group for the overall process was led by WHO and the International Agency for the Prevention of Blindness for Africa (IAPB) with Adam Ahmat, Simona Minchiotti, Jennifer Nyoni and Mwansa Nkowane (World Health Organization), in collaboration with Simon Day, Renee du Toit and Ronnie Graham (The International Agency for the Prevention of Blindness – IAPB) and Luigi Bilotto (Brien Holden Vision Institute). WHO African Region | iii The contribution of Dr Adrian Hopkins (Facilitator, Adrian Hopkins Consulting) who facilitated at both experts’ consultation and the validation meeting as well as providing the technical proof reading is acknowledged. Within WHO we wish to thank Hillary Kipruto and Silvio Paolo Mariotti for their contributions. WHO also wishes to express sincere gratitude to the Organisation pour la Prévention de la Cécité (OPC, Paris, France) for translating the working draft version of the core competencies document into French to facilitate the validation process of the experts. Graphic design and layout was done by Rail Graphic Design CC (Durban, South Africa). WHO acknowledges the financial contribution of IAPB and Sightsavers to the overall process of developing this document. iv | Core Competencies for the Eye Health Workforce in the WHO African Region Foreword The majority of countries in sub-Saharan Africa are facing a severe crisis of skilled health workforce shortages that could impede the realization of Universal Health Coverage, especially in specialized fields such as eye health. This policy document is a step towards improvement of the quality of eye health care. It describes the development of core competencies for the cadres that constitute the professional eye health team. In sub-Saharan Africa, an estimated 3.6 million persons are blind, 17.4 million have moderate and severe visual impairment, and 100 million have near vision impairment. Visual impairment does not only impact negatively a person’s quality of life but also the national and regional economy. The majority of people who are visually impaired are over 50 years old and many live in rural areas. This places a huge burden on the WHO African Region that already has a myriad of challenges compounding this shortage of skilled eye health providers. What is worse, the distribution of available eye health providers is skewed, with most of them deployed in the urban areas. Given the shortage of human resources for eye health, and in line with the WHO approach to task shifting or sharing, this policy document is a unique contribution to detailing the competencies required of a range of eye health professionals. Countries can select and tailor these core competencies to meet their specific country needs. The corps of eye health professionals may share some competencies, but others are unique to some cadres. The selected competencies can then be included in educational curricula, enhancing a transformation of task shifting or sharing from often informal delegation and unstructured training to the production of competent eye health professionals who perform tasks that are within their role and allowed under country and professional regulatory frameworks. Team-based education is also in line with the WHO approach to inter-professional education and collaborative practice. WHO continues to call for high-quality eye health services that focus on integrated, people-centred services. Integrated services ensure that there is a continuum of care that includes both promotive, preventive, palliative and rehabilitative eye care, and diagnosis and management of eye disorders – all coordinated among the different disciplines and providers. Person-centred eye care, for its part, means that the person’s needs and preferences are taken into consideration and that the person is an active participant in the provision of care. To this end, WHO urges that traditional teaching and learning methods be transformed into competency-based education. It also calls for traditional methods of education to shift towards an interdependence that harmonizes education with health systems and supports networking and collaborative practice. WHO and the International Agency for the Prevention of Blindness (IAPB) are working towards the harmonization of tasks and roles in human resources for health (HRH) within a global framework, and have worked closely together to develop the tasks and roles of the eye health team of professionals in line with global standards. A rigorous process of engaging eye health experts and training institutions in the WHO African Region followed, with the aim of developing core competencies for the team, reaching consensus on them, and ensuring their ownership. The result of all these efforts was the validation of the present core competencies for the eye health professional team for the African Region. This policy document is a first step in the development of competency-based education for eye health professionals that meets the needs of the African Region and its unique challenges. It is largely a reference document that can be used when reviewing or developing curricula for eye health professionals. Further, it can also be used in workforce planning, management, regulation, etc. We envisage that use of the document will contribute to a higher quality of care that is harmonized across the Region. Its use will also spur development of the capacities of training institutions, strengthen health systems, and support eye health professional teams to apply the competencies acquired to the provision of quality eye health care as a step towards Universal Health Coverage. DR MATSHIDISO MOETI WHO Regional Director for Africa WHO African Region | v Abbreviations and acronyms AFCO African Council of Optometry AOP Allied Ophthalmic Personnel AFRO WHO Regional Office for Africa IAPB-Africa International Agency for the Prevention of Blindness - Africa Region HReH Human Resources for eye Health ICO International Council of Ophthalmology ISCO International Standard Classification of Occupations OCO Ophthalmic Clinical Officers SDGs Sustainable Development Goals SSA Sub-Sahara Africa SAG Standing Advisory Group UHC Universal Health Coverage WCO World Council of Optometry WHO World Health Organization vi | Core Competencies for the Eye Health Workforce in the WHO African Region Working definitions Behaviour A way of conducting oneself in a specific environment. Competency Sufficient knowledge and psychomotor, communication and decision-making skills and attitudes to enable the performance of actions and specific tasks to a defined level of proficiency. Competency statement Description of outcomes expected from the performance of professionally-related functions. Competent Ability to perform specific tasks to a defined level of proficiency using acquired knowledge, skills, and professional behaviour. Core competency Aspects of a discipline that are common to all students, and that should be mastered in order to graduate and enable professional practice. Competency domain Umbrella term covering areas of learning. Competency-based approach A disciplined approach that specifies the health problems to be addressed; identifies the requisite competencies required of graduates for health system performance; tailors the curriculum to achieve competencies; and assesses achievements and shortfalls. It embraces a highly individualized learning process rather than the traditional one-size-fits-all curriculum. Eye health team In the context of this document, the focus is on the three skilled eye health professional groups (ophthalmologists, optometrists and allied ophthalmic personnel). The eye health team is generally larger than this. Health behaviour Any activity undertaken by an individual, regardless of actual or perceived health status, for the purpose of promoting, protecting or maintaining health, whether or not such behaviour is objectively effective towards that end. Health promotion The process of enabling people to increase control over, and to improve their health. Health-seeking behavior Personal actions to promote optimal wellness, recovery, and rehabilitation (NOC 1603). Integrated health services The management and delivery of health services such that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services through the different levels, specialities and sites of care within the health system, and according to their needs throughout the life course. Knowledge Understanding of a subject and ability to apply skills. People-centred An approach to care that is consciously organized around and responds to the health needs, expectations, and preferences of the people or beneficiaries in a holistic manner. Skill Ability to perform specific tasks to a specified level of measurable performance. Universal Health Coverage Ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. Validation Ascertain and confirm through a process that the competencies are suitable. Vision rehabilitation A continuum of activities from assessment of visual functions through to provision of appropriate assistive devices and technologies, and social inclusion, all geared to optimizing visual functioning and a sense of well- being. (https://www.aoa.org/optometrists/membership/aoa-sections/vision- rehabilitation-section/membership-benefits/definition-of-vision-rehabilitation Vision therapy Also known as vision training, is defined as using a series of procedures carried out in home, school and office settings, sometimes with optical or non-optical devices, to improve residual vision and vision skills such as eye movement control and coordination. It is usually under professional supervision. CHAPTER 5 Competencies for Optometrists 1 Introduction 2 | Core Competencies for the Eye Health Workforce in the WHO African Region 1.1 Introduction Worldwide, 285 million persons are visually impaired. Among these, 39 million are blind and 246 million suffer from low vision. Visual impairment increases with age (13). Sixty-five percent (65%) of the visually impaired and 82% of the blind are above 50 years of age (11). In Africa, there are 4.8 million blind persons and 16.6 million visually impaired; yet, even with the huge burden of eye disorders in Africa, less than 1% of the global number of ophthalmologists practise in Africa. Only 13 countries in Africa meet the minimum requirement of one eye health professional to 55,000 people (14). Most ophthalmologists and optometrists practise in urban areas while allied ophthalmic personnel (AOP) tend to move out of the capital cities to smaller towns. While the rate of growth among the cohort of people aged over 60 years is 2.9% worldwide, the rate of growth of ophthalmologists is 1.2% (less than half) (15, 16). The shortage of human resources for eye health (HReH) has further been compounded by the limited capacity of the eye health training institutions in the African Region (Table 1). The eye health workforce crisis thus has an even greater impact in the African Region. To make a significant impact on the cataract surgical rate and coverage and correct refractive error, thus reducing vision impairment and blindness globally, sufficient skilled human resources for eye health are required (17, 18). The quality, quantity and distribution of health workers correlates with positive health outcomes (8). Health worker density is used as one of the indicators of service capacity and access used to monitor progress towards Universal Health Coverage (UHC) (2). Table 1: Needs analysis and capacity of eye health training institutions in the WHO African Region Category Needs assessment Capacity of eye health training institutions in the WHO African Region Recommended ratios Number required Total existing Existing gap Total number of institutions Annual intake Number of years to reach targets** Ophthalmologists 1/250,000 4,000 2,075 1,925 (48%) 51 250 8 Optometrists1 1/250,000 4,000 8,900 90%* 27 500 7 Allied ophthalmic professionals 1/100,000 10,000 6,390 3,610(36%) 30 763 6AOP (clinicians) 24 277 AOP (nurses) 6 486 Source: IAPB Vision Atlas and Training Institutions Database * Estimates; ** figures not adjusted for attrition 1.2 The global call to action The Lancet commission on education of health professionals for the 21st century, among many other recommendations, proposes the Adoption of competency-based curricula that are responsive to rapidly changing needs rather than being dominated by static coursework. Competencies should be adapted to local contexts and be determined by national stakeholders, while harnessing global knowledge and experiences. Simultaneously, the present gaps should be filled in the range of competencies that are required to deal with 21st century challenges common to all countries… (1). Efforts have also been made to emphasize patient- and population-centredness; inter-professional team-based education; IT-empowered learning; policy, management and leadership skills as the foundations for the future. This transformative change in teaching and learning methods in order to develop person-centred competent service providers is hereby proposed (20). In response to the needs of the WHO African Region, in 2011 the WHO Regional Office for Africa developed a roadmap *±10,000 optometrists are in Nigeria and South Africa, and few other countries with a few hundred, 78% countries have less than 50, while some have 0 like Namibia. Jennifer J Palmer FC, Alice Gilbert, Devan Pillay, Samantha Fox, Jyoti Jaggernath, Kovin Naidoo, Ronnie Graham, Daksha Patel and Karl Blanchet.* Trends and implications for achieving Vision 2020: human resources for eye health targets in 16 countries of sub-Saharan Africa by the year 2020. Human Resources for Health. 2014. WHO African Region | 3 (2012–2025) for scaling up the health workforce for improved access to services (9). The proposed roadmap addresses all categories of the health workforce and analyses the challenges facing the Region. Recognizing the importance of eye health, WHO issued a global call for achieving high quality care that focuses on two particular dimensions: people-centeredness and integration (19). The WHO global action plan for 2014–2019 (Towards Universal Eye Health) aims to reduce by 25% by 2019 the burden of visual impairment from the 2010 baseline. It recommends strengthening eye care services through integration into the health system, rather than following the vertical programmes approach. The starting point for scaling up the quality, quantity and relevance of the eye health workforce is to strengthen training institutions to produce more of the skilled professionals based on appropriate standards, and ensure their integration into the health system. The development of eye health competencies is a step in that direction. 