An integrated model of care for vision impairment within the public health system of Limpopo province, South Africa

An integrated model of care for vision impairment within the public health system of Limpopo province, South Africa | 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 An integrated model of care for vision impairment within the public health system of Limpopo province, South Africa MODJADJI MARGARETH LESHABANE, NISHANEE RAMPERSAD, KHATHUTSHELO PERCY MASHIGE This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9080243/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Vision impairment (VI) remains a significant global public health challenge, with a disproportionate burden in resource-constrained settings where access to comprehensive eye care services (ECS) is limited. In South Africa, fragmented delivery and inequitable access to ECS hinder effective prevention and management of VI, particularly in rural provinces such as Limpopo. This study aimed to develop a context-specific, evidence-based VI model of care for integration within the public health system of Limpopo province. Methods An exploratory mixed-methods design was employed. The model of care was developed in three distinct stages. Stage 1 involved identification and critical appraisal of relevant global and national health frameworks, complemented by a situational analysis comprising retrospective chart reviews, interviews-administered questionnaires to optometrists, district optometry coordinators, and individuals with VI. Stage 2 involved synthesis of findings to inform model development, guided by relevant global and national health frameworks. Stage 3 focused on iterative refinement of the model through peer debriefing and alignment with national and provincial health priorities. Results A context-specific model was developed, grounded in empirical evidence and aligned with global and national frameworks. The model comprises four interrelated levels–community, primary, secondary, and tertiary care–designed to improve access, utilisation, referrals, integrating preventive and promotive, curative and rehabilitative ECS across the health system continuum with consideration of contextual risk factors and health system enablers. Iterative refinement of the model enhanced its contextual relevance, implementation feasibility and alignment with existing policies to address the increasing burden of VI and improve eye health outcomes. In this regard, the model addresses fragmented delivery and persistent gaps in access, availability, utilisation, and equity of ECS in the public health sector across the province. Conclusion The proposed VI model of care provides a contextually responsive framework to enhance the integration of comprehensive ECS, improve access to care, and maintain continuity of care, thereby reducing the burden of avoidable vision loss in Limpopo province. Contributions: The study provides a practical framework to inform policy, planning and implementation to improve ECS delivery and strengthen integration in resource-constrained public health settings. eye care services vision impairment vision-related quality of life health system integration eye health outcome referral vision impairment model of care Figures Figure 1 Figure 2 Introduction Good eye health, wherein vision, ocular health, and functional vision are maximised, contributes to overall health and wellbeing, social inclusion, and quality of life. 1 , 2 Vision is among the most dominant human senses and plays a fundamental role in perception, communication, interpersonal, and social interactions. 2 , 3 Vision impairment (VI) is the leading cause of disability worldwide and a growing public health concern. 4 Vision impairment is associated with reduced vision-related quality of life (VRQOL), increased dependency, and substantial socio-economic burden for affected individuals, their families, and healthcare systems. 1 , 2 , 4 , 5 Vision impairment can be either congenital or acquired. Some of the risk factors for acquired VI include rapid population growth, an ageing population, and lifestyle changes. 2 , 4 The key determinants of VI include accessibility, affordability of eye care services (ECS), and the population’s awareness of VI-related conditions including knowledge of their prevention and management. 4 Vision impairment is the most prevalent disability in South Africa, accounting for 9.9% of all reported disabilities. 6 The leading causes of VI in South Africa–uncorrected refractive errors (UREs), cataracts, and glaucoma, 7 –are largely preventable and/or treatable with cost-effective interventions such as spectacles and cataract surgery. 1 , 2 , 4 Given the increase in global life expectancy, the prevalence of age-related ocular conditions is expected to rise exponentially. 1 , 2 , 4 , 8 To mitigate this growing public health challenge, the World Health Organization (WHO) advocates for the integration of ECS into national health systems as a strategy to reduce avoidable VI and address the escalating demand for eye health care. 2 , 9 In this context, WHO’s Integrated People-centred Eye Care (IPEC) represents an optimal health-system approach, enabling coordinated and sustainable service delivery across the life course. The IPEC supports health systems in addressing demographic transitions and lifestyle-related risk factors affecting eye health, expanding the coverage and quality of ECS, and reducing inequalities in access to care and improving visual outcomes. 