Delphi-based validation and prioritisation of a national refractive error and optical service delivery model for Bhutan

Delphi-based validation and prioritisation of a national refractive error and optical service delivery model for Bhutan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Delphi-based validation and prioritisation of a national refractive error and optical service delivery model for Bhutan Indra Prasad Sharma, Kovin Shunmugam Naidoo, Khathutshelo Percy Mashige, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8712693/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Aim The World Health Organisation Refractive Error Situation Analysis Tool (RESAT) was recently implemented in Bhutan. Building on the findings of this assessment, the present study aimed to develop and validate a context-specific, evidence-based refractive error and optical service delivery model for Bhutan through a structured expert consensus process. Methods A two-round, online Delphi technique was employed to refine a 37-component model derived from a nationwide application of the RESAT. A purposive panel of national experts in Bhutan, each with a minimum of three years’ experience in eye care delivery, health systems, policy development, or programme implementation, evaluated each component for relevance, feasibility, and expected impact using a 5-point Likert scale. Consensus was defined a priori as at least 70% of respondents rating a component as 4 or 5 in Round 2. Descriptive statistics including proportions, medians, and interquartile ranges, were used to assess levels of consensus and changes in ratings across rounds. Qualitative data from open-ended responses were subjected to thematic analysis to inform iterative refinement of the model. Results Forty-six experts participated in Round 1 (response rate = 83.6%), with 33 retained in Round 2 (retention rate = 71.7%), representing a broad range of professional cadres and geographic regions. The median participant age remained 41 years across both rounds, while median professional experience increased from 14 to 15 years. The draft model comprised 37 components. In Round 2, consensus was reached for 30 components (81.1%) regarding relevance, 16 components (43.2%) regarding feasibility, and 32 components (86.5%) regarding expected impact. Components demonstrating consistently high consensus across all three dimensions included facility-based refraction services, optical dispensing, school-based vision screening, outreach services, supply-chain strengthening, regulation of optical services, and monitoring of effective refractive error coverage (eREC). Components identified as highly relevant and potentially impactful, yet constrained by lower feasibility such as workforce expansion, sustainable financing mechanisms, and digital innovations, were retained as medium-term or enabling elements. Feasibility ratings increased across successive rounds, resulting in a reduced divergence between relevance and feasibility assessments. Expert consensus highlighted workforce capacity, affordability of spectacles, quality assurance, and strong governance as key priority areas. Conclusions This Delphi study developed an expert-validated, evidence-based model for the delivery of refractive error services in Bhutan. Beyond its national application, the study demonstrates the utility of a structured expert-consensus methodology as a reproducible approach for translating health-system assessments into a validated, prioritised service-delivery framework. This approach is particularly relevant for informing policy, planning, and implementation in resource-constrained settings. The resulting model provides a structured framework to support strategic planning, resource allocation, and monitoring of refractive services in Bhutan and comparable health systems. Delphi study health systems research refractive error services optical service delivery effective refractive error coverage service delivery model Bhutan Figures Figure 1 Figure 2 Figure 3 Introduction Bhutan has attained near-universal coverage of essential health services through a publicly financed health system that provides care free at the point of delivery [1]. Eye-care services are provided within a tiered health system comprising a national referral hospital, regional referral hospitals, and district hospitals, and 10 bedded primary hospitals [2]. Over the past decade, substantial investments have been made to expand ophthalmic infrastructure and human resources, including the training and recruitment of the country’s first optometrist in 2010. Despite this progress, refractive error and optical services remain inadequately organised and poorly regulated. Limited system integration continues to constrain coordinated service delivery, thereby impeding consistent, equitable, and measurable scale-up. A nationwide situational analysis of refractive error and optical service in Bhutan was conducted in mid-2025 using the World Health Organization’s Refractive Error Situation Analysis Tool (RESAT). This assessment constituted the first comprehensive, multi-domain evaluation of refractive-error services in the country, encompassing governance and leadership, service delivery, workforce capacity, optical supply systems, health information systems, health promotion, and financing. The RESAT identified several system-level constraints affecting the delivery of refractive error services. These included the absence of a national refractive error service delivery framework; inadequate regulation and quality assurance mechanisms for optical dispensing; fragmented and inefficient spectacle supply chains, variability in the availability and quality of refraction services at primary health-care level; and the lack of routine monitoring of effective refractive error coverage within the national health information system. Comparable system-level deficiencies have been documented in refractive error service delivery models in similar settings [3]. Notwithstanding these challenges, the assessment also identified notable institutional strengths. These consisted of the integration of eye health, including refraction services, within the public health systems; strong political commitment to eye health; a growing eye-care workforce; and relatively high coverage of publicly funded eye-care services within the context of universal health coverage. These findings align with recent global eye-health reforms. In 2021, the World Health Assembly adopted Resolution WHA74.12 on Integrated People-Centred Eye Care, which calls for the systematic integration of eye-care services within national health systems [4]. Subsequently, in 2022, WHO introduced effective refractive error coverage (eREC) as a core global eye health indicator, marking a shift from measuring service volume to assessing quality and financial outcomes [5]. In the context of Bhutan, this policy direction necessitates more than service expansion; it requires a clearly articulated national model that coherently integrates governance, human resources, optical and supply chain systems, financing mechanisms, and health information systems. Despite the availability of global technical guidance, Bhutan currently lacks an evidence based, scalable national model for refractive-error and optical service delivery. In the absence of such a framework, refractive services are vulnerable to fragmentation, with parallel investments in community-based screening, hospital-based refraction, and workforce deployment occurring without harmonised national standards, clearly defined referral pathways, or coordinated optical dispensing and supply-chain systems. This gap is particularly consequential in small health systems with limited human resources and geographically dispersed populations, where efficient planning, system-wide coordination, and operational feasibility are essential to ensure equitable and sustainable service delivery. Recent evidence from other low- and middle-income countries demonstrates that structured expert-consensus approaches, particularly Delphi methodologies, are effective for the development and validation of refractive-error and optical service-delivery frameworks that are context-appropriate and implementation-ready [6]. Delphi-based validation frameworks have recently been applied to task-shifting and integration of tele-refraction services in Kenya, to national child eye-care planning in Sudan, and to the formulation of global eye-care competencies by WHO eye care experts [7–10]. In addition, global Delphi-based prioritisation exercises have highlighted the utility of expert consensus in aligning eye-health system design with policy and financing priorities [11]. Notwithstanding this growing body of evidence, nationally validated, evidence-based models for refractive-error and optical service delivery are currently lacking in Bhutan. To address this gap, a multi-phase study was undertaken to develop and validate Bhutan’s first national refractive-error and optical service-delivery model. An initial evidence-informed model was formulated based on findings from a nationwide situational analysis con-_ducted using the WHO RESAT [12]. This draft model was subsequently evaluated through a two-round modified-Delphi process involving Bhutanese eye-health experts. This paper reports the results of the Delphi validation process and presents a final, consensus-based national model intended to inform policy development, strategic planning, resource allocation, and performance monitoring of refractive error services in Bhutan, in alignment with the WHO 2030 effective coverage targets. Methods Study design and overview Based on the nationwide RESAT findings, an evidence-based refractive error and optical service delivery model was developed (Phase 1). Subsequently, a Delphi consensus process (phase 2) was conducted to validate and refine the Phase 1 model. A two-round, online Delphi methodology was employed to elicit structured expert consensus on the relevance, feasibility and expected impact of each model component. The number of Delphi rounds were pre-specified, as the model was derived from a comprehensive national situational analysis. The Delphi process was used for validation, refinement and prioritisation of components rather than for the initial generation of the model. Expert panel selection Purposive sampling was employed to recruit national experts and with diverse perspectives on refractive error and optical services in Bhutan. Eligibility criteria included: (i) a minimum of three years’ experience in eye care or health systems within Bhutan; and (ii) current or recent involvement in clinical service delivery, programme management, policy-development, planning, training or research related to eye health. Given Bhutan’s relatively small health system and limited specialist workforce, a threshold of three years’ experience was considered sufficient to ensure adequate operational familiarity with refractive-error services across different levels of care. The sampling strategy generated representation from ophthalmologists, optometrists, ophthalmic technicians, programme managers, policy-makers, public health specialists, non-governmental organisations, and the private optical sector, as well as geographic representation across all regions and levels of care (primary, secondary, tertiary). Potential participants were identified through the professional network of the study investigators, existing health professional and expert databases maintained by the Ministry of Health, and a snowball sampling approach to recruit additional participants. Eligible individuals were subsequently invited to participate via email. Delphi procedure The Delphi survey was administered electronically using Google Forms. The survey instruments for Rounds 1 and 2 are provided in Annexures 1 and 2, respectively. Each Delphi round remained open for a two-week period, during which up to two reminder emails or SMS notifications were issued at one-week intervals to participants who had not yet responded. To preserve methodological rigour and minimise response bias, individual responses were anonymised with respect to other panel members, and only aggregated and summarized feedback was disseminated to participants between successive rounds. Round 1: Participants were provided with a concise narrative description and a visual schematic of the draft model, outlining its core domains and constituent components. These components were systematically discussed, refined, and validated by the investigative team, informed by the findings of the nationwide RESAT. Each component was subsequently evaluated by subject-matter experts across three predefined assessment domains: Relevance: “How important is this component for addressing refractive error and optical service needs in Bhutan?” Feasibility: “How realistic is it to implement this component within Bhutan’s current and foreseeable health system context?” Expected impact: “If implemented as intended, how much impact is this component likely to have on increasing refractive error coverage and improving equity?” All items were assessed using a five-point Likert scale, from 1 (very low/not at all) to 5 (very high). In addition, three open-ended questions were included to enable respondents to identify key components required for achieving