1.3 The development process Development of the core competencies for the eye health workforce will be the first course of training in the competency-based approach (1). Competency-based training is a more responsive and transformative method of education centred more on patient needs rather than the traditional way of training. IAPB and WHO engaged in a collaborative and extensive consultative process to develop the core competencies for the eye health team (Annex I). Eye health experts, trainers, policy makers and service providers have been actively involved in the process since 2013. A sequence of activities took place between that date and 2018. These are described below. (a) Desk review: A broad range of reference documents were used including, the International standard classifications of occupations (ISCO-08) (for identified occupational roles) and CanMEDS (an existing competency framework for medical education). (b) Expert consultations: Experts from English-, French- and Portuguese-speaking countries in sub- Saharan Africa were engaged with the aim of building consensus and validating the competencies. Two nominal meetings (Annexes II and III), and several e-meetings and consultations took place. (c) Delphi survey: Two rounds of Delphi surveys were conducted and findings therefrom used to improve draft versions of the document. (d) Validation: A validation workshop was held in Nairobi, Kenya, from 27 February to 01 March 2018 involving a wider group of experts and representatives of African Member States. The purpose of the workshop was to analyse in detail, evaluate, and review both the whole process and the document in order to definitively validate core competencies for the eye health workforce in the WHO African Region. The primary beneficiaries of these competencies are: • Ophthalmologists • Optometrists • Allied ophthalmic personnel (AOP). These core competencies can be used as a starting point in developing competency-based specific training curricula for different cadres of the eye health team in the Region. This could help in harmonizing eye health programmes, thus improving the standard of care in the Region. In addition, the competencies will have several other uses. They can be used as a guide for self-directed learning, as an advocacy tool, and for assessments. There will also be a broad range of users of the competencies. They include: (a) Educational institutions (b) Learners of eye health (c) Professional associations (d) Licensing and regulatory bodies (e) Policy makers, e.g., ministries for health and education. Annex IV provides detailed options for their use. 4 | Core Competencies for the Eye Health Workforce in the WHO African Region 1.4 The competence framework The ultimate purpose of these competencies is to improve the quality and relevance of the care provided by the professional eye care health workforce. The allocation of specific competencies to a specific cadre of eye health personnel is the remit of training institutions and regulatory bodies. The document outlines a comprehensive set of core (minimum) competencies for the eye health workforce as a step towards development of competency-based training. The framework is divided into 10 domains comprising 4 clinical and 6 non-clinical domains. Each competence is further broken down into associated relevant knowledge, skills, attitudes and behaviours. CHAPTER 2 Classification of the Eye Health Workforce 6 | Core Competencies for the Eye Health Workforce in the WHO African Region 2.1 Introduction The Ouagadougou Declaration on primary health care and health systems influenced the choice of CanMEDS – an existing competency framework for medical education and practice – as the appropriate organizing framework. It was adapted and 10 domains created to organize the competencies. The competencies associated with the domains, which are either unique or shared between the three professional workforce groups, are outlined in Section 3. The International standard classification of occupations (ISCO-08) is a detailed four-level hierarchically structured classification system for occupations. It allows production of relatively detailed and internationally comparable data. Globally, it is endorsed by labour organizations and is used by WHO and the governments of many countries in Africa. ISCO-08 classifies, codes, and broadly outlines the services that health care personnel provide, along with their levels of autonomy and supervision (21). 2.2 Classification system Whilst the categorization and definition of ophthalmologists and optometrists is, to a large extent, uncomplicated and uncontroversial, it is not so with the mid-level eye care workforce, as there is a wide range of nomenclatures, education and roles associated with these persons. Allied ophthalmic personnel (an alternative used in the literature to avoid the term ‘mid-level personnel’), are a heterogeneous group of staff with specialist ophthalmic training. In contrast to ophthalmologists and optometrists, AOPs often serve in rural areas (17). They work in interdisciplinary teams to receive patients with eye disorders. The patients are sent to them directly or referred from primary and community health workers. AOPs diagnose and treat eye illnesses and refer patients with conditions beyond their scope of practice, thereby providing a bridge between ophthalmologists and primary and community-level workers. They also provide links to health and social services in the community and elsewhere that include education, rehabilitation and low vision services (as illustrated in Figure 1 below) – all contributing to UHC. The term ‘allied ophthalmic personnel’ is widely used for this group as a whole and can be used instead of the term ‘mid-level’. Neither mid-level personnel in general nor AOPs specifically exist as occupational groups in ISCO-08. Apart from ophthalmologists and optometrists, dedicated specialist eye care cadres may be included in the ISCO-08 categories of paramedical practitioners, nursing professionals, and medical assistants and technologists (Figure 1). The latter group, who have on-the- job or short-term training to ‘perform basic clinical and administrative tasks to support patient care under direct supervision’, is not very prevalent in sub-Saharan Africa, neither are optical dispensers (3254) or orthoptists (2267). These groups have, therefore, not been included in this process. The definition of competencies in this document thus pertains to the three main eye health professional groups: ophthalmologists, optometrists and allied ophthalmic personnel (nursing professionals and paramedical practitioners). The rationale for considering the nursing and paramedical practitioners as a single group within AOPs is that allied ophthalmic personnel play varying roles in different countries. Some of the competencies expected of these personnel can be identified as clinical or nursing competencies. In countries without paramedical cadres, in particular, nurses perform many of the tasks traditionally considered to be in the province of paramedics or ophthalmologists. Countries can, therefore, define which cadres perform these roles and select competencies appropriate to their human resource requirements and structures. WHO African Region | 7 Figure 1: AOPs are a bridge between the community and the ophthalmologist Ophthalmologists and other specialists in eye or general health care Paramedical practitioners (2240) surgical technicians e.g., Ophthalmic clinical officers; non-physician cataract/trichiasis surgeons Nursing professionals (2221) e.g., Specialist nurses; ophthalmic nurses Medical assistants (3256) and others e.g., Ophthalmic assistants, orthoptists (2267), dispensing opticians (3254), ophthalmic technologists, photographers, and imagers (medical imaging assistants - 5329) Primary and community health workers link to health and social services (Figure by Renée du Toit on behalf of the IAPB Human resources for eye health AOP working group) Thereafter, ISCO-08 referencing and coding for the major categories of eye health professionals was used to assist with further categorization to ensure that these would be globally acceptable (Table 2). Table 2: International standard classification of eye health professionals Cadre General reference ISCO - 08 code Description Ophthalmologists Specialist medical practitioners 2212 An ophthalmologist is a medical practitioner who has had specialized post-graduate training in Ophthalmology. Ophthalmologists may further train in subspecialties (not included in this document). They are expected to diagnose, treat (medically and surgically), and prevent eye diseases, ailments and injury, using specialized procedures and techniques, applying principles of modern medicine to deliver comprehensive eye care. They may also diagnose general diseases of the body and treat ocular manifestations of systemic diseases (21-23) Optometrists Other health professionals 2267 Optometrists and ophthalmic opticians provide diagnosis, management and treatment services for disorders of the eye and visual system. They counsel on eye care and prescribe optical aids or other therapies for visual disturbance.2 Allied ophthalmic personnel Paramedical practitioners Nursing professionals 2240 2221 (Source: ILO (2008) International Standard Classification of Occupations (21)) R E F E R R A L D ec re as in g au to no m y In cr ea si ng su p er vi si o n 2 The World Council of Optometry defines optometry as a ‘…health care profession that is autonomous, educated, and regulated (licensed or registered), and optometrists are the primary health care practitioners of the eye and visual system who provide comprehensive eye and vision care, which includes refraction and dispensing, detection or diagnosis and management of disease in the eye, and the rehabilitation of conditions of the visual system. An optometrist has as a minimum successfully completed a bachelor’s degree or equivalent education from a tertiary level educational institution and is categorized minimally in the category of the Global competency-based model of scope of practice in Optometry* which includes optical technology services, visual function services and investigation, examination and evaluation of the eye and adnexa, and associated systemic factors, to detect, diagnose and manage disease. All other formal or informal cadres that fall below this level (e.g., optometric technicians, optometric assistants, opticians, refractionists) are not entitled to call themselves optometrists’. https://worldcouncilofoptometry.info/wp-content/uploads/2017/03/wco_global_competency_model_2015.pdf 8 | Core Competencies for the Eye Health Workforce in the WHO African Region 2.3 Organization of the eye health team The eye health team works in an interdependent manner, with each member strategically assigned specific roles as illustrated in Figure 2. The three eye health professional groups considered in this document: ophthalmologists, optometrists and allied ophthalmic personnel (nursing professionals and paramedical practitioners) practice with a high level of autonomy, as designated by the International Standard Classification of Occupations (ISCO-08) (21). Generalist health care providers at the primary and community level are also a valuable addition to the eye team but are not included here. Figure 2: Organization of the eye health team; categories and codes from the International Standard Classification of Occupations (ISCO-08). Shaded blocks indicate the eye health professionals to whom this document pertains. Eye health team (ISCO-08 Classification) Generalist health care providers (eye health competencies included in general training) Specialist eye health personnel (special or advanced eye health training) Community based Facility based Facility based Allied ophthalmic personnel Community health workers (3253) Front line health workers & primary health care providers (Ophthalmic) Assistants (Medical assistants 3256) (Ophthalmic) Nurses (Nurse professionals 2221) (Ophthalmic) Clinical officers, etc. (Paramedical practitioners 2240) Optometrists (2267) Ophthalmologist (Specialist medical practitioners 2212) (Figure by Renée du Toit on behalf of the IAPB Human resources for eye health working group) CHAPTER 3 Roles of the Eye Health Workforce 10 | Core Competencies for the Eye Health Workforce in the WHO African Region 3 In the development of roles and competencies, this document focuses on the largest three eye health professional groups in the eye health team and whose work is largely autonomous: ophthalmologists, optometrists and AOP - the ISCO-08 categories of paramedical practitioners and professional nurses. 3.1 Introduction The IAPB human resources for eye health working groups identified CanMEDS, a medical education and practice framework, as suitable for adaptation to produce the domains for organizing the eye health competencies. By the end of the process, the 7 CanMEDS roles had been expanded to 10 domains. The roles of the three eye health professional groups in the eye health team3 have been broadly divided into (a) technical or clinical domains and (b) non-clinical domains. Normally, the different cadres share the non-clinical domains (also called collaborative domains) (Figure 3). The overlap indicates those aspects of the roles that are shared. For example, many of the aspects of ‘communicator’ are relevant to both non-clinical and clinical roles (e.g., using clear, simple non-technical language to explain treatment options to a patient (clinical) or when doing advocacy (non-clinical). Competent eye health care providers integrate the competencies of all the roles into their practice (25). Figure 3: Domains of the eye health team: clinical and common or shared non-clinical domains 3.2 Common vs unique technical or clinical competencies The eye health team can also share some clinical or technical competencies (common technical or clinical competencies); however, the competencies may be unique to a group, thus differentiating the work of one group from the work of the other (Figure 4). 3.2.1 ‘Common’ technical or clinical competencies ‘Common’ or shared technical or clinical competencies are those expected of all eye health professionals in the eye team, e.g., taking a history. These can also be seen as competencies that are common or overlapping more than one eye health profession but not necessarily all eye health professions. In the United Kingdom, overlaps in competencies have been used as a strategy to make the most effective use of professional (but non-medical) members of the eye health team such as optometrists, orthoptists, and ophthalmic nurses. Shared or common competencies of the non-medical eye team are listed at three levels of autonomy: • Ability to perform clinical work that assists medical decision-making • Ability to follow a protocol with clearly defined delegated decision-making • Ability to make decisions independently with appropriate support and back up. This enables non-medical members of the eye care team, based on their level of competence, to take on expanded roles to help manage demand and to provide safe and efficient care for patients. This is the rationale for task shifting or sharing (26, 27). Technical/clinical domains • Non-surgical care • Surgical care • Preventive and promotive care • Palliative and rehabilitative care Common non-clinical collaborative domains • Communicator • Leader/Manager • Health Advocate • Community Practitioner • Scholar/Researcher/ Teacher/Mentor/Lifelong Learner • Professional WHO African Region | 11 3.3.2 Unique, ‘complementary’ and technical or clinical competencies Unique, ‘complementary’ and clinical competencies distinguish one profession from another and complement the competencies of other professions. These individual professional competencies are based on the unique aspects of a professional’s practice, and the profession’s unique body of knowledge, skills, attitudes, and judgments. Ophthalmologists and optometrists, for example, have unique expertise in surgical and refractive care competencies respectively. Likewise, the advanced surgical skills of ophthalmologists enable them to manage complex cases and complement the basic surgical skills of a cataract surgeon. These unique clinical competencies differentiate one profession from the other. Figure 4: Common non-clinical competencies and clinical competencies that are either common or unique to eye health professional groups 3.3 Technical or clinical domains The technical or clinical role of the eye health team is to provide comprehensive eye health care that encompasses curative care (assessment and treatment), rehabilitative and palliative care, preventive care, health promotion that is continuous, and high-quality, safe and person-centred care. 3.3.1. Non-surgical care As curative care providers, the eye health team elicit a history, perform an examination, select appropriate investigations, synthesize and interpret results to inform diagnosis; then, advise on management in collaboration with patients and their families as well as with other health providers, depending on the context. 3.3.2 Surgical care The eye team works to provide information and counselling about eye surgery and assists patients to access screening, high-quality and safe surgery, and follow-up care. The team obtains consent for invasive procedures, ensures appropriate care and takes measures for infection control in the pre-, peri-, and post-operative phases. 3.3.3 Preventive and promotive care The eye team counsels patients and their families and provides information to support people to contribute and adhere to management plans, promote eye health, utilize health and social services, support healthy behaviours, and prevent or reduce damage from eye disorders. Common non-clinical competencies Clinical competencies unique to optometrists Clinical competencies unique to allied ophthalmic personnel Clinical competencies unique to ophthalmologists 12 | Core Competencies for the Eye Health Workforce in the WHO African Region 3.3.4 Palliative and rehabilitative care The eye health team helps to provide links to an inclusive, supportive environment. It also facilitates access to rehabilitation and low vision care, including optical and non-optical assistive products to optimize use of the remaining vision. Finally, the eye health team helps provide links to services for those who are irreversibly visually impaired. In addition to this, it provides an inter-professional and multidisciplinary approach to resolving the problems of persons with life-limiting illnesses in order to improve quality of life for both the patient and their family. 