2 , 10 Preventing avoidable VI and mitigating the effects of irreversible vision loss contribute to poverty reduction and align with Sustainable Development Goals (SDGs), including those related to health, education, and economic productivity. 1 , 2 , 4 Improved ECS is a cost-effective strategy for maximising human potential and contributing to achieving some of the SDGs. 1 , 2 Adequate integration of eye health services within the health system is required to achieve the Universal Health Coverage (UHC) goal, reduce the prevalence of avoidable VI, improve access to comprehensive ECS and promote optimum eye health. 1 , 2 , 4 , 10 Comprehensive ECS spans four interrelated levels of care: promotive, preventative, curative, and rehabilitative services. Evidence indicates that comprehensive ECS are feasible, cost-effective, and associated with meaningful improvements in VRQOL and functional independence. 2 . 4 , 5 , 11 Notwithstanding these demonstrable benefits, substantial inequalities persist in the awareness, accessibility, and availability of comprehensive ECS, with disparities most pronounced in rural and underserved settings. 1 , 2 , 12 In South Africa, the provision of ECS remains uneven, particularly within the public health sector, where systemic constraints disproportionately affect rural provinces such as Limpopo province. 6 , 7 , 13 , 14 , 15 A multi-stage situational analysis was undertaken to examine the prevalence, causes and factors associated with VI, 16 optometrists’ perceptions of VI-related services in public hospitals, 17 VRQOL and its associated factors among individuals with VI, 18 levels of awareness, knowledge, and barriers to accessing VI services, 19 as well as the perceptions of optometry coordinators regarding ECS in public hospitals in Limpopo province. 15 Collectively, the findings demonstrated a significantly high prevalence of VI, predominantly attributable to correctable causes. The provision of comprehensive ECS, particularly VI-related services, was reportedly limited, with contributing factors largely preventable or modifiable. Furthermore, VRQOL among individuals with VI attending public hospitals for ECS was relatively low. Awareness of the causes of VI and knowledge of the availability of VI-related services among affected individuals were limited, and the barriers restricting access to such services were largely avoidable. This manuscript consolidates these findings to develop an evidence-based VI model of care for integration within the public health system in Limpopo province. The proposed model is intended to generate meaningful outcomes that strengthen ECS service delivery and enhance the health and well-being of individuals with VI attending public health facilities for ECS in Limpopo province. Its implementation is expected to reduce the prevalence of avoidable VI, mitigate the effects of irreversible VI, improve equity in service distribution, and strengthen the health system's capacity to respond effectively to the population's eye-health needs. Furthermore, the model seeks to improve VRQOL, educational attainment, workforce participation, and social inclusion, with particular emphasis on vulnerable groups, including the elderly, women, rural communities, and low-income populations. The model will be valuable to policymakers, eye care professionals, and Department of Health authorities for informing evidence-based planning, resource allocation, and effective management of ECS, while also serving as a foundation for future research. Methods Study design The study employed a sequential exploratory mixed-methods design, involving a critical review of relevant global and national health frameworks, complemented by a situational analysis that integrated quantitative and qualitative findings to provide a comprehensive, in-depth understanding of the phenomenon under investigation and to guide the model development. 20,21,22 This approach was purposefully selected to facilitate the development of a context-specific, evidence-based VI model of care suitable for integration in the public health system of Limpopo province, South Africa. Study setting The study was conducted in public hospitals providing ECS in Limpopo province. The province is located in the northernmost part of South Africa. It borders Mozambique, Zimbabwe, and Botswana within the Southern African Development Community. As of 2020, the population in Limpopo province was approximately 5.9 million, making it the fifth most populous province in the country. 23 The province is divided into five district municipalities: Capricorn, Mopani, Sekhukhune, Vhembe, and Waterberg. 23,24 Each district municipality is served by one secondary-level hospital, which supports the primary-level hospitals, health centres, and clinics. 