universal eREC and to provide supplementary feedback not captured by the structured survey items. Round 2: In Round 2, participants were provided with anonymised feedback from Round 1, comprising summary statistics of the ratings (median) for each component, together with a thematic synthesis of qualitative comments. Participants were subsequently invited to re-evaluate and re-rate each component in light of this feedback, as well as to appraise any revised or newly proposed components that emerged from Round 1. Ratings were again recorded using the same 5-point Likert scale, accompanied by open-ended comment fields. Two rounds were pre-specified, as the model had been comprehensively developed during Phase 1. Consequently, expert input was anticipated to concentrate on refinement and validation of existing components rather than the generation of new elements. Consensus definition and data analysis Consensus criteria were defined a priori. For each component and for each evaluation dimension (relevance, feasibility, expected impact), consensus was achieved when ≥ 70% of respondents assigned a rating of 4 or 5 on the 5-point scale in Round 2. This threshold is consistent with established practice in Delphi studies within health-systems and eye-health research. As a sensitivity analysis, central tendency and dispersion were also assessed. Components with a median score ≥ 4 and an interquartile range (IQR) ≤ 1 were interpreted as demonstrating strong agreement among participants. Quantitative data were analysed using SPSS version 26. Descriptive statistics were generated, including frequencies and proportions for each response category. For each item and Delphi round, medians and interquartile ranges (IQRs) were calculated to summarise central tendency and dispersion. Changes in response distributions between Round 1 and Round 2 were examined descriptively to evaluate the stability and convergence of participants’ opinions. Qualitative data from open-ended responses were imported into MS Excel and analysed using a rapid, pragmatic thematic analysis approach. Emergent themes informed iterative refinements to the wording, scope and categorisation of model components across successive rounds and in the final model. Components that failed to achieve the predefined consensus threshold were reviewed and modified based on the qualitative feedback provided. Data management and quality control All survey data were securely stored on password-protected servers with access limited to authorised members of the research team. Data entry procedures incorporated double verification to ensure accuracy, and any discrepancies were resolved through discussion among the research team. Ongoing quality assurance processes included systematic monitoring of response patterns and regular checks for coding reliability and consistency in the qualitative data. To safeguard confidentiality within a small professional community, findings are presented in aggregated form, and no individual or institution-specific statements are reported or attributed. Ethical considerations The Delphi study was conducted as part of a broader nationwide RESAT-based situational analysis. Ethical approval was obtained from the Research Ethics Board of Health (REBH), Ministry of Health, Bhutan (Ref: REBH/Approval/2023/003) and the Biomedical Research Ethics Committee (BREC), University of KwaZulu-Natal, South Africa (Approval no: BREC/00004482/2022). AThe study adhered to the principles of the Declaration of Helsinki and followed international best practices for clinical and public health research. All participants were provided with an information sheet detailing the study objectives, the proposed model and the Delphi process, together with a consent form. Informed consent was obtained prior to participation, with completion of the online survey constituting implied consent. Participation was entirely voluntary, with no financial or other incentives offered. Participants were informed of their right to withdraw from the study at any stage, without penalty or adverse consequences. Results Delphi panel characteristics and retention A total of 46 of the 55 invited health experts participated in Delphi Round 1, yielding a response rate of 83.6%. Of these, 33 experts completed Round 2, corresponding to a retention rate of 71.7%. The panel comprised a diverse and representative sample of stakeholders within Bhutan’s refractive error and optical service delivery system, including ophthalmologists, optometrists, ophthalmic technicians, programme managers, policy officials, NGO and development partners, and private optical sector professionals. Panel stability across Delphi rounds was high. The median age of participants remained constant at 41 years, with comparable interquartile ranges across rounds. Median duration of professional experience in eye health increased slightly from 14 years (IQR: 9–22) in Round 1 to 15 years (IQR: 10–23) in Round 2. Geographic representation across western, central, eastern, and southern regions of the country remained broadly consistent between rounds. Table 1 presents a summary of participants’ demographic characteristics, professional backgrounds, and geographic distribution. Table 1 Summary of participant characteristics across both Delphi rounds Characteristics Variables Round 1 (N = 46) Round 2 (N = 33) Age (years) Median (IQR) 41 (36–51.4) 41 (36–52) Years of experience in eye health Median (IQR) 14 (9–21) 15 (10–22) Professional cadres Ophthalmologist 9 (19.6%) 6 (18.2%) Optometrists 9 (19.6%) 9 (27.3%) Ophthalmic technicians 16 (34.8%) 12 (36.4%) MoH / NMS Public Health Officials 3 (6.5%) 2 (6.1%) NGO / Development Partners officials 3 (6.5%) 1 (3.0%) Private optical professional 3 (6.5%) 3 (9.1%) Present area of work Central Bhutan 12 (26.1%) 9 (27.3%) Eastern Bhutan 10 (21.7%) 7 (21.2%) Western Bhutan 14 (30.4%) 14 (42.4%) National 4 (8.7%) 2 (6.1%) International 3 (6.5%) 1 (3.0%) Delphi Round 1: Initial appraisal of model components The draft model consisted of 37 items organised into five components. Although Round 1 was exploratory in nature, an a priori consensus threshold of ≥ 70% agreement, defined as ratings of 4 or 5 was established for Round 2 across the domains of relevance, feasibility, and anticipated impact. Figure 1 depicts the extent to which consensus was achieved across these three evaluative dimensions. In Round 1, relevance ratings were uniformly high across most components, with particularly strong scores for facility-based refraction services, optical dispensing, school-based vision screening, and supply-chain strengthening. In contrast, feasibility ratings were consistently lower than relevance ratings, notably for components requiring regulatory reform, novel financing mechanisms, workforce expansion, or the development of digital infrastructure. Expected impact ratings more closely mirrored relevance scores than feasibility scores, indicating strong perceived potential benefits despite acknowledged implementation constraints. Only a limited number of components achieved the predefined ≥ 70% consensus threshold across all three dimensions (relevance, feasibility, and expected impact) during Round 1. This outcome justified progression to a second Delphi round to enable structured feedback, clarification and further refinement of the proposed components. Delphi Round 2: Consensus achievement and prioritisation Following structured feedback and controlled iteration, there was a measurable increase in consensus across all three dimensions in Round 2. Of the 37 components assessed, 30 (81.1%) achieved consensus on relevance, 16 (43.2%) on feasibility, and 32 (86.5%) on expected impact, based on a ≥ 70% agreement threshold ( Fig. 2 ) . Components that demonstrated borderline agreement in Round 1 showed the most pronounced gains in Round 2, particularly with respect to feasibility. Ratings for expected impact remained consistently high across most components, with no observed decline between rounds. Service-delivery components integrated within existing public-sector infrastructure such as facility-based refraction, the dispensing of ready-made and custom spectacles, preschool-linked vision screening, outreach services, and strengthening of the optical supply-chain strengthening achieved the highest and most consistent consensus across all three evaluative dimensions. In contrast, components dependent on new financing mechanisms, workforce expansion, or advanced digital platforms continued to demonstrate feasibility constraints, despite being rated highly in terms of relevance and expected impact. The Supplementary Table S1 presents the item level agreement percentages for each component across both Delphi rounds. Comparative shifts between rounds Comparative analysis between rounds demonstrated a systematic narrowing of the relevance to feasibility gap. Median feasibility scores increased for most components, while relevance scores remained largely stable, indicating convergence of expert opinion rather than increased agreement. No component demonstrated a decline in expected impact ratings between rounds. Components failing to reach feasibility consensus in Round 2 were not discarded but were reclassified as medium-term or enabling elements, contingent on policy reform, workforce expansion, or financing innovation. Table 2 delineates components that are immediately scalable from those requiring policy, financing, or workforce reforms prior to implementation. Table 2 Round-2 consensus status by model component (All 37 items) Item No Model component (abridged) Relevance ≥ 70% Feasibility ≥ 70% Impact ≥ 70% Overall status Item 1 Community awareness (local language) No No No Not prioritised Item 2 Awareness via community volunteers No No No Not prioritised Item 3 Subsidised spectacles Yes No Yes Modified (Enabler) Item 4 Free spectacles for vulnerable groups Yes No Yes Modified (Enabler) Item 5 National media advocacy No No No Not prioritised Item 6 Facility-based refraction (hospitals) Yes Yes Yes Retained (Core) Item 7 District hospital refraction services Yes Yes Yes Retained (Core) Item 8 PHC-level refraction services Yes Yes Yes Retained (Core) Item 9 Standardised refraction protocols Yes Yes Yes Retained (Core) Item 10 Quality assurance & supervision Yes Yes Yes Retained (Core) Item 11 Ready-made spectacle dispensing Yes Yes Yes Retained (Core) Item 12 Custom spectacle dispensing Yes Yes Yes Retained (Core) Item 13 Optical supply-chain strengthening Yes Yes Yes Retained (Core) Item 14 Centralised procurement Yes Yes Yes Retained (Core) Item 15 Preschool-based vision screening Yes Yes Yes Retained (Core) Item 16 School screening with spectacles Yes Yes Yes Retained (Core) Item 17 Teacher-led basic screening Yes No Yes Modified (Enabler) Item 18 Optometry workforce expansion Yes No Yes Modified (Enabler) Item 19 Task-sharing with technicians Yes No Yes Modified (Enabler) Item 20 Continuous professional development Yes Yes Yes Retained (Core) Item 21 Outreach/mobile refraction services Yes Yes Yes Retained (Core) Item 22 Targeted remote-area outreach Yes Yes Yes Retained (Core) Item 23 Tele-refraction services Yes No Yes Modified (Innovation) Item 24 Digital vision screening tools Yes No Yes Modified (Innovation) Item 25 Electronic refraction records Yes No Yes Modified (Enabler) Item 26 HMIS integration of RE indicators Yes No Yes Modified (Enabler) Item 27 Insurance inclusion for spectacles Yes No Yes Modified (Enabler) Item 28 Government subsidy mechanisms Yes No Yes Modified (Enabler) Item 29 Public–private partnerships Yes No Yes Modified (Innovation) Item 30 Social enterprise optical models Yes No Yes Modified (Innovation) Item 31 Regulation of private optical sector Yes Yes Yes Retained (Core) Item 32 Licensing/accreditation of optical shops Yes Yes Yes Retained (Core) Item 33 Spectacle price regulation Yes No Yes Modified (Enabler) Item 34 Equity-focused targeting Yes Yes Yes Retained (Core) Item 35 Monitoring effective RE coverage (eREC) Yes Yes Yes Retained (Core) Item 36 Routine evaluation and reporting Yes Yes Yes Retained (Core) Item 37 Alignment with national strategy Yes Yes Yes Retained (Core) Consensus defined a priori as ≥ 70% of respondents rating 4 or 5 Thematic analysis of expert feedback Thematic analysis of the open-ended responses from expert participants across both Round 1 and Round 2 of the Delphi surveys identified several key themes regarding the refractive error and optical service delivery model in Bhutan. The main themes encompassed workforce capacity and training, affordability and access to spectacles, service delivery and outreach mechanisms, quality assurance and regulatory frameworks, awareness and health education, the role of technology and innovation, and policy and governance considerations. A summary of these themes is presented in Table 3 . Table 3 Thematic analysis of expert feedback from Round 1 and Round 2 Delphi surveys Theme Illustrative Quotes Frequency in Feedback Workforce Capacity “Training of Health Assistants is important, but refraction and dispensing will be too high a task.” High Affordability of Spectacles “Provision of free spectacles for children, elderly, and low-income groups is important.” High Service Delivery & Outreach “Mobile refraction units and eyeglasses dispensing (mobile refractive error camps) should