3.4 Other common non-clinical collaborative domains The common or collaborative domains of the eye care team are those that are shared by all the three groups and support teamwork, implementation of technical or clinical roles, and inter-professional or collaborative practice. These include the roles played in Sections 3.4.1 to 3.4.6. 3.4.1 Communicator The eye health team member uses the most effective communication methods to obtain, discuss and share information with patients, their families and everyone involved in the patient’s care. This enables individuals, families and communities to make healthy decisions and become partners in their own health. The aim is also to understand the patients’ situation and expectations, meet their eye health needs, and share with them information for decision-making and goal-setting. 3.4.2 Leader and manager The team members work effectively with others, including patients and everyone involved in their management such as health care workers, other service providers, community partners, and others in the health system. The aim is to develop relationships based on trust, respect and shared decision- making among and within multidisciplinary teams, and thus, provide broader leadership in the context of health and social development. As a manager, the team member guides the work of colleagues working with him and assists and motivates them to create a healthy and professional work environment. The absolute goal of management is the achievement of high performance by all members of the team. Moreover, the team member plans and works efficiently to deliver eye health using available human and financial resources. 3.4.3 Health advocate The eye health team members are expected to advocate, in partnership with the community, for increased resources, including workforce allocation for eye health at different levels. 3.4.4 Community practitioner Members of the eye health team are expected to work with the community to ascertain and understand the determinants of health in the physical and social environment, the needs of the community and the potential mechanisms needed to address these. The aim here is to foster good health practices, discourage harmful practices and empower members to harness their own resources and access other available resources. 3.4.5 Scholar-researcher-teacher-mentor-lifelong-learner A team member is expected to demonstrate a lifelong commitment to excellence in practice by gathering information, evaluating and using evidence, continually evaluating the processes and outcomes of his or her own work and that of the teams in which he or she works, sharing and comparing his or her work with that of others, and actively seeking feedback. There is also the expectation that the team member will help patients and families to self-manage their health by providing training and supportive supervision to other health workers. To improve performance, the team member will be expected to engage in continuing personal development. The overall aim here is to use multiple ways of continuous learning to continuously improve the quality of service, increase responsiveness to patient needs, and ultimately achieve universal access to health. 3.4.6 Professional The eye health team member is expected to demonstrate accountability to individual patients and society, to the profession and to self through ethical practice, respect for others’ rights, and high personal standards of behaviour. All this indicates the need for dedication to the profession, commitment to the public good, adherence to ethical standards and values such as integrity, honesty, altruism, respect for diversity, and transparency with respect to potential conflicts of interest. The aim is the improved health and well-being of individuals and patient populations. CHAPTER 4 Competencies for Ophthalmologists 14 | Core Competencies for the Eye Health Workforce in the WHO African Region Table 3: Core competencies for an ophthalmologist CORE COMPETENCIES FOR AN OPHTHALMOLOGIST Domain Competency statement Competency Non-surgical care Conducts patient evaluations 1. Obtains patient history accurately 2. Conducts comprehensive patient evaluations Synthesizes the information to determine the diagnosis 3. Makes a clinical diagnosis based on the information gathered from the patient Formulates and implements appropriate management plans 4. Plans management together with patient or guardian and other health professionals with the available information 5. Identifies and manages ophthalmic emergencies and trauma 6. Refers patients as appropriate 7. Manages health information accurately and safely Surgical care Performs safe surgery 8. Performs safe and high-quality surgery 9. Maintains proficiency in standard surgical procedures (Refer to Annex VI(a)) Preventive and promotive care Provides health promotion to preserve and optimize eye health 10. Counsels patients & families on aspects of their eye health 11. Educates patients and the public on good health practices 12. Provides advice & educates employers and employees on eye health and protective measures at work and in different social environments Palliative and rehabilitative care Facilitates access to comprehensive care and social inclusion 13. Facilitates access to vision rehabilitation, rehabilitation of the blind, social and educational resources, and periodic re- evaluations 14. Facilitates access to palliative care following a multidisciplinary team approach WHO African Region | 15 Table 4: Components of the competencies for an ophthalmologist and related knowledge, skills and behaviours DOMAIN 1. NON-SURGICAL CARE: Clinical evaluation, diagnosis and treatment Competency Knowledge, skills and behaviours Obtains patient history accurately Knowledge: General information, including clinical manifestations and epidemiology of all eye diseases, and ocular manifestations of other systemic diseases; basic concepts and communication skills Skills: Obtains relevant information to identify the patient’s clinical problem Behaviours: Effective communication with patients, guardians, family members and other health care providers Conducts comprehensive patient evaluations Knowledge: General anatomical and physiological functioning of the ocular system; clinical presentation of common eye and systemic disorders, and use of suitable diagnostic procedures Skills: Evaluates systemic, ocular and visual systems Behaviours: Uses appropriate diagnostic tools proficiently to do comprehensive evaluations Makes clinical diagnoses based on the information gathered from the patient Knowledge: General ophthalmic clinical sciences, including gross ocular anatomy; histology, embryology, physiology, microbiology, pharmacology, biochemistry, refraction and genetics; clinical ophthalmology: principles, practice and clinical presentations Skills: Makes diagnoses using gathered history, examination findings; thinks critically based on gathered information Behaviours: Demonstrates ability to synthesize all data and information from history, examination, and investigation; uses findings to systematically make clinical diagnoses Plans management together with the patient or guardian and other health professionals using available information Knowledge: Determines the different options available for interventions (medical, surgical or optical, etc.) to resolve an identified problem and follow up outcomes Skills: Identifies the most appropriate intervention or treatment plan for the patient Behaviours: Communicates treatment options to enable the patient to make an informed decision Identifies and manages ophthalmic emergencies and trauma Knowledge: Possesses a good background in general medical emergencies, and in ophthalmic emergencies, Ocular Trauma Skills: Identifies general and ophthalmic emergencies; manages ophthalmic emergencies (medical & surgical); refers patients or involves other specialists Behaviours: Uses clinical judgment and critical appraisal decision- making; Identifies and manages with a sense of urgency; Ensures services are always available to manage emergencies 16 | Core Competencies for the Eye Health Workforce in the WHO African Region DOMAIN 1. NON-SURGICAL CARE: Clinical evaluation, diagnosis and treatment Refers patients as appropriate Knowledge: Is familiar with the overall scope of ophthalmology, and with the limitations and roles of other health personnel Skills: Identifies patients requiring further assessment or management Behaviours: Demonstrates ability to collaborate with other health professionals and clinical experts, and people from different health and non-health sectors; is a team player Manages health information accurately and safely Knowledge: Meets ethical and legislative requirements for obtaining, recording, storing, retaining and destroying patient records and other office documentation; has knowledge of the information system and how to analyse information Skills: Records patient information and data in a legible, secure, accessible, permanent and unambiguous manner; uses electronic records Behaviours: Maintains confidentiality of patient records DOMAIN 2. SURGICAL CARE: Performs safe surgery Performs safe and high- quality surgery Knowledge: The different surgical options for general or common eye conditions (Annex VI(a)), including emergencies; indications for certain procedures (surgical operations) and alternatives; description of a procedure in a systematic manner (including giving step-by-step explanations); knowledge of different approaches and of post-surgical management, including any anticipated complications; proficiency in follow-up, including referral if needed Skills: Prepares patients clinically and psychologically for specific procedures; performs standard surgical procedures (Annex VI(a)) Behaviours: Participates in patient assessments; observes and assists senior colleagues in carrying out procedures; accepts to be supervised by senior colleagues; counsels patients on procedures; is proficient in all standard surgical procedures; collects and records data; is proficient in the use of available equipment and instruments; displays the standard procedures and protocols to be used in theatre appropriately for quick reference Maintains proficiency in all surgical procedures Knowledge: Is proficient in all surgical procedures; knows the role of clinical audits Skills: Develops and maintains proficiency in all surgical skills; submits to updating personal skills through self-improvement in new procedures (CPD); performs all surgical procedures within scope (Refer Annex VI(a)) Behaviours: Can perform self-audits; can participate in structured wet lab activities and training; can use simulators and the wet (skills) lab. WHO African Region | 17 DOMAIN 3. PREVENTIVE AND PROMOTIVE CARE: Provide health promotion to preserve and optimize eye health Counsels patients and families on aspects of their eye health Knowledge: Is proficient in epidemiology and the natural history of common eye diseases in the Region, including outcomes after seeking early treatment; identifies cultural beliefs and practices around eye health issues Skills: Breaks communication barriers; effectively communicates to communities and patients to encourage positive health-seeking behaviours and adherence to treatment Behaviours: Displays a non-judgmental, friendly, attitude, recognizing socio-cultural and patient differences Educates patients and the public on good eye health practices Knowledge: Proficient in the basic principles of education and promotive health practices, e.g., hygiene, immunization, and nutrition Skills: Effectively communicates the benefits of good health practices, avoiding harmful traditional practices Behaviour: Displays good health habits Provides advice and educates employers and employees on eye health and protective measures in the workplace and other social environments Knowledge: Has a mastery of occupational and environmental health; of eye protection, vision and ergonomics Skills: Improves the workplace environment and cares for protective eye equipment and eye wear Behaviours: Is supportive, respectful and proactive in preventing eye injuries in the workplace and in different social environments Domain 4. PALLIATIVE AND REHABILITATIVE CARE: Facilitate access to comprehensive care and social inclusion Facilitates access to vision rehabilitation; rehabilitation of the blind; social and educational resources; and undertakes periodic re-evaluations Knowledge: Mastery of the principles of low vision; and of rehabilitation of visually impaired and blind persons Skills: Identifies patients who need low vision and rehabilitation services Behaviours: Supports solutions to improve the quality of life in low vision patients in different circumstances; refers patients to appropriate services and re-evaluates them periodically Facilitates access to palliative care through a multidisciplinary team approach Knowledge: Is proficient in medicine, ophthalmology and oncology Skills: Works in a team and communicates effectively Behaviours: Shows empathy 18 | Core Competencies for the Eye Health Workforce in the WHO African Region CHAPTER 5 Competencies for Optometrists 20 | Core Competencies for the Eye Health Workforce in the WHO African Region Table 5: Core competencies for an optometrist CORE COMPETENCIES FOR AN OPTOMETRIST Domain Competency statement Competency Non-surgical care Obtains the relevant patient history Makes general observations of patients Obtains case histories Conducts comprehensive patient evaluations Formulates examination plans Implements examination plans Assesses the ocular adnexa and the eye Assesses central and peripheral sensory visual function and the integrity of visual pathways Assesses refractive status Assesses oculomotor and binocular function Assesses visual information processing Assesses the significance of signs and symptoms found incidental to ocular examinations in relation to the patient’s eye or general health Synthesizes information to determine diagnoses Interprets and analyses findings to establish diagnoses Formulates appropriate management plans Designs management plans for individual patients and implements the plans agreed to with the patients Prescribes spectacles Prescribes contact lenses Manages patients requiring vision therapy Treats ocular disorders and injuries using appropriate pharmacological treatment regimens within the permissible scope or refers patients appropriately Dispenses optical prescriptions accurately Ensures emergency optometric care is available Manages health information accurately and safely Surgical care Supports ophthalmologists in pre- and post-operative patient management Identifies patients that require surgical management and refers them appropriately Conducts pre- and post-surgical examinations and observations in collaboration with a surgeon Conducts in-theatre objective refraction Preventive and promotive care Provides health promotion to preserve and optimize eye health Utilizes available resources to enhance patient outcomes Provides advice on vision and eye health and takes protective measures in the workplace and in the social environment Palliative and rehabilitative care Facilitates access to low vision services, rehabilitation, and social inclusion Provides for the care of patients with special needs Prescribes low vision devices and non-optical interventions WHO African Region | 21 Table 6: Components of competencies for an optometrist Domain 1. NON-SURGICAL CARE: Clinical evaluation, diagnosis and treatment Competency Knowledge, skills and behaviours Makes general observations of patients Knowledge: Proficiency in the fundamentals of general and gross anatomy of the human body; in normal aspects of gait and posture. Skills: Observes, recognizes and explores relevant physical and behavioural characteristics of patients Behaviours: Is observant, perceptive, and investigative Obtains case histories Knowledge: In-depth knowledge of the biomedical, visual, and clinical sciences; of clinical optometry, relevant clinical ophthalmology, common problems encountered in health care with emphasis on ocular manifestations Skills: Breaks communication barriers; elicits relevant history from patients Behaviours: Has inter-personal rapports and understanding; is an active listener and shows empathy Formulates examination plans Knowledge: In-depth knowledge of the biomedical, visual & clinical sciences; of clinical