• Timor-Leste
• primary eye care
• vision 2020
• epidemiology
• public health

The Vision 2020: Right to Sight Initiative calls for the inclusion of primary eye care (PEC) in primary healthcare interventions. To date, there is no agreement on a definition for PEC or how best to implement it.1 It has variously involved village health workers (VHWs) delivering health education to communities to prevent eye diseases, or general health workers at primary level facilities receiving training in basic eye health education, diagnosis and treatment.2

The Timor-Leste National Eye Health Survey (TLEHS) 2010, a population-based cross-sectional survey of adults aged ≥40 years, enabled exploration of actual and anticipated use of eye health services in Timor-Leste and provided an opportunity to consider a definition of PEC in this context.

The majority of Timor-Leste's 1.1 million people live in rural areas, where access to healthcare services remains a challenge. Since independence in 2002, the Ministry of Health (MOH) has prioritised the development of primary care; healthcare facilities were established throughout the country and a basic services package (BSP) was developed to outline primary healthcare services. Subsequently, a community health programme (Servisu Integradu da Saúde Communitária—‘SISCa’) was introduced, one component of which uses VHWs to coordinate monthly visits from the nearest community healthcare facility.

Eye health services have evolved within the developing healthcare system. In 2005, vision impairment in adults was high3 and there was a range of barriers to utilisation of eye care services, including access and awareness of services.4 Cataract and refractive error—causing over 90% of adult vision impairment3—were chosen as priorities for intervention in the MOH's first National Eye Health Strategy 2006–2011. Although not defined, PEC was listed as the third priority, dovetailing with the inclusion of eye care activities in the broader BSP and SISCa strategies. Despite this policy support, there has been little PEC activity, perhaps due to the lack of clarity of what PEC is or could be, given the capacity of the nascent health system.

The TLEHS was conducted in accordance with the Declaration of Helsinki and informed consent was obtained from each participant. From each of the survey's 50 clusters, 45 participants were enumerated, and a participation rate of 89.5% was achieved.

Survey results showed that community health centres (CHCs) were used by 43.4% (193/445) of participants with past experience of red eyes, blurred vision or eye injury. CHCs were also most commonly nominated for intended future use (table 1). No participant had sought care for a previous eye problem from SISCa and only eight nominated it for a future eye problem (table 1).

Human resource challenges suggest that existing PEC models may have limited success in Timor-Leste; although information is not readily available on general health worker capacity, separate evaluations have found that VHWs had only marginally better knowledge of simple conditions than their communities5 and that eye health workers (EHWs) had poor knowledge retention and clinical competency after completing their 1-year training.6

An alternative approach to PEC is proposed in table 2, involving integration of activities across a range of locations, cadres, policies and strategies. It takes into account the MOH plan to establish permanent eye clinics in all 66 CHCs, staffed by EHWs with 1 year of training, as well as the tendency of the existing population to seek care from CHCs. If this approach is incorporated into the next round of strategies, PEC roles for all cadres from VHWs to ophthalmologists could be clarified, and relevant training, equipping and monitoring planned accordingly. Realistic, measurable PEC targets could be set that are aligned with the developmental plans of general health and eye care services, which would form a basis for assessing the effectiveness of this PEC approach in the future.