24 At the time of the study, ECS were provided in 38 public health facilities across Limpopo, including 30 primary-, five secondary-, two tertiary-level hospitals, and one health centre. Notably, the two tertiary-level hospitals and the single health centre were located within the same district. Eye care services are primarily delivered by optometrists, ophthalmic nurses, and ophthalmologists within the province. Optometric services were available in all 38 facilities, with a relatively even distribution of workforce, infrastructure, diagnostic equipment, and standardised clinical assessments. In contrast, ophthalmology services are available in only three hospitals: one tertiary- and two primary-level hospitals, across different districts. Patients access ECS either through self-referral, referral from outreach optometrists within district clinics and schools, or from medical doctors and other healthcare practitioners. Model development process The study used methodological guidance for developing a health system and service delivery model that encompasses three key stages, including identifying evidence, developing a model, and refining the model to ensure its relevance and feasibility. 25-28 The adapted process applied in this study is illustrated in Figure 1. Stage 1: Identifying evidence This stage involved the identification and critical appraisal of existing conceptual and policy frameworks relevant to the study context, complemented by the generation of context-specific data to inform model development. Existing frameworks Access to health services and the extent to which population health needs are met are strongly shaped by the service delivery model adopted within a given country. Service delivery models are, in turn, influenced by various structural and contextual factors, including the degree of health system decentralisation, geographical distance between communities and health facilities, the scope of services provided at different levels of the health system, and the quality of care delivered at the facility level. 29 The Integrated People-Centred Eye Care (IPEC) framework provides a robust conceptual rationale and practical guidance for the effective integration of eye care across health systems and societal structures. This includes integration at the community and primary health care level, supported by clearly defined referral pathways for comprehensive diagnosis, treatment, and ongoing management. 1,2 Additionally, the model is informed by relevant national health priorities outlined in relevant guidelines such as the National Guideline for the Prevention of Blindness, 30 the guideline on refractive error screening for persons aged 60 years and older, 31 the district health system, 32 and the National Health Insurance (NHI) Act. 33 The design of the model also considered elements of global frameworks, particularly from the WHO, including the Health Systems 34 and UHC 9 frameworks. The integration of national and global evidence helped to ensure that key elements of the model support ECS that are coordinated, equitable, integrated, and sustainable to promote, restore, and maintain eye health. This alignment with global and national priorities underscores a best-practice approach to health system planning, 2,10 ensuring that the model is both contextually responsive and strategically positioned to advance public eye health in Limpopo province. Adoption of these guidelines would allow for individuals with, or at risk of, eye conditions to receive timely, integrated services that are people-centred, comprehensive, safe, effective, efficient, acceptable, and well-coordinated within the health system that strongly emphasises the prevention and management of all eye conditions, including those that may not result in VI. 1,9,35 Data collection and analysis A situational analysis of ECS in public hospitals of Limpopo province was conducted to determine the prevalence and causes of VI, assess VRQOL, and identify factors influencing the delivery of VI-related services. 15-18 Additionally, perspectives from various key stakeholders, including individuals living with VI, optometrists, and ECS coordinators, were explored to gain insights into their perceptions of VI-related service delivery, utilisation, and health system challenges. 15,17,19 Data were collected through retrospective clinical charts review, quantitative surveys with optometrists and individuals with VI, and qualitative interviews with district optometry coordinators. Quantitative and qualitative data were collected simultaneously and independently analysed. The quantitative data were collected using validated instruments that generated numerical data, which were subsequently analysed to determine the prevalence and causes of VI, VRQOL, awareness, knowledge, and associated factors influencing ECS delivery and its utilisation. 16-19 In parallel, qualitative data were gathered using open-ended validated instruments and inductively analysed to capture the detailed experiences of key informants involved in ECS within the province. 15 Subsequently, the quantitative and qualitative findings were integrated to identify recurring patterns of VI, gaps in ECS delivery, referral pathways, continuity of care, and the impact of VI on VRQOL, health system constraints, and barriers to the delivery and uptake of these services. In this regard, data triangulation enhanced the analytical rigour and advanced understanding of the trends, patterns, and outcomes related to ECS in the province. The findings provided a comprehensive overview of the burden and causes of VI, including factors influencing the provision, access, and uptake of ECS in public hospitals of Limpopo province, to guide the development of an evidence-based model of care for integration within the public health system in the province. Stage 2: Developing a model Synthesis of findings This stage comprised the synthesis of study findings grounded on the empirical evidence from the