optometry and relevant clinical ophthalmology; of structured clinical optometric evaluations and procedures Skills: Organizes and interprets information; conducts selective or oriented assessments and diagnostic tests Behaviours: Is an analytical and critical thinker; is flexible Implements examination plans Knowledge: Has a general understanding of eye health systems; clinical optometry; relevant clinical ophthalmology; structured clinical optometric evaluations and procedures Skills: Conducts clinical ophthalmic or optometric tests and procedures; is conversant with standard precautions Behaviours: Is proficient, confident and secure in using available tools to perform tests Assesses the ocular adnexa and the eye Knowledge: Has in-depth knowledge of gross human and ocular anatomy and physiology; of the function of the ocular adnexa, and of relevant ocular pharmacology Skills: Can evaluate the external anatomical structure of the eye and how it functions Behaviours: Is observant, demonstrates a clear understanding of normal from abnormal structures; is culturally sensitive Assesses central and peripheral sensory visual function and the integrity of visual pathways Knowledge: Has in-depth knowledge of the biomedical and (neuro) visual sciences; has a general understanding of eye health systems, clinical optometry, relevant clinical ophthalmology, and clinical optometric procedures Skills: Can test for comprehensive visual functions Behaviours: Can conduct various optometric assessments with confidence; is analytical in interpretation of test outcomes 22 | Core Competencies for the Eye Health Workforce in the WHO African Region Domain 1. NON-SURGICAL CARE: Clinical evaluation, diagnosis and treatment Competency Knowledge, skills and behaviours Assesses refractive status Knowledge: Has in-depth knowledge of the biomedical and (neuro) visual sciences; has a general understanding of eye health systems; of clinical optometry; relevant clinical ophthalmology; clinical optometric procedures; ocular and diagnostic pharmacology Skills: Can determine the refractive status of the eye (subjectively and objectively); can use relevant pharmacological agents to establish refractive status Behaviours: Has proficiency in using tools for and conducting refractive testing, e.g., the use of retinoscopes, ophthalmoscopes, refraction bars, autorefractors Assesses oculomotor and binocular function Knowledge: Has in-depth knowledge of the biomedical, visual, and clinical sciences; has a general understanding of eye health systems; clinical optometry, relevant clinical ophthalmology, clinical optometric procedures Skills: Can identify abnormal oculomotor functions and conduct orthoptic assessments; can test binocular vision Behaviours: Is analytical in interpretations of test outcomes; is proficient, confident, adaptable, and culturally sensitive Assesses visual information processing Knowledge: Has in-depth knowledge of the biomedical and (neuro) visual sciences; has a general overview of eye health systems, clinical optometry, relevant clinical ophthalmology, clinical optometric procedures, visual information processing, development milestones, and learning problems; is conversant with image fusion, binocular single vision, and stereopsis Skills: Can use visual processing assessment tools Behaviours: Is proficient in using different tools; is observant and analytical Assesses the significance of signs and symptoms found incidental to ocular examinations in relation to the patients’ eye or general health * Knowledge: Has in-depth knowledge of the biomedical, visual and clinical sciences; has a general overview of eye health systems, clinical optometry, relevant clinical ophthalmology, clinical optometric procedures, and common systemic diseases Skills: Can recognize and act on incidental clinical findings Behaviours: Is an analytical and critical thinker; is proactive with referrals Interprets and analyses findings to establish diagnoses Knowledge: Has in-depth knowledge of the biomedical and visual sciences; has a general overview of eye health systems, clinical optometry, relevant clinical ophthalmology, ocular pharmacology, and clinical optometric procedures Skills: Can analyse, synthesize and correlate clinical findings Behaviours: Can analyse, reflect on and use all clinical and diagnostic findings WHO African Region | 23 Domain 1. NON-SURGICAL CARE: Clinical evaluation, diagnosis and treatment Competency Knowledge, skills and behaviours Designs management plans for individual patients and implements the plans agreed to with the patients Knowledge: Knows available clinical interventions and management options; is conversant with the course and prognosis of conditions; follows best practice Skills: Can formulate appropriate patient-centred management plans Behaviours: Reasons deductively; is problem-oriented; has clinical judgment; communicates well with patients and their families Prescribes spectacles Knowledge: Has in-depth knowledge of refraction and the visual sciences; is conversant with refractive correction modalities, binocular status, prescribing indications and philosophies, appliance and lens modalities and adjustments Skills: Can determine optical prescriptions based on individual patient needs Behaviours: Is understanding, empathic, supportive, flexible, culturally sensitive, and respectful; assists patients in the use of spectacles Prescribes contact lenses * Knowledge: Has in-depth knowledge of refraction, binocular status, prescribing indications and philosophies, biomedical, visual and clinical optometry sciences, contact lens modalities, contact lens indications, contra-indications, maintenance, and complications Skills: Can accurately determine contact lens fit and modality based on individual patient status and visual requirements Behaviours: Is understanding, empathic, and supportive; can confidently assist patients who use contact lenses Manages patients requiring vision therapy * Knowledge: Has in-depth knowledge of the biomedical and visual sciences; has an overview of eye health systems, clinical optometry, relevant clinical ophthalmology, clinical optometric procedures, and oculomotor and binocular vision; is conversant with the different approaches to vision therapy Skills: Can manage binocular vision anomalies using vision therapy Behaviours: Can critically appraise and analyse situations; can reason deductively and make clinical judgments; can support patients optimize residual vision; can offer vision therapy Treats ocular disorders, diseases and injuries using appropriate pharmacological treatment within the permissible scope or refers patients appropriately regimens. Knowledge: Has in-depth knowledge of the biomedical and visual sciences; has an overview of eye health, clinical optometry, relevant clinical ophthalmology, pharmacology, therapeutic pharmacology, basic anatomy and the physiology of the eye Skills: Can select appropriate pharmacological agents for the treatment of patient disorders within the scope of practice (Annex VI(b)) Behaviours: Can critically appraise and analyse situations; reasons deductively; exercises clinical judgment; manages creatively and is always ready to refer; can self-evaluate; is confident and recognizes personal and legal limitations 24 | Core Competencies for the Eye Health Workforce in the WHO African Region Domain 1. NON-SURGICAL CARE: Clinical evaluation, diagnosis and treatment Competency Knowledge, skills and behaviours Dispenses optical prescriptions accurately Knowledge: Has in-depth knowledge of the principles of vision and refractive status, ophthalmic optics, characteristics of spectacles, and the anatomy of the head and neck; is conversant with basic visual ergonomics Skills: Can interpret spectacle prescriptions according to patient needs; can fit spectacles Behaviours: Is understanding, empathic, supportive, and confident when communicating Ensures emergency optometric care is available Knowledge: Has in-depth knowledge of the biomedical and visual sciences; has a general overview of eye health systems, clinical optometry, relevant clinical ophthalmology, and clinical optometric procedures; can manage emergencies in optometry Skills: Can plan or organize for emergency optometric services; can identify optometric and other medical emergencies Behaviours: Shows empathy with patients in distress; allows needed use of time; employs a flexible management approach; reports optometric emergencies; refers other medical emergencies; is understanding, supportive, flexible, and culturally sensitive Manages health information accurately and safely Knowledge: Has deep knowledge of the ethical and legislative requirements for obtaining, recording, storing, retaining and destroying patient records and other office documentation; is knowledgeable about information systems Skills: Can record patient information and data in a legible, secure, accessible, permanent, and unambiguous manner, including in electronic format Behaviours: Can maintain confidentiality of patient records DOMAIN 2. SURGICAL CARE: Support of ophthalmologists in pre- and post-operative management of patients Competency Knowledge, skills and behaviours Identifies patients that require surgical management and refers them appropriately Knowledge: Has in-depth knowledge of the biomedical, visual and clinical sciences; of general eye health and referral systems; of clinical optometry, relevant clinical ophthalmology, clinical optometric procedures, and of available surgical options Skills: Can identify and refer patients who need surgery Behaviours: Can make critical appraisals and analyses; exudes confidence and is adaptable; can take decisions; recognizes personal and legal limitations; is a team player Conducts pre- and post- surgical examinations and observations in collaboration with a surgeon Knowledge: Has in-depth knowledge of the biomedical and visual sciences; has a general overview of eye health systems, clinical optometry, relevant clinical ophthalmology, clinical optometric procedures, available surgical options; can determine pre-operative indications and requirements, and manage post-operative outcomes Skills: Can evaluate selected patients before and after surgical procedures; can take standard precautions Behaviours: Is proficient, confident, flexible and ethical; can maintain inter-professional rapport WHO African Region | 25 DOMAIN 2. SURGICAL CARE: Support of ophthalmologists in pre- and post-operative management of patients Competency Knowledge, skills and behaviours Conducts in-theatre objective refractions Knowledge: Has in-depth knowledge of refraction and the visual sciences; has knowledge of refractive assessments and correction modalities; and of prescribing indications and philosophies Skills: Performs objective refraction to determine patient refractive status and manage accordingly Behaviours: Shows proficiency and confidence in both objective and subjective refraction DOMAIN 3. PREVENTATIVE AND PROMOTIVE CARE: Provide health promotion to preserve and optimize eye health Competency Knowledge, skills and behaviours Utilizes available resources to enhance patient outcomes Knowledge: Knows the functions of and resources available from optometric and other organizations; the roles of organizations and government bodies such as health ministries, registration authorities, and professional associations Skills: Understands and can use available resources; can appraise information; understands local health and eye health systems Behaviours: Is understanding, supportive and resourceful; can collaborate with other team members and cross-sectoral services Provides advice on vision and eye health and takes protective measures in the workplace and the social environment Knowledge: Has in-depth knowledge of refraction, the visual sciences, refractive correction modalities, binocular status, occupational and environmental optometry, eye protection and visual ergonomics, vision standards, disability-friendly environments Skills: Improves home and institutional environments to maximize vision and comfort Behaviours: Is understanding, empathic, supportive, confident, flexible, culturally sensitive, and respectful; is proactive in preventing eye injuries at the workplace or in different social environments DOMAIN 4. PALLIATIVE AND REHABILITATIVE CARE: Contribute to and facilitate access to low vision services, rehabilitation and social inclusion Competency Knowledge, skills and behaviours Provides for the care of patients with special needs Knowledge: Has in-depth knowledge of the biomedical and visual sciences; has a general overview of eye health systems, clinical optometry, basic ophthalmology, and clinical optometric procedures; is conversant with inclusive eye care. Skills: Can identify patients with special needs Behaviours: Is understanding, empathic, supportive, confident, flexible, culturally sensitive, and respectful 26 | Core Competencies for the Eye Health Workforce in the WHO African Region DOMAIN 4. PALLIATIVE AND REHABILITATIVE CARE: Contribute to and facilitate access to low vision services, rehabilitation and social inclusion Competency Knowledge, skills and behaviours Prescribes low vision devices and non-optical interventions Knowledge: Has in-depth knowledge of refraction, the visual sciences, the classification of visual impairment and low vision, low vision management options, and indications for rehabilitation services Skills: Conducts patient-centered low vision assessments; communicates low vision needs of patients; can collaborate with other players Behaviours: Is understanding, empathic, supportive, confident, flexible, culturally sensitive, respectful, and patient; assists patients with low vision devices (Refer to Annex VI(b)) * CHAPTER 6 Core Competencies for Allied Ophthalmic Personnel 28 | Core Competencies for the Eye Health Workforce in the WHO African Region Allied ophthalmic personnel play varying roles in different countries. Some of the competencies expected of these staff can be identified as clinical or nursing competencies, or both. Countries can define which cadres perform these roles and select competencies appropriate to their human resource requirements and structures. Table 7: Core competencies for allied ophthalmic personnel CORE COMPETENCIES FOR ALLIED OPHTHALMIC PERSONNEL Domain Competency statement Competency Non-surgical care Conducts patient evaluations 1. Creates a welcoming and patient-friendly environment 2. Obtains relevant patient history 3. Conducts basic patient clinical examinations and investigations Synthesizes the information to determine a diagnosis 4. Makes diagnoses based on information gathered from the patient and knowledge in the ophthalmic clinical sciences Formulates and implements management plans 5. Plans treatment together with the patients or their guardians and other health professionals using the available information 6. Develops appropriate management and care plans for ophthalmic medical patients 7. Administers medications relevant to eye care 8. Recognizes and refers patients as required 9. Manages health information accurately and safely Surgical care Works with ophthalmologists in the provision of safe surgery 10. Identifies and assesses patients for surgery 11. Obtains consent for treatments and surgery 12. Prepares patients for surgical procedures and treatment 13. Ensures infection prevention; ensures that aseptic techniques are observed 14. Assists in providing safe surgery by facilitating implementation of standards and safety measures 15. Administers local anaesthesia for cataract, glaucoma and other intraocular procedures 16. Performs minor surgery (**Annex VI(a)) 17. Performs cataract surgery according to skill level (**Annex VI(a)) 18. Manages ophthalmic wounds 19. Develops management plans for the care of ophthalmic surgical patients 20. Assesses and manages pain 21. Manages and refers post-operative complications as appropriate Preventive and promotive care Provides health promotion to preserve and optimize eye health 22. Counsels patients and their families on aspects of their eye health 23. Educates patients on good health practices 24. Plans and participates in community health promotion and education activities WHO African Region | 29 CORE COMPETENCIES FOR ALLIED OPHTHALMIC PERSONNEL Domain Competency statement Competency Palliative and rehabilitative care Facilitates access to comprehensive care and social inclusion 25. Conducts basic low vision assessments and assist in the use of assistive products 26. Facilitates and follows up access to rehabilitation and social inclusion 27. Refers