be established.” High Quality & Regulation “Development of national quality standards and regulatory oversight for optical shops.” High Awareness & Education “Community awareness campaigns in local languages to increase uptake of refractive error services.” High Technology & Innovation “Use of tele-refraction services in remote districts may not be effective.” Medium Policy & Governance “Establishment of a National Refractive Error Taskforce under the Ministry of Health.” Medium Participants consistently highlighted the need for a robust and well-trained workforce, affordable and accessible spectacles, and effective outreach programs to ensure universal coverage. Strong consensus emerged around the need for quality assurance mechanisms and robust regulatory oversight to ensure the safety, effectiveness and consistency of optical services. In addition, participants highlighted the critical role of community awareness initiatives and the integration of eye health education into school curricula in enhancing service uptake, adherence and long-term preventive behaviours. Although technological innovations, including tele-refraction, were viewed as potentially valuable for expanding access, concerns were expressed regarding their practical feasibility, quality assurance, and contextual suitability. Finally, experts underscored the urgent need for comprehensive national policies and clinical guidelines to systematically coordinate, regulate, and monitor refractive error services, with particular emphasis on strengthened government leadership, sustained financing, and policy-level commitment. Table 4 summarizes the validated and prioritized core components and enabling elements emerging from the consensus process for the development of a refractive error and optical service delivery model for Bhutan Table 4 Validated and prioritized core components and enabling elements for development of refractive error and optical service delivery model for Bhutan System level Primary Role Core Components (High Consensus ≥ 70%) Enabling / Medium-Term Elements Level 1. National Level (System Stewardship & Governance) Policy direction, regulation, financing levers, and system performance monitoring Alignment with national eye-health strategy (Item 37); Regulation of private optical sector (Item 31); Licensing & accreditation of optical shops (Item 32); Monitoring effective refractive error coverage (eREC) (Item 35); Routine evaluation & reporting (Item 36); Equity-focused service targeting (Item 34); Centralised procurement of optical supplies (Item 14) Insurance inclusion for spectacles (Item 27); Government subsidy mechanisms (Item 28); Price regulation of spectacles (Item 33); Public–private partnerships (Item 29); Social enterprise optical models (Item 30); HMIS integration of refractive error indicators (Item 26) Level 2. Apex Hospital (Tertiary / National Referral) Clinical leadership, quality assurance, training hub, and complex case management Facility-based refraction services (Item 6); Standardised refraction protocols (Item 9); Quality assurance & supervision (Item 10); Custom spectacle dispensing (Item 12); Continuous professional development (CPD) (Item 20); Optical supply-chain strengthening (Item 13) Optometry workforce expansion (Item 18); Electronic refraction records (Item 25) Level 3. Referral (Secondary) Hospitals Regional access to comprehensive refractive and optical services Secondary-level refraction services (Item 7); Ready-made spectacle dispensing (Item 11); Custom spectacle dispensing (Item 12); Outreach/mobile refraction services (Item 21); Targeted outreach to remote areas (Item 22); Quality assurance linkages (Item 10) Task-sharing with ophthalmic technicians (Item 19); Tele-refraction services (Item 23) Level 4. District & 10-Bedded Hospitals First-contact facility-based refractive care Facility-based refraction (Item 6); PHC-linked refraction pathways (Item 8); Ready-made spectacle dispensing (Item 11); Outreach/mobile services (Item 21) Digital vision screening tools (Item 24); Electronic refraction records (Item 25) Level 5. PHC & School Level Early detection, referral, and prevention of avoidable visual impairment PHC-level refraction services (Item 8); Pre-school-based vision screening (Item 15); School screening linked to spectacle provision (Item 16) Teacher-led basic screening (Item 17); Digital screening tools (Item 24) Level 6. Community Level Demand generation and last-mile interface None prioritised in Delphi Round 2 Community awareness (local language) (Item 1); Awareness via community volunteers (Item 2); National media advocacy (Item 5) Cross-Cutting Elements (All Levels) System coherence, quality, and equity Standardized refraction protocols (Item 9); Quality assurance & supervision (Item 10); Optical supply-chain strengthening (Item 13); Continuous professional development (Item 20); Equity-focused targeting (Item 34); Monitoring eREC and routine reporting (Items 35–36) Discussion This Delphi study provides a system-level validation of a nationally applicable refractive error and optical service delivery model for Bhutan. The findings demonstrate a high degree of consensus among experts on priority intervention areas, while simultaneously delineating implementation constraints imposed by the current capacity of the health system. At the time of the study, Bhutan was developing its National Eye Health Strategy (2025–2030) in alignment with the WHO SPECS 2030 framework [13]. The study therefore contributes directly to national strategic planning by providing an evidence-based, contextually relevant, and expert-validated framework to guide refractive error and optical service delivery ( Fig. 3 ) . Beyond its national relevance, this study makes a methodological contribution by illustrating how a structured expert consensus process can be used to translate health-system assessment findings into an implementation-ready service-delivery model. Although the resulting configuration is context-specific to Bhutan, key design features; namely, the staged prioritisation of core and enabling components, explicit feasibility appraisal, and alignment with outcome-oriented indicators such as effective refractive error coverage (eREC), provide a transferable framework for other small and resource-constrained health systems. This approach is particularly applicable to settings aiming to align refractive error service planning with WHO Integrated People-Centred Eye Care and SPECS 2030 priorities. Most components were rated highly in terms of relevance and anticipated impact; however, fewer achieved consensus regarding feasibility. This disparity likely reflects underlying structural constraints, including limitations in workforce capacity, financing mechanisms, regulatory environments, and digital infrastructure. Comparable discrepancies have been documented in other health-system Delphi studies, wherein experts endorse proposed reforms conceptually but express reservations about their practical implementation [14–16]. Components integrated within existing public-sector health services demonstrated the strongest and most consistent consensus among participants. These components included facility-based refraction, the dispensing of ready-made spectacles, outreach-based service delivery, and the strengthening of the optical supply chain. Global evidence shows that integrating refractive services within routine health-care services improves sustainability and promotes equitable access, particularly in geographically remote or resource-constrained settings [3, 4, 17]. Strong agreement was also observed regarding the importance of regulation, licensing, quality assurance, and the monitoring of eREC. Although Bhutan has attained relatively high service coverage, these findings highlight the need to prioritise quality and health outcomes rather than service volume alone. This perspective is consistent with WHO guidance, which advocates for outcome-based, people-centred eye care [18]. Furthermore, the existing disconnect between refraction services and optical dispensing requires targeted interventions to ensure continuity and effectiveness of care [19]. Strengthening regulatory oversight of the optical sector is also essential to guarantee equitable access to safe, affordable, and high-quality spectacles in Bhutan, as inadequately regulated optical markets have been associated with substandard care and inequitable access [20]. Community awareness initiatives and volunteer-led approaches did not achieve consensus and therefore warrant critical reflection. While these strategies are frequently emphasised within global eye-health programmes, the findings of this study indicate that demand-generation interventions alone are insufficient to improve effective service coverage. Meaningful gains are unlikely unless such efforts are integrated with accessible, adequately regulated, and affordable refraction and spectacle dispensing services that can respond to increased demand in a sustainable manner. Components relating to workforce expansion, financing mechanisms, digital health, and public–private partnerships received comparatively lower feasibility ratings. However, the decision to retain these low-feasibility components as enabling or medium-term elements, rather than excluding them, strengthens the policy relevance and pragmatic utility of the model. The literature consistently identifies workforce expansion, sustainable financing mechanisms (including insurance coverage for spectacles), digital health solutions, and public–private partnerships as high-impact interventions once health-system capacity and supporting infrastructure are strengthened. In particular, digital technologies and artificial intelligence demonstrate substantial potential to improve eye health service delivery; however, their effective implementation is contingent upon addressing contextual, infrastructural, and regulatory barriers [21]. The principal strength of this study lies in the application of a structured, two-round Delphi methodology to validate a national refractive error service delivery model. The expert panel was deliberately heterogenous, comprising clinicians, programme managers, policy-makers, NGO representatives, and private optical professionals from across Bhutan. Panel composition remained stable across both rounds, enhancing the credibility and robustness of the consensus attained. The use of clearly defined, a priori criteria—namely relevance, feasibility, and anticipated impact—facilitated transparent and systematic prioritisation of model components. The observed increase in feasibility ratings between rounds is indicative of genuine convergence of expert opinion rather than response bias, thereby supporting the internal validity of the Delphi process. Nevertheless, feasibility is inherently context-dependent and dynamic. Consequently, as Bhutan’s health financing mechanisms, workforce capacity, and digital health infrastructure evolve, periodic reassessment of these components will be necessary to ensure continued relevance and applicability. Successful implementation of the aspects achieving consensus in the study may serve as the catalyst to make the implementation of some of these components more feasible. This study has several limitations. The findings are derived from expert consensus rather than empirical implementation or outcome data. Feasibility assessments are contingent on prevailing health-system conditions and may evolve over time. Although some attrition occurred between study rounds, overall participant retention remained acceptable. As the study was conducted within the Bhutanese context, the transferability of the findings to other settings may be limited. The online study format likely mitigated dominance bias but constrained opportunities for in-depth deliberation. Consequently, the findings reflect informed expert consensus rather than observed implementation effects. Future research should therefore assess the real-world effectiveness, cost implications, and equity impacts of implementing the prioritised model components. Conclusion This study develops and validates an evidence-based model for refractive error and optical service delivery in Bhutan using a Delphi methodology informed by a comprehensive health-system situational analysis. The model is grounded in empirical evidence and refined through structured expert consensus, ensuring alignment between evidence and strategy. The validated framework adopts a phased approach that prioritises system-embedded, quality-assured service delivery, while explicitly identifying the future need for policy, workforce, financing, and governance reforms to achieve universal effective refractive error coverage. The Delphi method proved appropriate for Bhutan’s context, yielding pragmatic, policy-relevant recommendations. Overall, the model provides a realistic and actionable roadmap for strengthening refractive error services, is aligned with WHO SPECS 2030, and offers direct utility for informing Bhutan’s forthcoming National Eye Health Strategy. Declarations Clinical trial number Not applicable. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors Author Contribution IPS is the study’s principal investigator. IPS, KSN and KPM conceptualized the protocol, and study design. IPS, NTL, DW and TL participated in study implementation including data collection and analysis. All were involved in the interpretation of the finding and validated the data. IPS drafted the manuscript and all authors critically reviewed the draft manuscript and approved the final version. Acknowledgement The authors thank all eye-health professionals and experts in Bhutan who participated in the Delphi process for their time and expertise. We also acknowledge the Ministry of Health, Bhutan, for facilitating access to professional networks and supporting the broader refractive error situational analysis that informed this study. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References 1. Sharma J, Zangpo K, Grundy J. Measuring universal health coverage: a three-dimensional composite approach from Bhutan. WHO South East Asia J Public Health . 2014;3(3):226–237. doi:10.4103/2224-3151.206745. PMID:28612807. 2. Lepcha NT, Sharma IP. Primary eye care in Bhutan: achievements and challenges. Community Eye Health . 2021;34(113):S11–S12. Epub 2022 Mar 1. PMID:36033415; PMCID:PMC9412122. 3. Umaefulam V, Safi S, Lingham G, Gordon I, Mueller A, Krishnam NS, Alves Carneiro VL, Yu M, Evans JR, Keel S. Approaches for delivery of refractive and optical care services in community and primary care settings. Cochrane Database Syst Rev . 2024;5(5):CD016043. doi:10.1002/14651858.CD016043. PMID:38808577; PMCID:PMC11134311. World Health Organization. Integrating eye care into health systems [Internet]. Geneva: World Health Organization; 2023 [cited 2025 Dec 10]. Available from: https://www.who.int/activities/integrating-eye-care-in-health-systems World Health Organization. World report on vision [Internet]. Geneva: World Health Organization; 2019 [cited 2025 Dec 10]. Available from: https://www.who.int/publications-detail-redirect/world-report-on-vision 6. McCormick I, Tong K, Abdullah N, Abesamis-Dischoso C, Gende T, Hashim EB, Ho SM, Jalbert I, Jeronimo B, Matoto-Raikabakaba E, Ono K, Piyasena PN, Rogers JT, Szetu J, Tran MA, Tse DY, Win Y, Yap TP, Yoon S, Yusufu M, Burton MJ, Ramke J; Promoting Equity in Refractive Error Services in the Western Pacific Study Group. Strategies to address inequity of uncorrected refractive error in the Western Pacific: a modified Delphi process. Ophthalmic Physiol Opt . 2024;44(6):1148–1161. doi:10.1111/opo.13348. PMID:38881170. 7. Muma S, Naidoo KS, Hansraj R. Telemedicine integration into the eye health ecosystem in scaling of effective refractive error coverage in Kenya. Sci Rep . 2024;14(1):18170. doi:10.1038/s41598-024-68993-5. PMID:39107375; PMCID:PMC11303391. 8. Muma S, Naidoo KS, Hansraj R. Proposed task shifting integrated with telemedicine to address uncorrected refractive error in Kenya: a Delphi study. BMC Health Serv Res . 2024;24(1):115. doi:10.1186/s12913-024-10618-8. PMID:38254104; PMCID:PMC10801974. 9. Alrasheed SH, Naidoo KS, Clarke-Farr PC, Binnawi KH. Building consensus for the development of child eye care services in South Darfur State of Sudan using the Delphi technique. Afr J Prim Health Care Fam Med . 2018;10(1):e1–e9. doi:10.4102/phcfm.v10i1.1767. PMID:30456975; PMCID:PMC6244194. 10. Yu M, Keel S, Mariotti S, Mills JA, Müller A. Development of the WHO eye care competency framework. Hum Resour Health . 2023;21(1):46. doi:10.1186/s12960-023-00834-4. PMID:37337207; PMCID:PMC10278260. 11. Ramke J, Evans JR, Habtamu E, et al. Grand challenges in global eye health: a global prioritisation process using Delphi method. Lancet Healthy Longev . 2022;3(1):e31–e41. doi:10.1016/S2666-7568(21)00302-0. World Health Organization. Primary eye care package [Internet]. Geneva: World Health Organization; 2022 [cited 2025 Dec 10]. Available from: https://www.who.ineat/publications/b/78046 World Health Organization. Bhutan charts a new course for eye health by 2030 [Internet]. Geneva: World Health Organization; 2023 [cited 2025 Dec 10]. Available from: https://www.who.int/news-room/feature-stories/detail/bhutan-charts-new-course-for-eye-health-by-2030 14. Roberti J, Teijeiro ME, Fernández-Pazos A, Saenz V, García-Elorrio E. Modified RAND/UCLA Delphi consensus of recommendations to advance towards a value-based healthcare model for the Argentine health system. IJQHC Commun . 2025;5(2):lyaf013. doi:10.1093/ijcoms/lyaf013. 15. Tudisca V, Valente A, Castellani T, et al. Development of measurable indicators to enhance public health evidence-informed policy-making. Health Res Policy Syst . 2018;16(1):47. doi:10.1186/s12961-018-0323-z. 16. Aghaji A, Burchett HED, Mathenge W, et al. Technical capacities needed to implement the WHO primary eye care package for Africa: results of a Delphi process. BMJ Open . 2021;11(3):e042979. doi:10.1136/bmjopen-2020-042979. 17. Burton MJ, Ramke J, Marques AP, et al. The Lancet Global Health Commission on global eye health: vision beyond 2020. Lancet Glob Health . 2021;9(4):e489–e551. doi:10.1016/S2214-109X(20)30488-5. World Health Organization. Indicator metadata registry: effective refractive error coverage (eREC) [Internet]. Geneva: World Health Organization; 2023 [cited 2025 Dec 10]. Available from: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/3154 19. Ramke J, du Toit R, Palagyi A, Williams C, Brian G. Public sector refraction and spectacle dispensing in low-resource countries of the Western Pacific. Clin Exp Ophthalmol . 2008;36(4):339–347. doi:10.1111/j.1442-9071.2008.01768.x. International Agency for the Prevention of Blindness. The supply-side market for glasses [Internet]. London: IAPB; 2024 [cited 2025 Dec 10]. Available from: https://www.iapb.org/wp-content/uploads/2024/02/Supply-side-market-for-glasses.pdf 21. Tan TF, Ting DSW, et al. Artificial intelligence and digital health in global eye health: opportunities and challenges. Lancet Glob Health . 2023;11(9):e1432–e1443. doi:10.1016/S2214-109X(23)00296-5. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.pdf Annexure1ValidationoftheRefractiveErrorOpticalServiceDeliveryModelforBhutan.pdf Annexure2ValidationoftheRefractiveErrorOpticalServiceDeliveryModelforBhutanRound2.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 19 Mar, 2026 Reviews received at journal 11 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviewers agreed at journal 09 Mar, 2026 Reviewers invited by journal 25 Feb, 2026 Editor invited by journal 02 Feb, 2026 Editor assigned by journal 30 Jan, 2026 Submission checks completed at journal 30 Jan, 2026 First submitted to journal 27 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8712693","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":585932098,"identity":"34583ea8-b2f3-4acf-b02e-ad19d6221ad0","order_by":0,"name":"Indra Prasad 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components achieving consensus in Delphi Round 1\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8712693/v1/99b73dedae192b85d7657059.png"},{"id":102310729,"identity":"e3a11d39-f10f-4069-9782-f1a5600bc83a","added_by":"auto","created_at":"2026-02-10 11:55:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21100,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of model components achieving consensus in Delphi Round 2.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8712693/v1/b0ae844156d0be3ecebe1f83.png"},{"id":102310730,"identity":"eb6c08e4-32ca-47fe-b0af-4519052bb5e2","added_by":"auto","created_at":"2026-02-10 11:55:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":611538,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEvidence based model for refraction and optical service delivery in Bhutan\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8712693/v1/fe0cbd6711c448474e1f6bb7.png"},{"id":102312193,"identity":"8b1e3af4-665a-4ddb-a6f5-c4558b4fcbf9","added_by":"auto","created_at":"2026-02-10 12:00:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1946401,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8712693/v1/10ff46d4-7174-4601-906d-05456e544c08.pdf"},{"id":102311285,"identity":"01ecc287-aa0b-4d20-932f-9670d0703072","added_by":"auto","created_at":"2026-02-10 11:57:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":57441,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8712693/v1/939c93b1759f041dc77bcbf5.pdf"},{"id":102310772,"identity":"b2fcd96f-96f0-42dc-b905-f9a24e15c04c","added_by":"auto","created_at":"2026-02-10 11:56:07","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":222863,"visible":true,"origin":"","legend":"","description":"","filename":"Annexure1ValidationoftheRefractiveErrorOpticalServiceDeliveryModelforBhutan.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8712693/v1/9eadbaa3cc1630032077ac38.pdf"},{"id":102311706,"identity":"c6563328-3643-4dca-8d0f-3efbfd40ae1e","added_by":"auto","created_at":"2026-02-10 11:58:39","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":233814,"visible":true,"origin":"","legend":"","description":"","filename":"Annexure2ValidationoftheRefractiveErrorOpticalServiceDeliveryModelforBhutanRound2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8712693/v1/454a924a2ce6b05703314ace.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Delphi-based validation and prioritisation of a national refractive error and optical service delivery model for Bhutan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBhutan has attained near-universal coverage of essential health services through a publicly financed health system that provides care free at the point of delivery [1]. Eye-care services are provided within a tiered health system comprising a national referral hospital, regional referral hospitals, and district hospitals, and 10 bedded primary hospitals [2]. Over the past decade, substantial investments have been made to expand ophthalmic infrastructure and human resources, including the training and recruitment of the country\u0026rsquo;s first optometrist in 2010. Despite this progress, refractive error and optical services remain inadequately organised and poorly regulated. Limited system integration continues to constrain coordinated service delivery, thereby impeding consistent, equitable, and measurable scale-up.\u003c/p\u003e \u003cp\u003eA nationwide situational analysis of refractive error and optical service in Bhutan was conducted in mid-2025 using the World Health Organization\u0026rsquo;s Refractive Error Situation Analysis Tool (RESAT). This assessment constituted the first comprehensive, multi-domain evaluation of refractive-error services in the country, encompassing governance and leadership, service delivery, workforce capacity, optical supply systems, health information systems, health promotion, and financing. The RESAT identified several system-level constraints affecting the delivery of refractive error services. These included the absence of a national refractive error service delivery framework; inadequate regulation and quality assurance mechanisms for optical dispensing; fragmented and inefficient spectacle supply chains, variability in the availability and quality of refraction services at primary health-care level; and the lack of routine monitoring of effective refractive error coverage within the national health information system. Comparable system-level deficiencies have been documented in refractive error service delivery models in similar settings [3]. Notwithstanding these challenges, the assessment also identified notable institutional strengths. These consisted of the integration of eye health, including refraction services, within the public health systems; strong political commitment to eye health; a growing eye-care workforce; and relatively high coverage of publicly funded eye-care services within the context of universal health coverage.\u003c/p\u003e \u003cp\u003eThese findings align with recent global eye-health reforms. In 2021, the World Health Assembly adopted Resolution WHA74.12 on Integrated People-Centred Eye Care, which calls for the systematic integration of eye-care services within national health systems [4]. Subsequently, in 2022, WHO introduced effective refractive error coverage (eREC) as a core global eye health indicator, marking a shift from measuring service volume to assessing quality and financial outcomes [5]. In the context of Bhutan, this policy direction necessitates more than service expansion; it requires a clearly articulated national model that coherently integrates governance, human resources, optical and supply chain systems, financing mechanisms, and health information systems.\u003c/p\u003e \u003cp\u003eDespite the availability of global technical guidance, Bhutan currently lacks an evidence based, scalable national model for refractive-error and optical service delivery. In the absence of such a framework, refractive services are vulnerable to fragmentation, with parallel investments in community-based screening, hospital-based refraction, and workforce deployment occurring without harmonised national standards, clearly defined referral pathways, or coordinated optical dispensing and supply-chain systems. This gap is particularly consequential in small health systems with limited human resources and geographically dispersed populations, where efficient planning, system-wide coordination, and operational feasibility are essential to ensure equitable and sustainable service delivery.