situational analysis. This was further strengthened by peer debriefing and the integration of diverse perspectives from the research team to reduce potential bias arising from a single researcher's interpretation. Both inductive and deductive strategies were applied to synthesise and triangulate the study findings. The synthesised findings were categorised into 9 themes comprising: 1) Prevalence and vision impairment categories, 2) Distribution of vision impairment, 3) Causes of vision impairment, 4) Factors associated with vision impairment, 5) Vision-related quality of life, 6) Eye care service delivery, 7) Eye care workforce, 8) Equipment, technologies and consumables, and 9) Leadership and governance. Table 1 illustrates the identified gaps in ECS delivery within public hospitals of Limpopo province identified from the synthesised findings. The findings showed the substantial burden and unique distribution of VI across the different population strata attending public hospitals for ECS within the province. The majority of patients were classified with MSVI. There were discrepancies regarding the classification of VI across key service providers. The leading causes of VI were largely preventable or treatable. The risk factors, including ageing, presence of chronic conditions, rural residency, delayed presentation, limited eye health literacy, and poverty, showed that biological, social, and/or environmental determinants influenced vision outcomes. The VRQOL was relatively low. These findings reflected the inadequate coverage of ECS, poor eye-seeking behaviours, which may be influenced by inadequacies within the health system, individual socio-economic and cultural factors. Multifaceted barriers for ECS exist and include those within the health system and individuals. Eye care services in public hospitals were further restricted by workforce shortages, training gaps, weak retention strategies, and deficient continued professional development activities to meet population demands. Inadequate or outdated equipment limited the diagnostic accuracy and therapeutic intervention of eye conditions. The absence of updated national eye health policies and limited integration of eye health care further reflect systemic gaps in the health system. Collectively, these findings provide essential insights for the development of an equitable, comprehensive, people-centred eye care model aimed at reducing the burden of VI and improving the delivery of ECS for individuals utilising public hospitals in Limpopo province. Table 1: Synthesis of findings and identified gaps in eye care service delivery within public hospitals in Limpopo province. Theme Synthesis of findings Identified gaps 1. Prevalence and categories of vision impairment The prevalence of VI was high (61.5%), with most cases presenting as moderate-to-severe VI (57.3%), followed by blindness (22.7%), and mild VI (20.0%). 16 This indicates that most individuals tend to seek ECS only when their VI has reached an advanced stage, resulting in functional limitations. There were discrepancies in VI classification among practitioners. 15,17 Inadequate community-based eye health education and screening services, and delayed eye health-seeking behaviour. Absence of standardised VI classification guidelines, limited and outdated diagnostic equipment, and gaps in clinical training. 2. Distribution of vision impairment Vision impairment was prevalent among adults aged 50 years and older, adult females, and male children. 15 The age-related increase in VI observed in this study population aligns with trends found from the clinical chart reviews, indicating persistent unmet eye care needs. 16 Delayed eye care-seeking behaviours. Gender-related and socio-cultural barriers to accessing ECS. Limited integration of ECS and eye health education in schools, elderly programmes, and community-based programmes. 3. Causes of vision impairment Uncorrected refractive errors, cataracts, and glaucoma were the leading causes of VI, while glaucoma and cataracts were the main causes of blindness. 16 Additional adult-specific causes included oculocutaneous albinism, sequelae of eye trauma, retinal conditions, and complications of systemic diseases, whereas paediatric corneal diseases, complications of ocular surface diseases such as vernal keratoconjunctivitis, and retinal conditions. Widespread use of herbal and/or traditional eye treatments was reported across all age groups. 15 Limited access to comprehensive ECS, including refractive error correction, cataract surgeries, and glaucoma coverage, weak referral pathways and poor treatment adherence compounded by inadequate integration of eye care within the health system, workforce shortages, resource constraints, and prevailing socio-cultural barriers. 4. Factors associated with vision impairment Vision impairment was associated with ageing, non-communicable diseases, poor eye health literacy, poverty, and late presentation. 15,16 Limited access and affordability to comprehensive ECS, including refractive error correction and cataract surgery, further contributed to the burden of VI. 15,17 Limited integration for ECS within non-communicable diseases programmes, and inadequate decentralisation of ECS within the health system, worsened by socio-cultural barriers. 