patients appropriately Table 8: Components of the competencies for allied ophthalmic personnel DOMAIN 1. NON-SURGICAL CARE: Clinical evaluation, diagnosis, treatment and care Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Creates a welcoming and patient friendly environment Knowledge: Basics of the cultural context; management of common eye diseases; technical procedures carried out at different levels of care and expected outcomes Skills: Effective use of relevant information to identify patient clinical problems Behaviours: Effective communication Obtains relevant patient history Knowledge: Basic information in epidemiology and clinical presentation of common eye diseases Skills: Effective use of relevant information to identify the patient clinical problems Behaviours: Interpersonal and communication skills; readiness to discuss with patients and guardians; interaction with eye care team; ability to read communications or talk to other professionals to improve skills Conducts basic patient clinical examinations and investigations Knowledge: Knowledge of gross anatomical and physiological functioning of the ocular system Skills: Use of appropriate tools and equipment (including laboratory tools and equipment) to examine the anatomical and physiological functioning of the ocular and visual systems Behaviours: Appraisal and utilization of appropriate tools and laboratory services Makes diagnoses based on information gathered from the patient and knowledge in the ophthalmic clinical sciences Knowledge: Basic ophthalmic clinical sciences, including ocular anatomy, embryology, physiology, microbiology, pharmacology, biochemistry, and refraction Skills: Ability to point to a provisional diagnosis using data gathered from evaluation and knowledge of ophthalmic clinical sciences Behaviours: Use of clinical, laboratory and other data to make diagnoses Plans treatments together with the patients or their guardians and other health professionals using available information Knowledge: Available options for interventions (medical, surgical, optical, etc.) where they can be sourced; outcomes of the identified problems or diagnoses Skills: Identify and administer the best treatment option for the patient Behaviours: Analyze previous treatment options and outcomes where available 30 | Core Competencies for the Eye Health Workforce in the WHO African Region DOMAIN 1. NON-SURGICAL CARE: Clinical evaluation, diagnosis, treatment and care Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Develops appropriate management and care plans for ophthalmic medical patients Knowledge: Basic anatomy, physiology and pathology of eye diseases; clinical presentations and treatment (medical or surgical) of common eye diseases Skills: Develop and execute nursing treatment and care plans for patients who have undergone medical and surgical eye care Behaviours: Share care plans with the eye care team; ensure seamless patient flow Administers medications relevant to eye care Knowledge: Basic ocular system: anatomy, physiology, microbiology and pharmacology; basic essential medicine principles; practical considerations in the administration of oral, parenteral, eye drops and ointments, including undesirable effects and possible allergic reactions; proper storage of medications Skills: Correct drug administration techniques Behaviours: Demonstrate safe and professional management of drugs and other medical products; educate patients on their drug therapy, including patient self-administration of eye preparations and their storage Recognizes and refers patients as required Knowledge: Scope of practice of AOP; their limitations; role of other health personnel; knowledge of the referral pathways in the country Skills: Identify when treatment options do not give optimal outcomes due to limited scope (personnel skills or facilities); triage Behaviours: Willingness to collaborate with other higher-level health professionals (members of the team) or clinical experts; team players in ophthalmology, including social services and education Manages health information accurately and safely Knowledge: Ethical and legislative requirements in obtaining, recording, storing, retaining and destroying patient records and other office documentation Skills: Record patient information and data in a legible, secure, accessible, permanent and unambiguous manner, including in electronic records Behaviours: Maintain confidentiality of patient records DOMAIN 2. SURGICAL CARE: Work with ophthalmologists in the provision of safe surgery Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Identifies and assesses patients for surgery Knowledge: The different surgical options for common eye conditions in the Region; pre-operative requirements and criteria for the different surgical procedures Skills: Perform standard pre-op assessments for general and common surgical procedures; use diagnostic equipment and tools for assessment; counsel patients on the details of surgical procedures Behaviours: Demonstrate confidence in clinical assessments and communication; ensure that all equipment needed for assessments are in good working order WHO African Region | 31 DOMAIN 2. SURGICAL CARE: Work with ophthalmologists in the provision of safe surgery Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Obtains informed consent for treatments or surgery Knowledge: Knowledge of procedures, processes, and outcomes of all ophthalmic surgical and medical treatments; and of ethical principles Skills: Counsel patients for different ophthalmic procedures; explain to patients the processes and outcomes of treatments Behaviour: Demonstrate good communication skills; assist patients to freely make informed decisions and give informed consent Prepares patients for surgical procedures or treatment Knowledge: Basic anatomy, physiology and pathology of eye diseases; clinical manifestations and treatment (medical or surgical) of common eye diseases; principles and practices of ophthalmic surgery; practical aspects of pre- operative preparation in ophthalmic surgery, including basic visual assessment Skills: Prepare the patients for different surgical procedures or treatments Behaviours: Assist and participate in all surgical and medical ophthalmic procedures Ensures infection prevention and ensures that aseptic techniques are observed Knowledge: Basic ocular anatomy, physiology, microbiology, pharmacology; principles and practice of aseptic techniques, including hand hygiene; standard infection prevention; safety strategies, including the different processes of disposal, decontamination, disinfection and sterilization Skills; Provide sterile and safe working environments for the eye care team; development of surgical safety checklists Behaviours: Practice of aseptic techniques; safe waste disposal; conduct of continuous safety checks before, during, and after surgery; report unexpected outcomes Assists in providing safe surgery by facilitating implementation of standards and safety measures Knowledge: Basic anatomy, embryology and physiology of the eye; different surgical options for general or common eye disorders; theoretical and practical (descriptions) steps in the different surgical procedures; instruments and machines used for different procedures Skills: Assess capacity and readiness for specific surgical procedures Behaviours: Display appropriately for quick reference standard procedures and protocols to be used in the theatre; report unexpected outcomes Administers local anesthesia for cataract, glaucoma and other intraocular surgical procedures Knowledge: Detailed anatomy of the eye orbit and its contents; pharmacology of available local anesthetics; critical risks and events Skills: Infiltrate local anesthetic solutions or instill topical anesthesia appropriately and safely; monitor patients during and after administration of local anaesthesia Behaviours: Confident while administering local anesthesia 32 | Core Competencies for the Eye Health Workforce in the WHO African Region DOMAIN 2. SURGICAL CARE: Work with ophthalmologists in the provision of safe surgery Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Performs minor surgery (Refer to Annex VI(a)) Knowledge: Detailed anatomy, embryology, physiology and pathology of the ocular adnexa Skills: Perform minor extra-ocular surgical procedures Behaviour: Demonstrate proficiency in the extra-ocular procedures Performs cataract surgery according to skill level (Refer to Annex VI(a)) Knowledge: Detailed anatomy, embryology and physiology of the eyeball and orbit (including the lens); ageing; complications of cataract surgery, including posterior capsule opacification; the physics and functioning of lasers Skills: Perform cataract surgery and manage complications Behaviours: Use of wet-lab facilities to maintain and improve on skills; demonstration of proficiency in cataract surgery Manages ophthalmic wounds Knowledge: Basic ocular anatomy, physiology, microbiology, and pharmacology; infection prevention; practical aspects of wound asepsis and healing Skills: Ability to dress, pad and bandage the eye Behaviours: Demonstrate sterile and adequate techniques during management of eye disorders Develops appropriate management plans for care of ophthalmic surgical patients Knowledge: Basic anatomy, physiology, and pathology of eye diseases; clinical manifestations and treatment (medical and surgical) of common eye diseases Skills: Develop and execute nursing treatments and care plans for patients who have undergone medical or surgical eye care Behaviours: Share care plans with the eye care team; ensure seamless patient flow Assesses and manages pain Knowledge: Causes of pain after different surgical procedures; principles of pain management in ophthalmology after surgery Skills: Administer and interpret pain scoring scales; manage pain Behaviours: Recognize, empathize, and manage patients in pain Manages and refers post-operative complications as appropriate Knowledge: Possible complications of different surgical procedures; principles of minor complications in ophthalmology after surgery; knowledge of referral systems Skills: Manage minor complications as appropriate; refer patients Behaviours: Recognize and empathize with patients; willingness to collaborate with other higher-level health professionals WHO African Region | 33 DOMAIN 3. PREVENTIVE AND PROMOTIVE CARE: Provide health promotion to preserve and optimize eye health Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Counsels patients and their families on aspects of their eye health Knowledge: The natural history of common eye diseases, including outcomes after seeking early treatment; cultural beliefs and practices surrounding eye health issues Skills: Effectively counsel patients and families to encourage, positive health- seeking behaviours and adherence to treatment; support patient self-management, especially for people at risk or requiring long or lifetime care Behaviours: Display a non-judgmental, friendly, attitude; recognize socio-cultural and patient factors Educates patients on good health practices Knowledge: Basic principles of health education and promotive health practices, e.g., hygiene, immunization, and nutrition Skills: Effectively communicate the benefits of good health practices; avoid harmful practices Behaviours: Acknowledge and display good health practices Plans and participates in community health promotion and education activities Knowledge: Basic epidemiology of common eye diseases; principles of planning; diagnosis and dialogue within the community; community engagement and mobilization; theories, principles and concepts of communication Skills: Effectively communicate eye health issues to the communities Behaviours: Display interpersonal skills; participate in community eye health promotion and education activities in a spirit of collaboration with other professional communicators DOMAIN 4. PALLIATIVE AND REHABILITATIVE CARE: Facilitate access to comprehensive care and social inclusion Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Conducts basic low vision assessments and assist in the use of assistive products Knowledge: Categories of visual impairment; definition of low vision; basic knowledge of refraction; optical and non-optical support for low vision; patients with different eye disorders Skills: Conduct basic (but not limited to) low vision assessments; identify and manage low vision and refer patients appropriately Behaviours: Support in providing basic solutions to improve quality of life in low vision patients under different circumstances; assist patients to use basic low vision assistive products appropriately Facilitates and follows up access to rehabilitation and social inclusion Knowledge: Required rehabilitation services, where available; and integrated and special needs schools Skills: Identify needs and refer patients for rehabilitation or special placement Behaviours: Work with other non-technical members of the eye health team; communicate rehabilitation needs appropriately; advise, support and empower families to utilize services and engage in inclusive education 34 | Core Competencies for the Eye Health Workforce in the WHO African Region CHAPTER 7 Common Non-Clinical Core Competencies for the Eye Health Workforce 36 | Core Competencies for the Eye Health Workforce in the WHO African Region Table 9: Common non-clinical core competencies for the eye health team NON-CLINICAL CORE COMPETENCIES FOR THE EYE HEALTH WORKFORCE Domain Competency statement Competency Communicator Obtains, discusses, and shares information with patients, their families, and everyone involved in caring for the patient Communicates effectively with the health care team, the patients, their families, the community, and other relevant stakeholders Uses relevant communication principles to improve patient eye care Leader and manager Provides leadership in the delivery of quality eye care Provides guidance to promote teamwork and collaboration, good work-life balance, and a healthy workplace environment Promotes quality person-centred integrated eye care services Develops multidisciplinary relationships and partnerships to promote quality, people-centred, and integrated eye care services Facilitates opportunities for community eye health services in all sectors Participates in inter-professional health care activities at all levels Manages available resources for the effective delivery of quality eye care Manages available resources in a way that facilitates the work of the eye health team in the delivery of services Health advocate Promotes change at the policy and community level Advocates for relevant policy changes Uses available policies for district planning and implementation of eye care plans Community practitioner Participates in community development programmes Conducts and appropriately presents community needs assessments Scholar, researcher, teacher, mentor, and lifelong learner Maintains and enhances knowledge and skills through lifelong learning; adopt best practices and standards through the evidence-based approach Performs comprehensive clinical interventions, audits, and reviews Engages in research Promotes, plans and facilitates lifelong learning, including continuing professional development Professional Acts in accordance with the legal framework and professional standards of public good ethical behaviour and practice, commitment and accountability Practices within the existing national legal framework governing general and eye care practice Practices in accordance with professional ethics and code of conduct Adheres to human rights tenets and maintains human dignity Maintains a good work-life balance WHO African Region | 37 Table 10: Components of the common non-clinical competencies for the eye health team DOMAIN 5. COMMUNICATOR: Obtain, discuss and share information with patients, their families and everyone involved in caring for the patient Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Communicates effectively with the health care team, patient, family, community and other relevant stakeholders Knowledge: Theories, principles, concepts, and methods of effective communication and conflict resolution Skills: Communicates clearly using language appropriate to the person(s) with whom he or she is communicating; uses effective written, verbal and non-verbal communication; has active listening skills Behaviours: Displays mediation and interpersonal skills; provides feedback; is friendly, empathetic and respectful; collaborates with other professions Uses relevant communication principles to improve patients eye care Knowledge: Theory and principles of social and behavioural change communication (SBCC) (Ref. Annex SBCC) Skills: Applies the components of SBCC; is conversant with communication techniques; follows appropriate channels Behaviours: Communicates and collaborates with other professionals DOMAIN 6. LEADER AND MANAGER: Provide leadership, develop multidisciplinary relationships and partnerships, manage available resources to deliver quality people-centred and integrated eye care services Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Provides guidance to promote teamwork and collaboration, good work-life balance, and a healthy workplace environment Knowledge: Principles, concepts, and practices in leadership and organizational management; concept of work-life balance, and of healthy workplace environments; time management strategies Skills: Has communication and interpersonal skills; knows how to demonstrate support for eye care team; has time management skills Behaviours: Guides, supports, delegates, motivates, and inspires the eye health team to work together effectively and within a healthy work environment; maintains adequate work-life balance Promotes quality person-centred integrated eye care services Knowledge: Health systems concepts and approaches; integrated patient- centred health care concepts; continuous quality improvement strategies Skills: Prioritizes, and plans to continually improve quality care and maintain the continuum of care Behaviours: Sets priorities; participates with and supports other team members; is a facilitator Facilitates opportunities for community eye health services in all sectors Knowledge: Role of government ministries and other partners in health at all levels; national and local planning cycles and timing; principles of good partnerships and relevant stakeholder engagements Skills: Identifies opportunities for partnerships; can mobilize resources; can write proposals Behaviours: Participates in joint fora; initiates partnerships for eye health 38 | Core Competencies for the Eye Health Workforce in the WHO African Region DOMAIN 6. LEADER AND MANAGER: Provide leadership, develop multidisciplinary relationships and partnerships, manage available resources to deliver quality people-centred and integrated eye care services Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Participates in inter- professional health care at all levels Knowledge: Understands the role of other health care providers in eye health Skills: Communicates effectively for inter-disciplinary eye care case management Behaviours: Promotes cross-sectoral cooperation; participates in joint patient care Manages available resources in a way that facilitates the work of the eye health team in the delivery of services Knowledge: Management principles for financial and human resources, including management of infrastructure (buildings and equipment) and logistics; interpersonal skills Skills: Can plan and monitor budgets; delegates appropriately; practises preventive maintenance of equipment Behaviours: Works effectively with the management team DOMAIN 7. HEALTH ADVOCATE: Promote change at the policy and community level Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Advocates for relevant policy changes Knowledge: Knowledge of sources of information relevant to UHC; national, international, and global health and eye health policies; monitoring and evaluation of eye health programmes; epidemiological and communication needs assessment data; their importance for future planning; principles governing the integration of eye health in the health system Skills: Strategic communication; other advocacy skills with health and other political administrative leaders; ability to do advocacy planning; interpersonal skills Behaviours: Is sensitive, assertive, objective and a good listener when advocating for eye health Uses available policies for district planning and implementation of eye care plans Knowledge: Sources of relevant information; national, international, and global health and eye health policies; monitoring and evaluation of eye health programmes; epidemiological and communication needs assessment data; principles governing the integration of eye health in the health system Skills: Gathers, analyses and uses evidence to develop eye care plans at national, district and community levels Behaviours: Contributes and collaborates WHO African Region | 39 DOMAIN 8. COMMUNTY PRATICTIONER: Participate in community development Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Conducts and appropriately presents community needs assessments Knowledge: Basic tenets of participatory community practice; quantitative and qualitative methods of data collection (e.g., for action research) Skills: Conducts community needs assessments; disseminates findings to stakeholders; uses findings to inform planning of community programmes, or for formulating advocacy strategies Behaviours: Supports community members to identify needs and solutions in a respectful and culturally sensitive manner DOMAIN 9. SCHOLAR, RESEARCHER, TEACHER, MENTOR AND LIFELONG LEARNER: Maintain and enhance knowledge and skills through lifelong learning and adopt best practice standards through the evidence-based approach Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Performs comprehensive interventions, audits, and reviews Knowledge: Clinical audit processes and cycles; information gathering methods; change management; concepts of reflection and self- regulation; the ‘no blame’ culture Skills: Ability to conduct audits and to use gathered information for continued improvement Behaviours: Performs audits, examines outcomes, and facilitates constructive quality improvement processes; embraces change processes Engages in research Knowledge: Basic principles of research, research methods, biostatistics, epidemiology, participatory research, general public health; concepts and approaches; evidence-based practice; principles of ethical research Skills: Ability to establish research concepts and protocols; adherence to ethical principles; ability to implement research protocols; interpretation and utilization of research results; results dissemination skills Behaviours: Can initiate or participate in research; complies with ethics in research; respects contributors; disseminates and uses research findings Promotes, plans or facilitates lifelong learning, including continuing professional development Knowledge: Adult learning theories; principles and processes of continuing professional development (CPD), including mentoring; current developments and advances in eye health; different learning modes, including e-learning Skills: Aptitude in teaching, mentoring and learning; ability to use different teaching and learning platforms; ability to maintain personal professional development Behaviours: Facilitates an environment conducive to adult learning; demonstrates patience and flexibility with diverse groups; is a mentor and provides supportive supervision and feedback 40 | Core Competencies for the Eye Health Workforce in the WHO African Region DOMAIN 10. PROFESSIONAL: Acts in accordance with professional standards; stays within the legal framework; follows good ethical behaviour and practice; is sworn to commitment and accountability Competency statement Knowledge, attitudes and skills required to demonstrate core competencies Practises within the existing national legal framework for general and eye care practice Knowledge: Laws and regulations in general and eye care practice, including organ donation and data protection and sharing Skills: Ability to interpret and apply laws and regulations; ability to adhere to existing rules and regulations Behaviours: Conforms to regulations and legal processes; acts with integrity and transparency; maintains high professional standards Practises in accordance with professional ethics and code of conduct Knowledge: Understanding of relevant professional ethics and code of conduct Skills: Ability to act according to an ethical and professional code of conduct Behaviours: Observes professional ethics and complies with the code of conduct; acts with integrity; recognizes the limits of his or her own competence Adheres to human rights tenets and maintains human dignity Knowledge: Basic human rights tenets: gender equity, child protection, social inclusiveness, diversity, cultural sensitivity Skills: Ability to apply human rights tenets in practice Behaviours: Observes human rights in professional behaviour, including tolerance, respect, social inclusion, and cultural sensitivity; preserves patient dignity Maintains a work-life balance Knowledge: Concepts of socialization, including work-life balance and healthy workplace environment; understands time management strategies Skills: Ability to plan, prioritize and apply work-life balance and self-care skills Behaviours: Displays a healthy and balanced life CHAPTER 8 Implementation 42 | Core Competencies for the Eye Health Workforce in the WHO African Region The eye health competency framework provides a standard base from which WHO and its partners can engage a regional response to improve eye health services in countries over time. The implementation of eye health competencies embraces the principles of (a) partnership: working collaboratively with relevant partners to enhance eye health in the Region; (b) relevance: promoting the adoption or adaptation of the competencies in a way that responds to the context of the African Region; (c) ownership: engaging relevant partners as they implement, monitor, and evaluate them; (d) people- centeredness: taking into account the needs of the population and responding in an equitable and fair manner, while showing respect for gender and human rights. Collaboration Joint efforts in scaling up education and training for the health workforce is one of the six strategic areas in the African roadmap in this area. At the same time, promoting and sharing education and training capacities in the Region (9) is critical. Proposed interventions include promoting and facilitating the harmonization of curricula, educational standards, accreditations, and professional regulations. The interventions will fully support the realization of the Global Strategy on Human Resources for Health: Workforce 2030 since it is a core mandate of WHO to facilitate and share best practices, provide technical support to the health workforce and broaden the scope of different cadres (24). Supporting documents Adaptation and assessment tools are some of the other supporting documents that are envisaged. These tools will be crucial for generating and documenting best practices and lessons learnt. Countries are encouraged to take the present eye health competencies into account when developing their respective guides for training, policy, advocacy, etc. For its part, the WHO Regional Office for Africa will strive to: • Provide technical assistance for capacity building • Mobilize partners to provide support to improve eye health training • Generate and document lessons learnt, in collaboration with partners. WHO African Region | 43 References 1. Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. 2010; 376(9756): 1923–1958. 2. WHO. Fact Sheets. 2016; http://www.who.int/mediacentre/factsheets/fs395/en. 3. National Ageing Research Institute. What is person-centered health care? 2006. 4. WHO. Health promotion glossary 1998; WHO/HPR/HEP/98.1. Epub 1998. 5. Zalika Klemenc-Ketis, JK. Health-seeking behaviour in the general population with psychological symptoms. Psychiatria Danubina, 2014; 2014; Vol. 26 (No. 2,): pp. 181–6. 6. Moorhead S, Johnson, M, Maas, M. Nursing outcomes classification. (NOC) Labels Definitions. 3rd Edition. 2004. 7. Palmer, Jennifer J et al. Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards Vision 2020. Human Resources for Health, 2014. 8. WHO. Working together: World Health Report 2006. 2006. 9. WHO. Roadmap for scaling up the human resources for health for improved health service in the African Region 2012–2025. Brazzaville, 2013. 10. WHO. Global strategy on human resources for health: Workforce 2030. Geneva, 2016. 11. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. The British Journal of Ophthalmology. May 2012; 96 (5): 614–8. PubMed PMID: 22133988. 12. Bourne, Rupert RA et al. Magnitude, temporal trends, and projections of the global prevalence of blindness and distance and near vision impairment: a systematic review and meta-analysis, 2017. 13. Naidoo, Kovin et al. Prevalence and causes of vision loss in sub-Saharan Africa: 1990–2010. Global issues/bjophthalmology 2013. 2014. 14. IAPB. IAPB Position Paper. 2014. Epub 2014. 15. Resnikoff S, et al. The number of ophthalmologists in practice and training worldwide: a growing gap despite more than 200,000 practitioners. The British Journal of Ophthalmology. June 2012; 96 (6):783–7. PubMed PMID: 22452836. 16. Palmer, Jennifer J et al. Trends and implications for achieving Vision 2020: human resources for eye health targets in 16 countries of sub-Saharan Africa by the year 2020. Human Resources for Health. 2014. 17. Palmer, Jennifer J et al. Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards Vision 2020. Human Resources for Health 2014. (http://www. human-resources-health.com/content/12/1/44). 18. IAPB. The crisis in the eye health workforce in Africa. November 2014. 19. WHO. WHO strategy on people-centred and integrated health services. 2014. 20. WHO. Transforming and scaling up health professionals’ education and training: World Health Organization Guidelines 2013. Geneva, 2013. 21. ILO. International Standard Classification of Occupations. 2008;1. 22. Medicine Io. Crossing the quality chasm: a new health system for the 21st century, 2001. Washington DC: National Academy Press, 2001. 23. ICO. International Council of Ophthalmology. 2017;http://www.icoph.org/about/what_are_ ophthalmologists.html. Epub 2017. 24. WCO. A global competency-based model of scope of practice in optometry. April 2005. 25. Royal College of Physicians and Surgeons et al. CanMEDS 2015. Physician competency framework. 2015. Epub 2015. 26. RCOph. The common clinical competency framework for non-medical ophthalmic healthcare professionals in secondary care 2016. Epub, November 2016. 27. WHO. Task shifting: global recommendations and guidelines. Policy Guide, 2008. 28. WHO. Midwifery educator core competencies 2014. Epub 2014. 