\u003c/p\u003e \u003cp\u003eRecent evidence from other low- and middle-income countries demonstrates that structured expert-consensus approaches, particularly Delphi methodologies, are effective for the development and validation of refractive-error and optical service-delivery frameworks that are context-appropriate and implementation-ready [6]. Delphi-based validation frameworks have recently been applied to task-shifting and integration of tele-refraction services in Kenya, to national child eye-care planning in Sudan, and to the formulation of global eye-care competencies by WHO eye care experts [7\u0026ndash;10]. In addition, global Delphi-based prioritisation exercises have highlighted the utility of expert consensus in aligning eye-health system design with policy and financing priorities [11]. Notwithstanding this growing body of evidence, nationally validated, evidence-based models for refractive-error and optical service delivery are currently lacking in Bhutan.\u003c/p\u003e \u003cp\u003eTo address this gap, a multi-phase study was undertaken to develop and validate Bhutan\u0026rsquo;s first national refractive-error and optical service-delivery model. An initial evidence-informed model was formulated based on findings from a nationwide situational analysis con-_ducted using the WHO RESAT [12]. This draft model was subsequently evaluated through a two-round modified-Delphi process involving Bhutanese eye-health experts. This paper reports the results of the Delphi validation process and presents a final, consensus-based national model intended to inform policy development, strategic planning, resource allocation, and performance monitoring of refractive error services in Bhutan, in alignment with the WHO 2030 effective coverage targets.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and overview\u003c/h2\u003e \u003cp\u003eBased on the nationwide RESAT findings, an evidence-based refractive error and optical service delivery model was developed (Phase 1). Subsequently, a Delphi consensus process (phase 2) was conducted to validate and refine the Phase 1 model. A two-round, online Delphi methodology was employed to elicit structured expert consensus on the relevance, feasibility and expected impact of each model component. The number of Delphi rounds were pre-specified, as the model was derived from a comprehensive national situational analysis. The Delphi process was used for validation, refinement and prioritisation of components rather than for the initial generation of the model.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eExpert panel selection\u003c/h3\u003e\n\u003cp\u003ePurposive sampling was employed to recruit national experts and with diverse perspectives on refractive error and optical services in Bhutan. Eligibility criteria included: (i) a minimum of three years\u0026rsquo; experience in eye care or health systems within Bhutan; and (ii) current or recent involvement in clinical service delivery, programme management, policy-development, planning, training or research related to eye health. Given Bhutan\u0026rsquo;s relatively small health system and limited specialist workforce, a threshold of three years\u0026rsquo; experience was considered sufficient to ensure adequate operational familiarity with refractive-error services across different levels of care. The sampling strategy generated representation from ophthalmologists, optometrists, ophthalmic technicians, programme managers, policy-makers, public health specialists, non-governmental organisations, and the private optical sector, as well as geographic representation across all regions and levels of care (primary, secondary, tertiary).\u003c/p\u003e \u003cp\u003ePotential participants were identified through the professional network of the study investigators, existing health professional and expert databases maintained by the Ministry of Health, and a snowball sampling approach to recruit additional participants. Eligible individuals were subsequently invited to participate via email.\u003c/p\u003e\n\u003ch3\u003eDelphi procedure\u003c/h3\u003e\n\u003cp\u003eThe Delphi survey was administered electronically using Google Forms. The survey instruments for Rounds 1 and 2 are provided in Annexures 1 and 2, respectively. Each Delphi round remained open for a two-week period, during which up to two reminder emails or SMS notifications were issued at one-week intervals to participants who had not yet responded. To preserve methodological rigour and minimise response bias, individual responses were anonymised with respect to other panel members, and only aggregated and summarized feedback was disseminated to participants between successive rounds.\u003c/p\u003e\n\u003ch3\u003eRound 1:\u003c/h3\u003e\n\u003cp\u003eParticipants were provided with a concise narrative description and a visual schematic of the draft model, outlining its core domains and constituent components. These components were systematically discussed, refined, and validated by the investigative team, informed by the findings of the nationwide RESAT. Each component was subsequently evaluated by subject-matter experts across three predefined assessment domains:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eRelevance: \u0026ldquo;How important is this component for addressing refractive error and optical service needs in Bhutan?\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFeasibility: \u0026ldquo;How realistic is it to implement this component within Bhutan\u0026rsquo;s current and foreseeable health system context?\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExpected impact: \u0026ldquo;If implemented as intended, how much impact is this component likely to have on increasing refractive error coverage and improving equity?\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAll items were assessed using a five-point Likert scale, from 1 (very low/not at all) to 5 (very high). In addition, three open-ended questions were included to enable respondents to identify key components required for achieving universal eREC and to provide supplementary feedback not captured by the structured survey items.\u003c/p\u003e\n\u003ch3\u003eRound 2:\u003c/h3\u003e\n\u003cp\u003eIn Round 2, participants were provided with anonymised feedback from Round 1, comprising summary statistics of the ratings (median) for each component, together with a thematic synthesis of qualitative comments. Participants were subsequently invited to re-evaluate and re-rate each component in light of this feedback, as well as to appraise any revised or newly proposed components that emerged from Round 1. Ratings were again recorded using the same 5-point Likert scale, accompanied by open-ended comment fields.\u003c/p\u003e \u003cp\u003eTwo rounds were pre-specified, as the model had been comprehensively developed during Phase 1. Consequently, expert input was anticipated to concentrate on refinement and validation of existing components rather than the generation of new elements.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eConsensus definition and data analysis\u003c/h2\u003e \u003cp\u003eConsensus criteria were defined a priori. For each component and for each evaluation dimension (relevance, feasibility, expected impact), consensus was achieved when \u0026ge;\u0026thinsp;70% of respondents assigned a rating of 4 or 5 on the 5-point scale in Round 2. This threshold is consistent with established practice in Delphi studies within health-systems and eye-health research. As a sensitivity analysis, central tendency and dispersion were also assessed. Components with a median score\u0026thinsp;\u0026ge;\u0026thinsp;4 and an interquartile range (IQR)\u0026thinsp;\u0026le;\u0026thinsp;1 were interpreted as demonstrating strong agreement among participants.\u003c/p\u003e \u003cp\u003eQuantitative data were analysed using SPSS version 26. Descriptive statistics were generated, including frequencies and proportions for each response category. For each item and Delphi round, medians and interquartile ranges (IQRs) were calculated to summarise central tendency and dispersion. Changes in response distributions between Round 1 and Round 2 were examined descriptively to evaluate the stability and convergence of participants\u0026rsquo; opinions.\u003c/p\u003e \u003cp\u003eQualitative data from open-ended responses were imported into MS Excel and analysed using a rapid, pragmatic thematic analysis approach. Emergent themes informed iterative refinements to the wording, scope and categorisation of model components across successive rounds and in the final model. Components that failed to achieve the predefined consensus threshold were reviewed and modified based on the qualitative feedback provided.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData management and quality control\u003c/h3\u003e\n\u003cp\u003eAll survey data were securely stored on password-protected servers with access limited to authorised members of the research team. Data entry procedures incorporated double verification to ensure accuracy, and any discrepancies were resolved through discussion among the research team. Ongoing quality assurance processes included systematic monitoring of response patterns and regular checks for coding reliability and consistency in the qualitative data.\u003c/p\u003e \u003cp\u003eTo safeguard confidentiality within a small professional community, findings are presented in aggregated form, and no individual or institution-specific statements are reported or attributed.\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eThe Delphi study was conducted as part of a broader nationwide RESAT-based situational analysis. Ethical approval was obtained from the Research Ethics Board of Health (REBH), Ministry of Health, Bhutan (Ref: REBH/Approval/2023/003) and the Biomedical Research Ethics Committee (BREC), University of KwaZulu-Natal, South Africa (Approval no: BREC/00004482/2022). AThe study adhered\u003c/p\u003e \u003cp\u003e to the principles of the Declaration of Helsinki and followed international best practices for clinical and public health research. All participants were provided with an information sheet detailing the study objectives, the proposed model and the Delphi process, together with a consent form. Informed consent was obtained prior to participation, with completion of the online survey constituting implied consent. Participation was entirely voluntary, with no financial or other incentives offered. Participants were informed of their right to withdraw from the study at any stage, without penalty or adverse consequences.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDelphi panel characteristics and retention\u003c/h2\u003e \u003cp\u003eA total of 46 of the 55 invited health experts participated in Delphi Round 1, yielding a response rate of 83.6%. Of these, 33 experts completed Round 2, corresponding to a retention rate of 71.7%. The panel comprised a diverse and representative sample of stakeholders within Bhutan\u0026rsquo;s refractive error and optical service delivery system, including ophthalmologists, optometrists, ophthalmic technicians, programme managers, policy officials, NGO and development partners, and private optical sector professionals. Panel stability across Delphi rounds was high. The median age of participants remained constant at 41 years, with comparable interquartile ranges across rounds. Median duration of professional experience in eye health increased slightly from 14 years (IQR: 9\u0026ndash;22) in Round 1 to 15 years (IQR: 10\u0026ndash;23) in Round 2. Geographic representation across western, central, eastern, and southern regions of the country remained broadly consistent between rounds. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents a summary of participants\u0026rsquo; demographic characteristics, professional backgrounds, and geographic distribution.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of participant characteristics across both Delphi rounds\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRound 1 (N\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRound 2 (N\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (36\u0026ndash;51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (36\u0026ndash;52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of experience in eye health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (9\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (10\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eProfessional cadres\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOphthalmologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (19.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (18.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOptometrists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (19.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOphthalmic technicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (34.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (36.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMoH / NMS Public Health Officials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNGO / Development Partners officials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (3.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate optical professional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (9.