5. Vision-related quality of life Vision impairment was significantly associated with poorer VRQOL across all domains, including mobility, independence, emotional well-being, and role participation. Poorer outcomes were associated with severe levels of VI, particularly in the functional and mental health domains. Male gender demonstrated poorer scores in role-related and mental health domains. 18 Inadequate integration of ECS within hospital multi-disciplinary teams, such as psychological and occupational therapy services, limited access to vision rehabilitation services, absence of gender- and age-responsive services, support for individuals with irreversible vision loss, and lack of mobility and orientation officers. 6. Eye care service delivery Public-sector optometrists provided community education through radio stations, school health programmes, and clinic outreach; however, the use of herbal remedies remained common among individuals attending public hospitals. 15 Awareness of VI causes and knowledge of available VI-related services were suboptimal, reflecting gaps in eye health education, service provision, and population-level understanding, information usage, and socio-cultural responsiveness. 19 Curative services were limited: Fewer than half of optometrists provided spectacle correction, only 9% offered limited low vision care, and optical interventions largely consisted of high-power spectacles. 17 Contact lenses and keratoconus care were available at one tertiary-level hospital. Medical interventions were co-managed by ophthalmic nurses, optometrists, and ophthalmologists. Cataract surgery services were offered at three hospitals, while advanced ophthalmology services were available at two hospitals. 15 These findings are reflected by substantial backlogs and long waiting times for ophthalmology services. Vision rehabilitation services were not available, and patient referrals for support varied by clinician discretion and patient preference. 15,17 Absence of culturally responsive eye health education tailored to diverse population groups, lack of eye health education, persistent cultural beliefs, and delayed presentation contribute to the delay in detection and diagnosis of vision-disabling conditions exacerbated by limited refractive error, cataract surgery and glaucoma coverage, including poor treatment adherence. Other gaps include erratic supply of spectacles and consumables, limited access to specialised services (e.g. keratoconus and orthoptics care) and specialised diagnostic equipment. Absence and novelty of low vision rehabilitation services, and operational costs to sustain the services. Workforce shortages and the lack of standardised disease management and referral guidelines, as well as insufficient recognition of expanded optometry scope. Outdated case booking systems impede timely and coordinated service delivery. 7. Eye care workforce The eye workforce comprised primarily optometrists (n=97), ophthalmic nurses (n=43), ophthalmic medical registrars (n=10), and ophthalmologists (n=3), distributed across the public hospitals. 15 Practitioner-to-population ratios were below national targets, indicating severe workforce shortages, particularly ophthalmic nurses. 15 Limited training of ophthalmic nurses, poor retention, attrition, and urban staff migration. outdated workforce targets, and underutilisation of optometrists’ diagnostic and therapeutic scope. Maldistribution of registrars, absence of vision rehabilitation specialists and dispensing opticians. 8. Equipment, technologies and consumables Most public-sector optometry clinics have the basic eye care equipment, including diagnostic sets, Snellen visual acuity chart, tonometer, and trial lens and frame sets. There were substantial deficiencies regarding advanced equipment and the maintenance of equipment and the availability of consumables for their optimal functioning. 15,17 Absence of advanced equipment and technologies and technologies, poor maintenance of eye care equipment, inadequate supply of consumables, and underutilisation of professional skills. These factors limit the range of clinical services that could be provided. 9. Leadership and governance Eye care services were fragmented and inadequately integrated into existing health policies and limited guidelines within the health system. 15 Inadequate integration of ECS across government sectors, absence of defined service delivery models and standardised guidelines, inadequate financing, lack of accountability, and monitoring of the ECS delivery. VI: vision impairment; ECS: eye care services; VRQOL: vision-related quality of life. Sources: Leshabane et al. 15-19 Model development The IPEC, 2 WHO Health Systems, 34 UHC 9 frameworks, together with relevant national and provincial health priorities, 30-33 complemented by evidence generated from the situational analysis, informed the model design. The model aims to ensure responsiveness to identified gaps in ECS delivery within the resource-constrained setting. Results Overall, the model is organised into four interrelated levels of care: community, primary, secondary, and tertiary. In this way, the model ensures comprehensive service delivery across the continuum of care, designed to facilitate enhanced access, referral, and service integration. Figure 2 illustrates the context-specific integrated ECS delivery model within the public health system of Limpopo province. The proposed model Interrelated levels of care Level 1 – Community-level care : Prioritise health promotion and