44 | Core Competencies for the Eye Health Workforce in the WHO African Region Annexes Annex I: PROCESS FOR DEVELOPING CORE COMPETENCIES FOR THE EYE HEALTH WORKORCE A standard process for developing core competencies for the eye health workforce was followed (Figure 5). Overall aim The overall aim was to produce core competencies for an eye health workforce (ophthalmologists, optometrists, and allied ophthalmic personnel) for the WHO African Region. Method A collaborative and consultative method was followed. The product from the extensive consultations between 2013 and 2016 that were held among IAPB human resources for eye health (HReH) groups, national eye care coordinators, subject experts from training institutions, professional and regulatory bodies, among others, was used to start the work by WHO. The rest of the WHO-led expert consultations comprised a series of meetings and workshops, Delphi surveys, separate subject-expert meetings of stakeholders between 2017 and 2018. Although the focus was Africa, experts from other continents were also engaged. The initial Process IAPB laid the appropriate groundwork for the process by initiating identification of the various workforce groups in the eye health team. IAPB specified not only the relationship between these workforce groups and ISCO-08 but also how tasks and roles should conform with international classifications. The format and flow of the CanMEDS framework (Royal College of Physicians of Canada) made it the most appropriate model to be selected for the process. This was followed by development of the first model draft of the tasks and activities of the corps of ophthalmic clinical officers (OCOs). The other cadres were to use a similar framework based on the nine priority areas of the Ouagadougou Declaration on primary health care and health systems. Tasks related to priority areas for eye health, (curative, preventive, promotive and rehabilitative, throughout the life course), were included. WHO formal technical process A formal collaborative arrangement between WHO Regional Office for Africa (AFRO) and IAPB-Africa was formalized through a concept note to WHO in 2014. It was recommended that only eye health professional groups be included in this process at this stage. Draft and documentation The consultant who was recruited produced the first draft using the content of the initial work developed by the IAPB -HReH task groups and the updates information coming from the scientific literature review. This draft was then developed using WHO framework of domains and eye health tasks. The tasks so developed were shared among the rapporteurs in each of the IAPB-HReH task groups for feedback. Literature search Sources of information from which to draw the competencies were identified and included. These comprised existing curricula from training institutions, documents from professional bodies in Africa and outside the continent, and national and global policy documents and publications, including the International Standard Classification of Occupations and relevant Regional Office documentation. Consensus building and consultations The WHO recruited consultant with the financial support of IAPB to draft the document by literature search, reviewing the concept note and competencies, developing tools and conducting Delphi surveys in the WHO African Region to build expert consensus (Annex V). A modified Delphi process was used to reach consensus on the essential core competencies required of the eye health workforce. Delphi participants were selected from the IAPB database of training institutions in Africa, virtual colleges, COECSA, RCOphth, ICO, NGOs in eye health, policy makers, national eye care coordinators, and professional and regulatory bodies. The process followed a snowball approach. WHO African Region | 45 Consultations with experts A selected group meeting of experts in the various subject areas was convened (Nairobi, 18 to 22 September 2017) to review the draft competencies based on Delphi Round 1 survey responses and to decide on the way forward. The group of experts reviewed the competencies for all the groups and made revisions by consensus. The resulting draft was now ready for Delphi Round 2 for consensus building as recommended. E-meetings and a series of teleconferences of the Standing Advisory Group (SAG) and experts in the subject area agreed with the results of Delphi Round 2, and proposed a second face-to-face meeting of an enlarged group of experts (Nairobi, 27 February to 1 March 2018). This expert group which constituted most of the experts from the first and additional ones from the Ministries of Health undertook a detailed and reflective structured analysis and review of the whole process and validated both the core competencies and the whole process as one document. The editorial team and final documentation The consultant whose role was to gather all the material from the processes and document both the process and the main product, drafted the final draft document with additional support from some selected experts’ format of this process. The material was further enriched by the recently-developed WHO nursing and midwifery educator core competencies (28). The validated document was also technically proof read for accuracy after the validation by experts before the official editing as part of the normal WHO process for publication. Figure 5: Process for developing, documenting and validating core competencies for the eye health workforce Delineate the occupational groups of specialist eye health providers: ophthalmologists, optometrists, allied ophthalmic personnel WHO occupational classification based on on ISCO-08 Develop competencies for each of the workforce groups Joint process by AFRO and IAPB Reviews and revise the competencies Small expert group Obtain consensus on the competencies DELPHI process - wide group of stakeholders Review and revise the competencies Small expert group to electronically incorporate the Delphi results Validate the competencies and reach FINAL CONSENSUS 27 February to 1 March 2018, Nairobi, Kenya 46 | Core Competencies for the Eye Health Workforce in the WHO African Region Annex II: PARTICIPANTS AT THE REGIONAL EXPERTS CONSULTATION WORKSHOP ON EYE HEALTH CORE COMPETENCIES (19–22 September 2017, Nairobi, Kenya) Name Function Country Prof Komi Matiklu Balo Professor of Ophthalmology, University of Lome Togo Dr Luigi Bilotto Director of Education, Brien Holden Vision Institute Canada Mrs Ellen Anyeley Clegg Former Principal, Ophthalmic Nursing School, Korle Bu Ghana Dr Renee du Toit Technical Advisor, IAPB Africa South Africa Prof. Richard Ganga- Limando WHO Collab. Centre for Postgrad. N&M Distance Ed., Res. U of S. Afr. South Africa Dr Adrian Hopkins Facilitator, Adrian Hopkins Consulting UK Prof Dunera Ilako Consultant Ophthalmologist, University of Nairobi Kenya Mr Godfrey Kaggwa SiB Project Coordinator, Brien Holden Vision Institute Uganda Prof Jefitha Karimurio Chair, Department of Ophthalmology, University of Nairobi Kenya Dr Abigail Kazembe Assoc. Professor & Deputy Dean, Kamuzu College of Nursing, Malawi Malawi Dr Grace Chipalo Mutati Senior Medical Superintendent, University Teaching Eye Hospital Zambia Prof Fikile Ntombi Mtshali Sch. of Nursing & Publ. H., University of Kwazulu-Natal (WHO Collab. Centre) South Africa Mr Peter Mwangi Kirigwi Optometry Technologist Trainer, Kenay Medical Training College Kenya Prof Kolawole Ogundimu Senior Global Technical Lead, Eye Health, Sightsavers Nigeria Dr Mollent Okech Senior Technical Advisor for HRH, Management Sciences for Health Kenya Dr Joseph Enyegue Oye Central Africa Co-Chair, IAPB-Africa, Country Director, Sightsavers Cameroon Mr Senanu K Quacoe- Wossinu Francophone & Lusophone West Africa, Co-Chair, IAPB-Africa Togo Ms Zahra Rashid Optometrist, Private Practice Kenya Prof Jefitha Karimurio Chair Department of Ophthalmology, University of Nairobi Kenya Dr Abigail Kazembe Assoc. Prof-Deputy Dean, Kamuzu Coll. of Nursing, Malawi University Malawi Prof Fikile Ntombi Mtshali Sch. of Nursing & Pub. Health, University of Kwazulu-Natal (WHO Collab. Centre) South Africa SECRETARIAT Dr Adam Ahmat Technical Officer, HRH & Planning, WHO Regional Office for Africa Congo Mr Simon Day Regional Coordinator, IAPB-Africa South Africa Dr Michael Gichangi NECC, Kenya, Ministry of Health Kenya Dr Hillary Kipruto Adviser, HSS, WCO, Kenya Kenya Mrs Anabay Mamo WCO, Kenya Kenya Ms Jennifer Nyoni Technical Officer, HRH Management, WHO Regional Office for Africa Congo WHO African Region | 47 AFRO-IAPB EXPERTS MEETING (Nairobi, 19–22 September 2017) Meeting Summary In September of 2017, AFRO and IAPB held a consultation workshop in Nairobi, Kenya. The workshop was attended by eye health experts with the overall objective of reviewing draft core competencies for the three groups of specialist eye health professionals in sub-Saharan Africa: ophthalmologists, optometrists, and allied ophthalmic personnel before finalization and validation by eye health and related experts. Development of competency frameworks for the different levels of the eye health workforce is a critical component of the IAPB-Africa strategy on human resources for health. The workshop was a major milestone in this regard. The ultimate purpose of the competencies was to improve the quality and relevance of the care provided by the professional eye health workforce. Such improvement would contribute to the attainment of Universal Health Care. The event was organized jointly by AFRO and IAPB-Africa and funded entirely by IAPB-Africa, with support from the International Centre for Eye Health Vision 2020 Workshop Fund. Throughout the event, the proceedings were facilitated by Dr Adrian Hopkins. Also in attendance was Dr Michael Gichangi, the consultant hired by AFRO to drive this process. Invited experts were made up of representatives of each of the cadres and were drawn from the different linguistic groups and sub- regions of the continent. During the workshop, their role was to critically review a set of draft core competencies in terms of their content, terminology and layout. Time was then allowed for discussion until consensus was reached on each component. There were rich and lively debates during the review and in plenary sessions which examined in detail the differences among the three cadres as well as the key content of the competencies and their domains. The outcome of the workshop was a revised set of core competencies which were approved by all participants. The next step was submission of the competencies to a Round 2 of the Delphi process. The outcome of Delphi Round 2 would be submitted for final review and approval during a second meeting of experts and country representatives scheduled for the first quarter of 2018. 48 | Core Competencies for the Eye Health Workforce in the WHO African Region Annex III: PARTICIPANTS AT THE VALIDATION CONSULTATION (Nairobi, Kenya, 27 February to 1 March 2018) NAME FUNCTION & ORGANIZATION COUNTRY Dr James Amoo Addy Head of Eye Unit, National Coordinator, Prevention of Blindness Ghana Dr Mouctar D Badiane Coordinator of the national eye health Promotion Program Senegal Dr Luigi Bilotto Director of Education, Brien Holden Vision Institute Canada Dr Grace Chipalo Mutati Sr Medical Superintendent, University Teaching Eye Hospital Zambia Mrs Ellen Clegg Anyeley Past Principle, Ophthalmic Nursing School, Korle Bu Ghana Dr Renee du Toit Technical Advisor, IAPB Africa South Africa Prof André Omgbwa Eballe Deputy Coordinator, Prevention of Blindness Programme Cameroon Prof RM Ganga-Limando WHO Collab. Centre for Postg. N&M Distance Ed., Res. Univ. of S. Africa South Africa Dr Adrian Dennis Hopkins Facilitator, Adrian Hopkins Consulting UK Prof Dunera Ilako Consultant Ophthalmologist, University of Nairobi Kenya Dr Michael Gichangi Head of ophthalmic Services Unit- MOH Kenya Mr Godfrey Kaggwa SiB Project Coordinator, Brien Holden Vision Institute Uganda Prof Jefitha Karimurio Chair Department of Ophthalmology, University of Nairobi Kenya Mrs Annette Kobusingye Program Manager, the Fred hollows Foundation, African Region Uganda Dr Aaron T. Magava Chair, IAPB Africa Zimbabwe Dr Silvio Paolo Mariotti Senior Medical Officer/WHO HQ Switzerland Dr Simona Minchiotti Eye Health Consultant/WHO AFRO Italy Prof Ntombi Fikile G Mtshali Sch. of Nursing & Pub. Health, Univ. Kwazulu-Natal (WHO Coll. Centre) South Africa Mr Peter Mwangi Kirigwi Optometry Technologist Trainer, Kenay Medical Training College Kenya Mrs Annette Mw Nkowane Independent consultant Zambia Dr Mollent Okech Senior Technical Advisor for HRH, Management Sciences for Health Kenya Dr Joseph Enyegue Oye Central Africa Co-chair IAPB Afr, Country Director Sightsavers Cameroon Mr Senanu Quacoe Francophone & Lusophone West Africa Co-Chair IAPB Togo Ms Zahra Rashid Optometrist, Consultant Low vision Kenya Dr Bernadetha Robert Shilio National Eye Care Program Manager, Ministry of Health Tanzania Mrs Kassa Tsehaynesh Tiruneh Direct T.A (acting as National Eye Health Coordinator) FMoH, Ethiopia Ethiopia Dr Linda Visser Acad. Head, Dep. of Ophth.,Vice-Pres. OSSA, Pres., College of Ophth., S. Afr South Africa Dr Adam Ahmat Technical Officer HRH and Planning, WHO Regional Office for Africa Congo Mr Simon Day Regional Coordinator, IAPB Africa South Africa Dr Hillary Kipruto Adviser, HSS, WCO, Kenya Kenya Mrs Anabay Mamo WCO, Kenya Kenya Dr Conall Ó Deasmhúnaigh WCO, Kenya Kenya Ms Jennifer Nyoni Technical Officer, HRH Management, WHO Regional Office for Africa Congo WHO African Region | 49 REGIONAL EYE COMPETENCIES VALIDATION WORKSHOP (Nairobi, Kenya, 27 February to 1 March 2018) Workshop summary The objective of the Nairobi workshop was to validate the core competencies required to inform training and the quality of care given by eye health personnel throughout the WHO African Region. An opening statement from the WHO Country Representative, Dr Rudolf Eggers, was delivered by Dr Joyce Nato, focal point for Noncommunicable diseases at the WHO Country Office, Nairobi, Kenya. In those opening remarks, the audience was reminded of the challenges of eye health and the enormous human suffering that loss of sight causes to affected individuals and their families. Poor eye health also represented a public health and social and economic problem, especially for developing countries. Dr Nato said that approximately 180 million people worldwide were visually disabled. Of these, between 40 million and 45 million persons were blind and that around 60% of them resided in sub-Saharan Africa, China and India. She said approximately 50% of the world’s blind suffered from cataract, and about 80% of global blindness was avoidable. Despite half a century of efforts, commencing with organized trachoma control activities, the global burden of blindness was continuing to growing largely because of population growth and ageing. WHO and its partners had launched a common agenda for global action called ‘Vision 2020 - the right to sight’ which provided a platform to address blindness. The validation workshop in Nairobi was therefore timely. A framework that helped professionals effectively address eye health problems in the African Region was important as the Region was the hardest-hit with cases of avoidable blindness. Dr Michael Gichangi, the consultant recruited to draft the competencies, also highlighted the crisis in human resources for health in the Region, underscoring the fact that of the close to 10,000 optometrists in Africa, most were in Nigeria and South Africa. The rest of the countries in the Region had very few. In fact, 78% of the countries in the Region had less than 50% of the optometrists. Even though Africa bore the heaviest burden of eye health disorders, the existing 200,000 ophthalmologists globally were concentrated in countries of the West and other regions. Based on the IAPB Vision Atlas and the training institutions database, current gaps in the Region were evaluated to be about: • 2,000 ophthalmologists • 3,600 optometrists • 6,000 allied eye health professionals. Ms Jennifer Nyoni, representing AFRO, provided the regional context and outlined the crisis in human resources for health (HRH) in the Region. The comprehensive response to the HRH crisis in the Region was based on World Health Assembly resolutions WHA 59.25 and 66.33 on scaling up the health workforce as well as on the subsequent guidelines on transforming health professional education as supported by the Lancet Commission report on transforming education (Frenk et al. 2010). Those documents provided a sound foundation for a comprehensive production of a health workforce that was relevant to the content, of good quality, and in appropriate numbers to address the needs of the peoples of the Region. Ms Nyoni further outlined the process for the development of the eye health competencies, stating that development of the initial draft had utilized key reference documents that included global and regional competencies, e.g., the WHO midwifery core competencies, CanMEDS, various curricula from educational institutions, national health policies, ISCO-08, scientific publications, and World 50 | Core Competencies for the Eye Health Workforce in the WHO African Region Health Assembly resolutions and reports. Experts at the workshop were invited to participate fully and to focus their attention on the successful validation of the process that had led to the current draft of competencies for eye health professionals. For the duration of the workshop, the experts held intensive discussions on the ten competency domains: (i) curative care; (ii) surgical care; (iii) preventive and promotive care; (iv) palliative and rehabilitative care; (v) communication; (vi) leadership and management; (vii) health advocacy; (viii) community practice, collaboration and team work; (ix) scholarship, research, teaching, mentoring, and lifelong learning; (x) professionalism. The domains embodied common non-clinical and clinical competencies. Feedback from group discussions was progressively integrated into the draft document over the three days of the workshop. Every evening, resource persons (comprising WHO, IABP and the consultant) reviewed the agenda and suggested ways of improving subsequent agendas as necessary. The way forward At the conclusion of the workshop, the agenda for immediate and long-term activities was discussed. Of special note was the interactive and very constructive character of the validation workshop. Many inputs were made by these senior-level participants both during group work and in plenary sessions. Since the lead facilitator was a professional in eye health, he played a key role in moderating the group to discuss and reach consensus on sometimes contentious aspects. WHO and IAPB reaffirmed their commitment to seeing through the process as set out