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003ePresent area of work\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral Bhutan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (26.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEastern Bhutan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (21.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (21.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWestern Bhutan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (30.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (42.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (3.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDelphi Round 1: Initial appraisal of model components\u003c/h2\u003e \u003cp\u003eThe draft model consisted of 37 items organised into five components. Although Round 1 was exploratory in nature, an a priori consensus threshold of \u0026ge;\u0026thinsp;70% agreement, defined as ratings of 4 or 5 was established for Round 2 across the domains of relevance, feasibility, and anticipated impact. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the extent to which consensus was achieved across these three evaluative dimensions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn Round 1, relevance ratings were uniformly high across most components, with particularly strong scores for facility-based refraction services, optical dispensing, school-based vision screening, and supply-chain strengthening. In contrast, feasibility ratings were consistently lower than relevance ratings, notably for components requiring regulatory reform, novel financing mechanisms, workforce expansion, or the development of digital infrastructure. Expected impact ratings more closely mirrored relevance scores than feasibility scores, indicating strong perceived potential benefits despite acknowledged implementation constraints.\u003c/p\u003e \u003cp\u003eOnly a limited number of components achieved the predefined\u0026thinsp;\u0026ge;\u0026thinsp;70% consensus threshold across all three dimensions (relevance, feasibility, and expected impact) during Round 1. This outcome justified progression to a second Delphi round to enable structured feedback, clarification and further refinement of the proposed components.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDelphi Round 2: Consensus achievement and prioritisation\u003c/h2\u003e \u003cp\u003eFollowing structured feedback and controlled iteration, there was a measurable increase in consensus across all three dimensions in Round 2. Of the 37 components assessed, 30 (81.1%) achieved consensus on relevance, 16 (43.2%) on feasibility, and 32 (86.5%) on expected impact, based on a\u0026thinsp;\u0026ge;\u0026thinsp;70% agreement threshold \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Components that demonstrated borderline agreement in Round 1 showed the most pronounced gains in Round 2, particularly with respect to feasibility. Ratings for expected impact remained consistently high across most components, with no observed decline between rounds.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eService-delivery components integrated within existing public-sector infrastructure such as facility-based refraction, the dispensing of ready-made and custom spectacles, preschool-linked vision screening, outreach services, and strengthening of the optical supply-chain strengthening achieved the highest and most consistent consensus across all three evaluative dimensions. In contrast, components dependent on new financing mechanisms, workforce expansion, or advanced digital platforms continued to demonstrate feasibility constraints, despite being rated highly in terms of relevance and expected impact. The \u003cb\u003eSupplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u003c/b\u003e presents the item level agreement percentages for each component across both Delphi rounds.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eComparative shifts between rounds\u003c/h2\u003e \u003cp\u003eComparative analysis between rounds demonstrated a systematic narrowing of the relevance to feasibility gap. Median feasibility scores increased for most components, while relevance scores remained largely stable, indicating convergence of expert opinion rather than increased agreement. No component demonstrated a decline in expected impact ratings between rounds. Components failing to reach feasibility consensus in Round 2 were not discarded but were reclassified as medium-term or enabling elements, contingent on policy reform, workforce expansion, or financing innovation. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e delineates components that are immediately scalable from those requiring policy, financing, or workforce reforms prior to implementation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRound-2 consensus status by model component (All 37 items)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem No\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel component (abridged)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRelevance\u0026thinsp;\u0026ge;\u0026thinsp;70%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFeasibility\u0026thinsp;\u0026ge;\u0026thinsp;70%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eImpact\u0026thinsp;\u0026ge;\u0026thinsp;70%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOverall status\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity awareness (local language)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot prioritised\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAwareness via community volunteers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot prioritised\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubsidised spectacles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Enabler)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFree spectacles for vulnerable groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Enabler)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNational media advocacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot prioritised\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFacility-based refraction (hospitals)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistrict hospital refraction services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHC-level refraction services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStandardised refraction protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuality assurance \u0026amp; supervision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReady-made spectacle dispensing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCustom spectacle dispensing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOptical supply-chain strengthening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentralised procurement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreschool-based vision screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSchool screening with spectacles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeacher-led basic screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Enabler)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOptometry workforce expansion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Enabler)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTask-sharing with technicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Enabler)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContinuous professional development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutreach/mobile refraction services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTargeted remote-area outreach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTele-refraction services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Innovation)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDigital vision screening tools\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Innovation)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElectronic refraction records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Enabler)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHMIS integration of RE indicators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Enabler)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsurance inclusion for spectacles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Enabler)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernment subsidy mechanisms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Enabler)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic\u0026ndash;private partnerships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Innovation)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial enterprise optical models\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Innovation)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegulation of private optical sector\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLicensing/accreditation of optical shops\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpectacle price regulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModified (Enabler)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEquity-focused targeting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMonitoring effective RE coverage (eREC)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRoutine evaluation and reporting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem 37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlignment with national strategy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetained (Core)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eConsensus defined a priori as \u0026ge;\u0026thinsp;70% of respondents rating 4 or 5\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eThematic analysis of expert feedback\u003c/h2\u003e \u003cp\u003eThematic analysis of the open-ended responses from expert participants across both Round 1 and Round 2 of the Delphi surveys identified several key themes regarding the refractive error and optical service delivery model in Bhutan. The main themes encompassed workforce capacity and training, affordability and access to spectacles, service delivery and outreach mechanisms, quality assurance and regulatory frameworks, awareness and health education, the role of technology and innovation, and policy and governance considerations. A summary of these themes is presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThematic analysis of expert feedback from Round 1 and Round 2 Delphi surveys\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIllustrative Quotes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency in Feedback\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWorkforce Capacity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;Training of Health Assistants is important, but refraction and dispensing will be too high a task.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAffordability of Spectacles\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;Provision of free spectacles for children, elderly, and low-income groups is important.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eService Delivery \u0026amp; Outreach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;Mobile refraction units and eyeglasses dispensing (mobile refractive error camps) should be established.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQuality \u0026amp; Regulation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;Development of national quality standards and regulatory oversight for optical shops.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAwareness \u0026amp; Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;Community awareness campaigns in local languages to increase uptake of refractive error services.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTechnology \u0026amp; Innovation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;Use of tele-refraction services in remote districts may not be effective.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePolicy \u0026amp; Governance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;Establishment of a National Refractive Error Taskforce under the Ministry of Health.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eParticipants consistently highlighted the need for a robust and well-trained workforce, affordable and accessible spectacles, and effective outreach programs to ensure universal coverage. Strong consensus emerged around the need for quality assurance mechanisms and robust regulatory oversight to ensure the safety, effectiveness and consistency of optical services. In addition, participants highlighted the critical role of community awareness initiatives and the integration of eye health education into school curricula in enhancing service uptake, adherence and long-term preventive behaviours. Although technological innovations, including tele-refraction, were viewed as potentially valuable for expanding access, concerns were expressed regarding their practical feasibility, quality assurance, and contextual suitability. Finally, experts underscored the urgent need for comprehensive national policies and clinical guidelines to systematically coordinate, regulate, and monitor refractive error services, with particular emphasis on strengthened government leadership, sustained financing, and policy-level commitment. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes the validated and prioritized core components and enabling elements emerging from the consensus process for the development of a refractive error and optical service delivery model for Bhutan\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eValidated and prioritized core components and enabling elements for development of refractive error and optical service delivery model for Bhutan\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystem level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary Role\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCore Components (High Consensus\u0026thinsp;\u0026ge;\u0026thinsp;70%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnabling / Medium-Term Elements\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel 1. National Level (System Stewardship \u0026amp; Governance)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolicy direction, regulation, financing levers, and system performance monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlignment with national eye-health strategy (Item 37); Regulation of private optical sector (Item 31); Licensing \u0026amp; accreditation of optical shops (Item 32); Monitoring effective refractive error coverage (eREC) (Item 35); Routine evaluation \u0026amp; reporting (Item 36); Equity-focused service targeting (Item 34); Centralised procurement of optical supplies (Item 14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInsurance inclusion for spectacles (Item 27); Government subsidy mechanisms (Item 28); Price regulation of spectacles (Item 33); Public\u0026ndash;private partnerships (Item 29); Social enterprise optical models (Item 30); HMIS integration of refractive error indicators (Item 26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel 2. Apex Hospital (Tertiary / National Referral)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical leadership, quality assurance, training hub, and complex case management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacility-based refraction services (Item 6); Standardised refraction protocols (Item 9); Quality assurance \u0026amp; supervision (Item 10); Custom spectacle dispensing (Item 12); Continuous professional development (CPD) (Item 20); Optical supply-chain strengthening (Item 13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptometry workforce expansion (Item 18); Electronic refraction records (Item 25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel 3. Referral (Secondary) Hospitals\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegional access to comprehensive refractive and optical services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecondary-level refraction services (Item 7); Ready-made spectacle dispensing (Item 11); Custom spectacle dispensing (Item 12); Outreach/mobile refraction services (Item 21); Targeted outreach to remote areas (Item 22); Quality assurance linkages (Item 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTask-sharing with ophthalmic technicians (Item 19); Tele-refraction services (Item 23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel 4. District \u0026amp; 10-Bedded Hospitals\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst-contact facility-based refractive care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacility-based refraction (Item 6); PHC-linked refraction pathways (Item 8); Ready-made spectacle dispensing (Item 11); Outreach/mobile services (Item 21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDigital vision screening tools (Item 24); Electronic refraction records (Item 25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel 5. PHC \u0026amp; School Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly detection, referral, and prevention of avoidable visual impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePHC-level refraction services (Item 8); Pre-school-based vision screening (Item 15); School screening linked to spectacle provision (Item 16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTeacher-led basic screening (Item 17); Digital screening tools (Item 24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLevel 6. Community Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDemand generation and last-mile interface\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone prioritised in Delphi Round 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommunity awareness (local language) (Item 1); Awareness via community volunteers (Item 2); National media advocacy (Item 5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCross-Cutting Elements (All Levels)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystem coherence, quality, and equity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eStandardized refraction protocols (Item 9); Quality assurance \u0026amp; supervision (Item 10); Optical supply-chain strengthening (Item 13); Continuous professional development (Item 20); Equity-focused targeting (Item 34); Monitoring eREC and routine reporting (Items 35\u0026ndash;36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis Delphi study provides a system-level validation of a nationally applicable refractive error and optical service delivery model for Bhutan. The findings demonstrate a high degree of consensus among experts on priority intervention areas, while simultaneously delineating implementation constraints imposed by the current capacity of the health system. At the time of the study, Bhutan was developing its National Eye Health Strategy (2025\u0026ndash;2030) in alignment with the WHO SPECS 2030 framework [13]. The study therefore contributes directly to national strategic planning by providing an evidence-based, contextually relevant, and expert-validated framework to guide refractive error and optical service delivery \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eBeyond its national relevance, this study makes a methodological contribution by illustrating how a structured expert consensus process can be used to translate health-system assessment findings into an implementation-ready service-delivery model. Although the resulting configuration is context-specific to Bhutan, key design features; namely, the staged prioritisation of core and enabling components, explicit feasibility appraisal, and alignment with outcome-oriented indicators such as effective refractive error coverage (eREC), provide a transferable framework for other small and resource-constrained health systems. This approach is particularly applicable to settings aiming to align refractive error service planning with WHO Integrated People-Centred Eye Care and SPECS 2030 priorities.\u003c/p\u003e \u003cp\u003eMost components were rated highly in terms of relevance and anticipated impact; however, fewer achieved consensus regarding feasibility. This disparity likely reflects underlying structural constraints, including limitations in workforce capacity, financing mechanisms, regulatory environments, and digital infrastructure. Comparable discrepancies have been documented in other health-system Delphi studies, wherein experts endorse proposed reforms conceptually but express reservations about their practical implementation [14\u0026ndash;16].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eComponents integrated within existing public-sector health services demonstrated the strongest and most consistent consensus among participants. These components included facility-based refraction, the dispensing of ready-made spectacles, outreach-based service delivery, and the strengthening of the optical supply chain. Global evidence shows that integrating refractive services within routine health-care services improves sustainability and promotes equitable access, particularly in geographically remote or resource-constrained settings [3, 4, 17].\u003c/p\u003e \u003cp\u003eStrong agreement was also observed regarding the importance of regulation, licensing, quality assurance, and the monitoring of eREC. Although Bhutan has attained relatively high service coverage, these findings highlight the need to prioritise quality and health outcomes rather than service volume alone. This perspective is consistent with WHO guidance, which advocates for outcome-based, people-centred eye care [18]. Furthermore, the existing disconnect between refraction services and optical dispensing requires targeted interventions to ensure continuity and effectiveness of care [19]. Strengthening regulatory oversight of the optical sector is also essential to guarantee equitable access to safe, affordable, and high-quality spectacles in Bhutan, as inadequately regulated optical markets have been associated with substandard care and inequitable access [20].\u003c/p\u003e \u003cp\u003eCommunity awareness initiatives and volunteer-led approaches did not achieve consensus and therefore warrant critical reflection. While these strategies are frequently emphasised within global eye-health programmes, the findings of this study indicate that demand-generation interventions alone are insufficient to improve effective service coverage. Meaningful gains are unlikely unless such efforts are integrated with accessible, adequately regulated, and affordable refraction and spectacle dispensing services that can respond to increased demand in a sustainable manner.\u003c/p\u003e \u003cp\u003eComponents relating to workforce expansion, financing mechanisms, digital health, and public\u0026ndash;private partnerships received comparatively lower feasibility ratings. However, the decision to retain these low-feasibility components as enabling or medium-term elements, rather than excluding them, strengthens the policy relevance and pragmatic utility of the model. The literature consistently identifies workforce expansion, sustainable financing mechanisms (including insurance coverage for spectacles), digital health solutions, and public\u0026ndash;private partnerships as high-impact interventions once health-system capacity and supporting infrastructure are strengthened. In particular, digital technologies and artificial intelligence demonstrate substantial potential to improve eye health service delivery; however, their effective implementation is contingent upon addressing contextual, infrastructural, and regulatory barriers [21].\u003c/p\u003e \u003cp\u003eThe principal strength of this study lies in the application of a structured, two-round Delphi methodology to validate a national refractive error service delivery model. The expert panel was deliberately heterogenous, comprising clinicians, programme managers, policy-makers, NGO representatives, and private optical professionals from across Bhutan. Panel composition remained stable across both rounds, enhancing the credibility and robustness of the consensus attained. The use of clearly defined, a priori criteria\u0026mdash;namely relevance, feasibility, and anticipated impact\u0026mdash;facilitated transparent and systematic prioritisation of model components. The observed increase in feasibility ratings between rounds is indicative of genuine convergence of expert opinion rather than response bias, thereby supporting the internal validity of the Delphi process. Nevertheless, feasibility is inherently context-dependent and dynamic. Consequently, as Bhutan\u0026rsquo;s health financing mechanisms, workforce capacity, and digital health infrastructure evolve, periodic reassessment of these components will be necessary to ensure continued relevance and applicability. Successful implementation of the aspects achieving consensus in the study may serve as the catalyst to make the implementation of some of these components more feasible.\u003c/p\u003e \u003cp\u003eThis study has several limitations. The findings are derived from expert consensus rather than empirical implementation or outcome data. Feasibility assessments are contingent on prevailing health-system conditions and may evolve over time. Although some attrition occurred between study rounds, overall participant retention remained acceptable. As the study was conducted within the Bhutanese context, the transferability of the findings to other settings may be limited. The online study format likely mitigated dominance bias but constrained opportunities for in-depth deliberation. Consequently, the findings reflect informed expert consensus rather than observed implementation effects. Future research should therefore assess the real-world effectiveness, cost implications, and equity impacts of implementing the prioritised model components.