prevention. The core functions include raising awareness, improving eye health literacy, facilitating vision screening, early detection, and strengthening referral pathways. The services are delivered in community-based settings, such as clinics, schools, early childhood development centres, old-age homes, and community radio stations. Level 2 – Primary-level care : Prioritise diagnostics, curative and rehabilitative interventions. Eye care services are delivered in health centres and district-level hospitals. Services encompass vision screening, comprehensive eye examinations, refractive error correction, eye disease screening, early detection, management, and referral of priority conditions such as glaucoma, cataracts, keratoconus, diabetic retinopathy, and other retinal disorders. This level of care also addresses the initiation of glaucoma treatment and low vision care services, strengthens referral pathways, and includes an electronic and telehealth booking system. Level 3 – Secondary-level care : Prioritise advanced diagnostic, curative and rehabilitative interventions. Eye care services are provided at regional and/or secondary-level hospitals. Services include advanced diagnostic care, advanced management of multifaceted eye diseases including glaucoma, contact lenses and keratoconus care, orthoptics care, paediatric eye health, low vision rehabilitation services, telehealth bookings, spectacle production and supply, and provision of cataract and other minor eye surgeries (e.g., pterygium excision and eyelid repair, etc.). This level of care also addresses complex eye conditions that are inadequately addressed at the primary level, facilitates appropriate referral and feedback mechanisms with both the primary and tertiary levels to minimise the escalation of unnecessary referrals to the tertiary level. Level 4 – Tertiary-level care : Prioritise advanced diagnostics, curative, rehabilitative and complex interventions. Eye care services are delivered at academic and tertiary-level hospitals. Services include advanced diagnostic, refractive, medical, surgical, and vision rehabilitative interventions, complex refractive procedures, comprehensive ophthalmology services such as advanced cataract, glaucoma and retinal care, orthoptics care, paediatric eye health, spectacle production and supply, training and support for eye health services. Other services include capacity building, clinical governance, strengthened referral feedback, and specialist expertise to support lower levels of care. Risk factors The developed VI model of care explicitly incorporates contextual risk factors influencing the burden of VI and access to ECS. The factors include poor access, poverty, an ageing population, rural residency, non-communicable diseases, low eye health literacy, cultural beliefs, and gender-related barriers. Health system enablers Cross-cutting health system enablers underpin all levels of care and further support service integration and continuity across all levels. These include leadership and governance, workforce training and retention, financing, equipment, consumables and technologies, including health information and telehealth systems. Strengthening these enablers is essential to ensure continuity of care and sustained support for preventive, promotive, curative, and rehabilitative services. Integrated service domains across the continuum This model incorporates the WHO core ECS domains, encompassing preventive and promotive, curative, and rehabilitative services, 9 with the four component levels of care outlined in the South African national guideline. 30 Collectively, the model aims to strengthen service delivery and ensure a continuum of care from health promotion to specialised treatment and vision rehabilitation, as depicted below: 1) Preventive and promotive services are the primary point of entry at the community and primary-level of care, and include awareness creation, health education, eye health safety promotion initiatives, immunisation programmes, as well as maternal and child health services, vision screening, and referral. 2) Curative services are delivered across primary, secondary, and tertiary levels and include diagnosis and therapeutic management of eye conditions, refractive error correction, and surgical interventions. 3) Vision rehabilitation services span primary, secondary, and tertiary levels. The services focus on minimising the impact of irreversible vision loss. Services include provision of assistive devices, counselling, functional training such as mobility and orientation training, and referral to other health or social services. Vision rehabilitation services may be accessed through preventative or curative pathways, reflecting continuous, life-course management of irreversible vision loss. Stage 3: Refining Feedback obtained from the previous stage guided iterative refinements to the model structure, terminology, and care pathways for better alignment and feasibility with the proposed implementation principles underpinning the South African national health policies. The findings were iteratively refined and systematically mapped onto the adapted frameworks and guidelines, ensuring contextual relevance through ongoing engagement with relevant literature and key stakeholders in the public health care system. Overall, the VI model of care depicts an integrated people-centred framework that links service delivery