above, with the support of the editorial team. WHO African Region | 51 Annex IV: FUNCTION AND TARGET AUDIENCES FOR THE COMPETENCY FRAMEWORK Function Target audience Development, review and implementation of curricula for initial and continuing competency-based education, e.g., for determining learning outcomes and for assessment of knowledge, skills, and attitudes that are relevant to the context and are socially suitable for inter-professional education Educational institutions Use of learning outcomes to help understand the expectations of training and as resource material for self-paced or directed learning Learners Guides for professional development requirements, and for peer appraisals Professional associations Assessments for qualification, licensure, institutional accreditation, and regulation Licensing and regulatory authorities; Examining boards Promotion and facilitation of networking and harmonized training to provide greater equivalence and mobility amongst the eye health workforce in sub-Saharan Africa Decision makers, policy makers and planners; educational institutions, ministries for education or health Guidance for policies on workforce planning and management, e.g., skills mix and task shifting or sharing, based on shared or common competencies, and differentiated by competencies unique to the group. The latter can be used to categorize the work of groups and subgroups; they help to clearly define roles and responsibilities in the eye health team as well as their tasks in job descriptions; this in turn also facilitates supervisory and mentoring activity, enhances professional recognition, career progression, and remuneration for existing or proposed cadres Policy makers and planners; ministries for education or health; labour groups and employers Strengthening the delivery of integrated and person-centred health services and care; Example, a decision on the competencies a team needs can lead to the appropriate allocation of these to team members, thereby facilitating or encouraging collaborative practice, work across health and non-health sectors and resulting in the provision of more holistic and integrated care Civil society Guidance for polices on health system strengthening and support can be provided in the form of supervision and equipment to enable the health workforce implement the competencies; doing so could help meet the needs of patients along with the expectations of both the population and the health system Policy makers; ministries for education or health 52 | Core Competencies for the Eye Health Workforce in the WHO African Region Annex V: THE DELPHI SURVEY Delphi 1 Expert group 1 Delphi 2 Expert Group 2 Number of competencies Number (%) reaching consensus* Number of competencies Number (%) reaching consensus* Number of competencies validated C o m p et en ci es Ophthalmologists 12 10 (92%) 12 12 (100%) 14 AOP (clinicians) 14 12 (86%) 17 16 (94%) 16 Total AOP 25AOP (nurses) 9 9 (10%) 10 10 (100%) 11 Optometrists 22 19 (91%) 26 24 (92%) 26 Ophthalmic opticians 18 8 (44%) Group omitted - lack of consensus; confusing terminology Common non-technical competencies 17 17 (100%) 16 16 (100%) 18 R es p o ns e ra te s Number of surveys emailed 94 57 Number of responses 57 (61%) 39 (68%) Percentage from Africa 91% 86% % from Kenya 36% 46% % from training institutions 63% 49% Q ua lifi ca ti o n/ ca d re s Ophthalmologists 62% 62% AOP (clinicians) 12% 9% AOP (nurses) 8% 6% Optometrists 15% 14% WHO African Region | 53 Western Sahara Tunisia Sudan Somalia Morocco Libya Egypt Djibouti Zimbabwe South Sudan Sierra Leone Seychelles Sao Tome and Principe Rwanda Niger Namibia Mauritius Mauritania Mali Madagascar Lesotho Guinea-Bissau Guinea Gambia Gabon Eritrea Equatorial Guinea Democratic Republic of Congo Congo Comoros Chad Central African Republic Cabo Verde Botswana Benin Angola Algeria Zambia UR Tanzania Uganda Togo South Africa Senegal Nigeria Mozambique Malawi Liberia Kenya Ghana Ethiopia Eswatini Côte d'Ivoire Cameroon Burundi Burkina Faso A summary of the respondents and responses on the core competencies during the two rounds of Delphi, discussions, consensus, and validation of the competencies at two expert meetings. Delphi respondents’ local across Africa Bukina Faso Burundi Cameroon Cote d’Ivoire Eswatini Ethiopia Ghana Kenya Liberia Malawi Mozambique Nigeria Senegal South Africa Togo Uganda United Republic of Tanzania Zambia Delphi respondent locations – Africa.csv 54 | Core Competencies for the Eye Health Workforce in the WHO African Region Annex VI (a): OPHTHALMIC DIAGNOSTIC TESTS AND SURGICAL PROCEDURES This Annex VI (a) gives general guidance for the purpose of harmonizing different clinical procedures within the scope of eye health service delivery. It also delineates the procedural scope of each provider. This is a core (minimum) list of basic procedures in Ophthalmology and should be viewed within the specific individual context of the country or institution. From this Annex, it is recommended that: • All newly qualified ophthalmologists should be proficient in performing and interpreting diagnostic tests; • All allied ophthalmic personnel should be proficient in performing and interpreting the above, except categories marked x** where additional competencies are required; • Optometrists should be able to acquire competencies to perform all the diagnostic tests; they will need the relevant competencies to be able to interpret the findings of the tests; • Optometrists with required competencies could perform limited surgical procedures; epilation, incision and drainage of chalazion and lid abscesses,*** removal of conjunctival and corneal foreign bodies, and participate in pre- and post-operative surgical care; • ++ Supervision is provided directly when the ophthalmologist is actually present, observes, works with and directs the clinician or indirectly when the ophthalmologist works in the same facility or organization as the clinician but does not constantly observe his or her activities. The ophthalmologist must be available for reasonable access, i.e., must be available at all times. Key to Annex VI (a) Sign Meaning • Within the primary competency of the cadre x Not within the primary competency of the cadre • ** Although within the primary competency of the cadre, a practitioner will seek persons with further competencies in refractory procedures x** Although the procedure may not be within the primary competency of the cadre, the person who has acquired relevant competencies is not limited and should seek to work within the country regulatory context. x*** As above (x**) but will need close direction++ by an ophthalmologist, directly or indirectly. PROCEDURE Ophthalmologists AOPs (clinicians) AOPs (nurses) Optometrists OPHTHALMIC DIAGNOSTIC TEST Tonometry ü ü ü ü Pachymetry ü ü ü ü Gonioscopy ü x** x** ü Retinal photographs ü ü ü ü Fluorescein angiography ü x** x** x** Visual field analysis ü ü ü ü Ocular-computerized tomography (OCT) ü ü ü ü Corneal topography ü ü ü ü Ultra-sound-eye* ü x** x** x Biometry ü ü ü ü Retinoscopy ü ü ü ü Endothelial cell count ü ü ü ü Direct & indirect fundus assessment ü ü ü ü Syringing and irrigation ü ü ü ü ü WHO African Region | 55 PROCEDURE Ophthalmologists AOPs (clinicians) AOPs (nurses) Optometrists SURGICAL PROCEDURE ORBIT, SOCKET, LACRYMAL AND LID Infiltrate local anesthesia ü ü x*** x** Dermoid excision simple ü ü x x Dermoid excision complex ü x x x Anterior orbitotomy ü x x x Lateral orbitotomy ü x x x Orbital wall repair x** x x x Orbital wall decompression x** x x x Mucoceale incision and drainage(I&D) ü x x x Exenteration ü x x x Evisceration ü ü x x Evisceration and orbit implant ü x** x x Enucleation ü x*** x x Enucleation and orbital implant ü x x x Socket fornix reconstruction x** x x x Punctoplasty ü x x x Punctal occlusion (temporary) ü ü x*** ü Probing irrigation and syringing ü ü x x Dacryo-cysto-rhinostomy(DCR) ü ** x x x Trachomatous entropion repair ü ü x ** x ** Other Non-trachomatous entropion repair ü ** x x x Epiblephron repair x** x x x Ptosis repair ü x x x Blow out lift x** x x x Lid – canaliculi laceration repair ü x x x Lid - Tumour excision (reconstruction) ü x x x Tarsorhaphy ü ü x** x Upper lid blepharoplasty- ü x x x Lower lid blepharoplasty- ü x x x Lid abscess (incision and drainage) ü ü x** x** Chalazion (incision and drainage) ü ü x** x** Epilation-A (simple non trachomatous) ü ü ü ü Lashes electrolysis-A ü ü x** x ANTERIOR SEGMENT AND CORNEA Small incision cataract surgery + IOL ü x** x x Small incision cataract surgery+IOL+TET ü x x x Phaco-emulsification +IOL ü x** x x Phaco-emulsification+IOL + Trabeculectomy ü x x x 56 | Core Competencies for the Eye Health Workforce in the WHO African Region PROCEDURE Ophthalmologists AOPs (clinicians) AOPs (nurses) Optometrists Cataract surgery+IOL+Anterior vitrectomy ü x x x Perforating eye injuries ü x** x x Conjunctival Lesion excision ü ü x x Conjunctival lesion excision+ a graft ü x x x Corneal transplant (penetrating keratoplasty) x** x x x Corneal transplant (Lamella keratoplasty) x** x x x Triple-procedure: Corneal transplant, Cataract surgery + IOL implantation x** x x x Removal of corneal sutures theatre slit lamp ü ü x x Removal of corneal foreign body ü ü ü ü Posterior capsulotomy ü x x x Anterior chamber(A/C) Tap/injection ü x x x Pre-/post- refractive surgery assessments ü x x ü Sub-conjunctiva/tenons injections ü ü x** x Refractive surgeries x** x x x Surface ablation x** x x x Phakic intraocular lens ü x x x Photo keratectomy x** x x x Removal of corneal scar x** x x x GLAUCOMA Trabeculectomy ü x x x Trabeculotomy ü x x x Goniotomy ü x x x Combined phaco/trabeculectomy x** x x x Combined MICs and trabeculectomy x** x x x Glaucoma-drainage implants (GDI) x** x x x Combined GDI and phaco x** x x x Surgical iridectomy ü x** x x EUA for congenital glaucoma ü x x x Retrobulbur alcohol/largactail ü ü x x Laser: Trabeculoplasty, iridotomy, suturelysis ü x x x Bleb revision ü ü x x CycloCryotherapy-A/B ü ü x x PAEDEATRIC OPHTHALMOLOGY Anterior chamber reformation x** x x x Goniotomy x** x x x Intra-ocular lens (IOL) exchange x** x x x Lensectomy and IOL implant x** x x x WHO African Region | 57 PROCEDURE Ophthalmologists AOPs (clinicians) AOPs (nurses) Optometrists PAEDEATRIC OPHTHALMOLOGY continued Anterior chamber membrane removal x** x x x Pupiloplasty x** x x x Anterior chamber wash out ü x x x Corneal repair ü x x x Removal of corneal FB ü ü x ü Examination under-anaesthesia (EUA) for Retinoscopy, Rb, FB ü ü x ü Pars plana capsulotomy ü x x x Iridectomy/Iridotomy ü x** x x Optical iridectomy ü x** x x STRABISMUS MANAGEMENT Surgical strabismus correction x** x x x POSTERIOR SEGMENT AND RETINA Central laser ü x x x Pan retinal photo coagulation (on slit lamp) ü x x x Pan retinal photo coagulation (on indirect head lamp) ü x x x Laser retinopexy ü x x x CycloCryotherapy ü x** x x Cyclophoto coagulation/therapy ü x x x Intra-vitreal injections ü x** x x Silicon oil removal x** x x x Cataract surgery with silicon oil removal x** x x x Posterior vitrectomy with dropped IOL or Vitreous foreign body removal x** x x x Posterior vitrectomy and gas x** x x x Posterior vitrectomy + oil x** x x x Posterior vitrectomy and delamination and gas and oil x** x x x Combined procedures (Posterior vitrectomy, cataract surgery and IOL implants) x** x x x Combined procedures (posterior vitrectomy buckle or band+ cataract surgery and IOL implant) x** x x x Posterior vitrectomy and macula hole surgery x** x x x Scleral buckle and explants removal ü x x x 58 | Core Competencies for the Eye Health Workforce in the WHO African Region Annex VI (b): OPTOMETRIST’S USE OF PHARMACHOLOGICAL PRODUCTS AND TREATMENT Category of ophthalmic medicine Indication Anti-infective agents Bacterial conjunctivitis and blepharitis Ocular (non-steroidal) allergy medicine Ocular allergies and inflammation Dry eye therapies and products Ocular surface disease or dry eye Dilation & cycloplegic agents Ocular examination Topical anesthetics Ocular examination and FB removal Topical dyes Ocular examination Contact lens solutions Contact lens hygiene, lubrication and maintenance Atropine Myopia management or control Note: NO STEROIDS WHO African Region | 59 IAPB HReH task development teams Renee du Toit (w AOP Chair + HReH Chair) Ellen Clegg Ciku Mathenge Halli Manalakos Lynn Anderson Joseph Oye Godfrey Kaggwa Janvier Kilangalanga Mary Wepo Ken Kagame (Ophthalmology Chair) Kunle Hassan Patrice Komi Balo Margarida Chagunda Dunera Ilako Yeshigeta Gelaw Seth Lartey Irmela Erdmann Ahmad Gomaa Henry Nkumbe Hannah Faal (CHW Chair) Uche Amazigo Henrietta Monye Amir Bedri Ima Chima E Appiah-Denkyra Bo Wiafe (PEC Chair) Maria Hagan Dorcas Chelanga Hannah Faal Kesi Naidoo (Optometry Chair) Imran Khan Senanu Quacoe Nigel Wilson Anguyo Dralega Vanessa Moodley Angela Affran Annex VII: LIST OF PERSONS INVOLVED IN THE PROCESS Delphi Rounds 1 and 2 participants No Name Country 1 AdedayoAdio Nigeria 2 Agnes Mualuko Kenya 3 AlemayahuWoldeyesTefera Ethiopia 4 Anne AmpaireMusika Uganda 5 BoubacarSarr Senegal 6 Catherine K. Gargu Liberia 7 Claire Studley Scott UK 8 Clare Gilbert UK 9 Claudio Owino Kenya 10 Dorothy Mutie Kenya 11 Elijah Mutoloki Munachonga Zambia 12 Ellen Anyeley Clegg Ghana 13 Ernest Ollando Kenya 14 George S. Odhiambo Ohito Kenya 15 Grace Chipalo Mutati Zambia 16 Imran Khan UK 17 Irmela Erdmann Togo 18 Jefitha Karimurio Kenya 19 Jonathan Buturu Kenya 20 Judith Mwende Tanzania 21 Kahaki Kimani Kenya 22 Karl Golnik USA 23 Kesi Naido South Africa 24 Margarida Chagunda Mozambique 25 Milliam Kamau Kenya 26 Millicent Muthoni Kenya 27 Nicholas Olobio Nigeria 28 Nick Astbury UK 29 Nyawira Mwangi Kenya 30 Okenwa-Vincent Emmanuel Kenya 31 Rebecca Oenga Kenya 32 Sheila Marco Kenya 33 Stephen Gichuhi Kenya 34 William Makupa Tanzania 35 Zahra Rashid Kenya 60 | Core Competencies for the Eye Health Workforce in the WHO African Region Participants in Delphi Round 1 only No Name Country 1 Dabilougou Adama Fulbert Burkina Faso 2 Levi Kandeke Burundi 3 Bella Assumpta Lucienne (2 rounds) Cameroon 4 Kouakoua Marie Madeleine Ivory Coast 5 Dennis Osiago (2 rounds) Kenya 6 Ernest B. Wanyama Kenya 7 Lucy Manyara Kenya 8 Monicah Bitok (2 rounds) Kenya 9 Petros Kanyange Malawi 10 Mariamo S Abdala Mozambique 11 Abubakar Jibril Rifun Nigeria 12 C Cook South Africa 13 France Nxumalo South Africa 14 Kgao Edward Legodi South Africa 15 Sharon Maseko Swaziland 16 Peter M. Kirigwi Kenya 17 Milka Mafwiri Tanzania 18 Quacoe-Wossinu Senanu (2 rounds) Togo 19 Babalanda Jean Uganda 20 Kaggwa Godfrey Uganda 21 Simon Arunga Uganda 22 Jessie Mbachi Innocencia Nyalazi Zambia Other technical support and back-up staff (who worked very hard or were constantly consulted behind-the-scene by the Consultant, Dr Michael Gichangi) Prof Emilee Epée Ophthalmologist (Proofreader) Cameroon Dr Augustine Mwangi Educational Consultant, Lecturer, University of Nairobi Kenya John Maina Murage, BSc IT and Data Manager Kenya Dr Anthony Gichangi Statistician, JEPAIGO, Nairobi Kenya Mrs Catherine Mwaura Ophthalmic Nurse-Trainer, Kenya Medical Training College Kenya Dr Eduardo Mayorga Ophthalmologist, ICO Educator Argentina Dr Joyce W Kabiru Ophthalmologist & Oculoplastic Surgeon Kenya Prof Dan Kiage Ophthalmologist & Glaucoma Specialist Kenya Dr Stephen Gichuhi Ophthalmologist & Epidemiologist, Senior Lecturer, University of Nairobi Kenya WHO-IAPB SUBJECT EXPERTS PANEL Dr Grace Misumbi Chipalo-Mutati Prof Komi Balo Dr Joseph Oye Prof Dunera Ilako Prof Abigail Kazembe Mrs Ellen Clegg Mr Godfrey Kaggwa Dr Renee Du Toit Dr Kola Ogundipe Prof JefithaKarimurio Prof Fikile Ntombi Mtshali Dr Luigi Bilotto Mr Senanu Quacoe Mr Peter Mwangi Kirigwi Ms Zahra Rashid Prof Richard Nganga Limando Dr Mollent Okech Dr Adrian Hopkins Dr Michael Gichangi Mr Adam Ahmat Dr Simona Minchiotti Ms Jennifer Nyoni Mr Simon Day WHO African Region | 61 Members of the Standing Advisory Group that steered the core competencies process Dr Adam Ahmat WHO African Region, HSS Cluster Dr Simona Minchiotti WHO African Region, NCD Cluster Mrs Mwansa Nkowane HWF Department, WHO HQ Ms Jennifer Nyoni WHO African Region, HSS Cluster Dr Michael Gichangi Main Consultant Mr Simon Day IAPB Dr Renee du Toit IAPB Expert Mr Ronnie Graham IAPB Mr Luigi Bilotto Director of Education, BHVI 62 | Core Competencies for the Eye Health Workforce in the WHO African Region Core Competencies for the Eye Health Workforce in the WHO African Region
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Core competencies for the eye health workforce in the WHO African Region
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