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study develops and validates an evidence-based model for refractive error and optical service delivery in Bhutan using a Delphi methodology informed by a comprehensive health-system situational analysis. The model is grounded in empirical evidence and refined through structured expert consensus, ensuring alignment between evidence and strategy. The validated framework adopts a phased approach that prioritises system-embedded, quality-assured service delivery, while explicitly identifying the future need for policy, workforce, financing, and governance reforms to achieve universal effective refractive error coverage. The Delphi method proved appropriate for Bhutan\u0026rsquo;s context, yielding pragmatic, policy-relevant recommendations. Overall, the model provides a realistic and actionable roadmap for strengthening refractive error services, is aligned with WHO SPECS 2030, and offers direct utility for informing Bhutan\u0026rsquo;s forthcoming National Eye Health Strategy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eIPS is the study\u0026rsquo;s principal investigator. IPS, KSN and KPM conceptualized the protocol, and study design. IPS, NTL, DW and TL participated in study implementation including data collection and analysis. All were involved in the interpretation of the finding and validated the data. IPS drafted the manuscript and all authors critically reviewed the draft manuscript and approved the final version.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank all eye-health professionals and experts in Bhutan who participated in the Delphi process for their time and expertise. We also acknowledge the Ministry of Health, Bhutan, for facilitating access to professional networks and supporting the broader refractive error situational analysis that informed this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e1. Sharma J, Zangpo K, Grundy J. Measuring universal health coverage: a three-dimensional composite approach from Bhutan. \u003cem\u003eWHO South East Asia J Public Health\u003c/em\u003e. 2014;3(3):226\u0026ndash;237. doi:10.4103/2224-3151.206745. PMID:28612807.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e2. Lepcha NT, Sharma IP. Primary eye care in Bhutan: achievements and challenges. \u003cem\u003eCommunity Eye Health\u003c/em\u003e. 2021;34(113):S11\u0026ndash;S12. Epub 2022 Mar 1. PMID:36033415; PMCID:PMC9412122.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e3. Umaefulam V, Safi S, Lingham G, Gordon I, Mueller A, Krishnam NS, Alves Carneiro VL, Yu M, Evans JR, Keel S. Approaches for delivery of refractive and optical care services in community and primary care settings. \u003cem\u003eCochrane Database Syst Rev\u003c/em\u003e. 2024;5(5):CD016043. doi:10.1002/14651858.CD016043. PMID:38808577; PMCID:PMC11134311. World Health Organization. Integrating eye care into health systems [Internet]. Geneva: World Health Organization; 2023 [cited 2025 Dec 10]. Available from: \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ehttps://www.who.int/activities/integrating-eye-care-in-health-systems\u003c/span\u003e World Health Organization. \u003cem\u003eWorld report on vision\u003c/em\u003e [Internet]. Geneva: World Health Organization; 2019 [cited 2025 Dec 10]. Available from: \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ehttps://www.who.int/publications-detail-redirect/world-report-on-vision\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e6. McCormick I, Tong K, Abdullah N, Abesamis-Dischoso C, Gende T, Hashim EB, Ho SM, Jalbert I, Jeronimo B, Matoto-Raikabakaba E, Ono K, Piyasena PN, Rogers JT, Szetu J, Tran MA, Tse DY, Win Y, Yap TP, Yoon S, Yusufu M, Burton MJ, Ramke J; Promoting Equity in Refractive Error Services in the Western Pacific Study Group. Strategies to address inequity of uncorrected refractive error in the Western Pacific: a modified Delphi process. \u003cem\u003eOphthalmic Physiol Opt\u003c/em\u003e. 2024;44(6):1148\u0026ndash;1161. doi:10.1111/opo.13348. PMID:38881170.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e7. Muma S, Naidoo KS, Hansraj R. Telemedicine integration into the eye health ecosystem in scaling of effective refractive error coverage in Kenya. \u003cem\u003eSci Rep\u003c/em\u003e. 2024;14(1):18170. doi:10.1038/s41598-024-68993-5. PMID:39107375; PMCID:PMC11303391.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e8. Muma S, Naidoo KS, Hansraj R. Proposed task shifting integrated with telemedicine to address uncorrected refractive error in Kenya: a Delphi study. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2024;24(1):115. doi:10.1186/s12913-024-10618-8. PMID:38254104; PMCID:PMC10801974.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e9. Alrasheed SH, Naidoo KS, Clarke-Farr PC, Binnawi KH. Building consensus for the development of child eye care services in South Darfur State of Sudan using the Delphi technique. \u003cem\u003eAfr J Prim Health Care Fam Med\u003c/em\u003e. 2018;10(1):e1\u0026ndash;e9. doi:10.4102/phcfm.v10i1.1767. PMID:30456975; PMCID:PMC6244194.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e10. Yu M, Keel S, Mariotti S, Mills JA, M\u0026uuml;ller A. Development of the WHO eye care competency framework. \u003cem\u003eHum Resour Health\u003c/em\u003e. 2023;21(1):46. doi:10.1186/s12960-023-00834-4. PMID:37337207; PMCID:PMC10278260.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e11. Ramke J, Evans JR, Habtamu E, et al. Grand challenges in global eye health: a global prioritisation process using Delphi method. \u003cem\u003eLancet Healthy Longev\u003c/em\u003e. 2022;3(1):e31\u0026ndash;e41. doi:10.1016/S2666-7568(21)00302-0. World Health Organization. \u003cem\u003ePrimary eye care package\u003c/em\u003e [Internet]. Geneva: World Health Organization; 2022 [cited 2025 Dec 10]. Available from: \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ehttps://www.who.ineat/publications/b/78046\u003c/span\u003e World Health Organization. Bhutan charts a new course for eye health by 2030 [Internet]. Geneva: World Health Organization; 2023 [cited 2025 Dec 10]. Available from: \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ehttps://www.who.int/news-room/feature-stories/detail/bhutan-charts-new-course-for-eye-health-by-2030\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e14. Roberti J, Teijeiro ME, Fern\u0026aacute;ndez-Pazos A, Saenz V, Garc\u0026iacute;a-Elorrio E. Modified RAND/UCLA Delphi consensus of recommendations to advance towards a value-based healthcare model for the Argentine health system. \u003cem\u003eIJQHC Commun\u003c/em\u003e. 2025;5(2):lyaf013. doi:10.1093/ijcoms/lyaf013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e15. Tudisca V, Valente A, Castellani T, et al. Development of measurable indicators to enhance public health evidence-informed policy-making. \u003cem\u003eHealth Res Policy Syst\u003c/em\u003e. 2018;16(1):47. doi:10.1186/s12961-018-0323-z.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e16. Aghaji A, Burchett HED, Mathenge W, et al. Technical capacities needed to implement the WHO primary eye care package for Africa: results of a Delphi process. \u003cem\u003eBMJ Open\u003c/em\u003e. 2021;11(3):e042979. doi:10.1136/bmjopen-2020-042979.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e17. Burton MJ, Ramke J, Marques AP, et al. The Lancet Global Health Commission on global eye health: vision beyond 2020. \u003cem\u003eLancet Glob Health\u003c/em\u003e. 2021;9(4):e489\u0026ndash;e551. doi:10.1016/S2214-109X(20)30488-5. World Health Organization. Indicator metadata registry: effective refractive error coverage (eREC) [Internet]. Geneva: World Health Organization; 2023 [cited 2025 Dec 10]. Available from: \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ehttps://www.who.int/data/gho/indicator-metadata-registry/imr-details/3154\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e19. Ramke J, du Toit R, Palagyi A, Williams C, Brian G. Public sector refraction and spectacle dispensing in low-resource countries of the Western Pacific. \u003cem\u003eClin Exp Ophthalmol\u003c/em\u003e. 2008;36(4):339\u0026ndash;347. doi:10.1111/j.1442-9071.2008.01768.x. International Agency for the Prevention of Blindness. \u003cem\u003eThe supply-side market for glasses\u003c/em\u003e [Internet]. London: IAPB; 2024 [cited 2025 Dec 10]. Available from: \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ehttps://www.iapb.org/wp-content/uploads/2024/02/Supply-side-market-for-glasses.pdf\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e21. Tan TF, Ting DSW, et al. Artificial intelligence and digital health in global eye health: opportunities and challenges. \u003cem\u003eLancet Glob Health\u003c/em\u003e. 2023;11(9):e1432\u0026ndash;e1443. doi:10.1016/S2214-109X(23)00296-5.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Delphi study, health systems research, refractive error services, optical service delivery, effective refractive error coverage, service delivery model, Bhutan","lastPublishedDoi":"10.21203/rs.3.rs-8712693/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8712693/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThe World Health Organisation Refractive Error Situation Analysis Tool (RESAT) was recently implemented in Bhutan. Building on the findings of this assessment, the present study aimed to develop and validate a context-specific, evidence-based refractive error and optical service delivery model for Bhutan through a structured expert consensus process.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA two-round, online Delphi technique was employed to refine a 37-component model derived from a nationwide application of the RESAT. A purposive panel of national experts in Bhutan, each with a minimum of three years\u0026rsquo; experience in eye care delivery, health systems, policy development, or programme implementation, evaluated each component for relevance, feasibility, and expected impact using a 5-point Likert scale. Consensus was defined a priori as at least 70% of respondents rating a component as 4 or 5 in Round 2. Descriptive statistics including proportions, medians, and interquartile ranges, were used to assess levels of consensus and changes in ratings across rounds. Qualitative data from open-ended responses were subjected to thematic analysis to inform iterative refinement of the model.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eForty-six experts participated in Round 1 (response rate\u0026thinsp;=\u0026thinsp;83.6%), with 33 retained in Round 2 (retention rate\u0026thinsp;=\u0026thinsp;71.7%), representing a broad range of professional cadres and geographic regions. The median participant age remained 41 years across both rounds, while median professional experience increased from 14 to 15 years. The draft model comprised 37 components. In Round 2, consensus was reached for 30 components (81.1%) regarding relevance, 16 components (43.2%) regarding feasibility, and 32 components (86.5%) regarding expected impact. Components demonstrating consistently high consensus across all three dimensions included facility-based refraction services, optical dispensing, school-based vision screening, outreach services, supply-chain strengthening, regulation of optical services, and monitoring of effective refractive error coverage (eREC). Components identified as highly relevant and potentially impactful, yet constrained by lower feasibility such as workforce expansion, sustainable financing mechanisms, and digital innovations, were retained as medium-term or enabling elements. Feasibility ratings increased across successive rounds, resulting in a reduced divergence between relevance and feasibility assessments. Expert consensus highlighted workforce capacity, affordability of spectacles, quality assurance, and strong governance as key priority areas.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis Delphi study developed an expert-validated, evidence-based model for the delivery of refractive error services in Bhutan. Beyond its national application, the study demonstrates the utility of a structured expert-consensus methodology as a reproducible approach for translating health-system assessments into a validated, prioritised service-delivery framework. This approach is particularly relevant for informing policy, planning, and implementation in resource-constrained settings. The resulting model provides a structured framework to support strategic planning, resource allocation, and monitoring of refractive services in Bhutan and comparable health systems.\u003c/p\u003e","manuscriptTitle":"Delphi-based validation and prioritisation of a national refractive error and optical service delivery model for Bhutan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 11:46:37","doi":"10.21203/rs.3.rs-8712693/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-19T20:21:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-11T20:45:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44715121470986097732524232633827278610","date":"2026-03-10T10:14:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"144768544466635745446744631953318186598","date":"2026-03-10T09:29:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192352143450181154536111577806507027203","date":"2026-03-09T17:11:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-25T11:55:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-02T20:15:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-30T12:01:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-30T12:00:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-27T16:02:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8a4b5411-e2da-42bf-bffc-2648a68f806e","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-25T12:09:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 11:46:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8712693","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8712693","identity":"rs-8712693","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}