across the different levels of care, provides a coherent approach to strengthening eye care integration within the public health system of Limpopo province, supported by system-level capacity to address the burden of VI across the life course. Table 2 illustrates resources required for effective ECS delivery at different levels of care. Importantly, the information is valuable for policymakers, eye care professionals, and the Department of Health authorities for informing evidence-based planning, resource distribution, and effective management of ECS within Limpopo province. Rigour and trustworthiness Methodological rigour was ensured through triangulation of multiple data sources, explicit and transparent alignment between empirical findings and model components, iterative model refinement supported by peer debriefing, and adherence to established frameworks for health system analysis and model development. The integration of context-specific epidemiological evidence, patient-reported outcomes, service delivery evaluations, and practitioners’ perspectives underpinned the validity of the proposed model of care, positioning it as a robust, contextually grounded, and evidence-informed framework for strengthening ECS delivery within the public health system of Limpopo province. Table 2: Required resources for eye care service delivery at each level of care within the public health sector of Limpopo province. Level Eye care services Facility Workforce Minimum equipment list Community care Preventive and promotive: Eye health education, awareness, and eye safety promotion. Vision screening, early detection and referral of asymptomatic or symptomatic eye conditions to the nearest health centre or hospital (visual acuity threshold referral: distance presenting visual acuity less than 6/12, and/or near visual acuity less than N6 or 20/40). Community radios, schools, clinics, early childhood development centres, old age homes, and community centres Ophthalmic nurses, optometrists, primary health care nurses, school health nurses, community health care workers Visual acuity charts (distance and near), trial lens set, penlight torch, portable ophthalmoscope, portable tonometer, extended hand-held occluder, pinhole, consumables, and transport, etc. Primary care Curative and rehabilitative services: Diagnostics, optical, non-optical, medical and rehabilitative interventions. Vision screening, comprehensive eye examinations, detection and management of refractive errors, eye diseases, screening for glaucoma, cataract, diabetic retinopathy, and other retinal disorders, as well as referrals. Initiation of glaucoma treatment, grading and monitoring the progression of non-emergency eye conditions such as cataract, pterygium, etc. Staggered introduction of specialised optometry clinics: binocular vision, contact lens and keratoconus care, low vision care services. Electronic case bookings, referral of eye emergencies, surgical, and advanced care to the secondary level of care. Health centres Primary-level hospitals Ophthalmic nurses, optometrists, mobility and orientation officers, assistant nurses, psychologists, medical practitioners, social workers, data capturers, occupational therapists, and other allied and clinical health practitioners. Visual acuity charts, trial lens sets, ophthalmoscope and retinoscope, tonometer, slit lamp, visual field screener, autorefractor and keratometer, lensometer, low vision care starter kit (optical and non-optical assistive devices), telehealth and electronic booking devices, penlight torch, extended hand-held occluder, trial contact lenses, and binocular vision kit, such as prism lenses, consumables, and transport, etc. Secondary care Advanced diagnostic, curative and rehabilitative interventions: Diagnostics, optical, non-optical medical, surgical, and rehabilitation interventions. Comprehensive eye examinations, detection and management of refractive errors, eye diseases, glaucoma and diabetic retinopathy management, cataract surgeries, including other minor surgical cases (e.g., pterygium and eyelid repair) and referral of eye emergency cases to tertiary-level care. Comprehensive low vision care, referral for complex cases, and advanced surgical and vision rehabilitation cases to the tertiary level. Provide referrals and feedback mechanisms between primary- and tertiary-level. Staggered introduction of subspecialty clinics, such as ophthalmology outreach services, contact lenses and keratoconus care, orthoptics clinics, paediatric eye health. An electronic case booking, telehealth system, and an established functional optical laboratory. Regional hospitals Ophthalmic nurses, ophthalmologists, ophthalmic medical officers, optometrists, dispensing opticians, mobility and orientation officers, assistant nurses, psychologists, social workers, data capturers, occupational therapists, eye care coordinators, and other allied and clinical health practitioners Visual acuity charts, ophthalmoscope and retinoscope, tonometer, trial lens set and frames, slit lamp, visual field tester and analyser, autorefractor and keratometer, lensometer, low vision care kit, binocular vision care kit, trial contact lenses and keratoconus care kit, binocular vision kit, operating microscope, biometry, optical coherent tomography and other advanced equipment, telehealth and electronic booking devices, equipped functional optical laboratory, penlight torch, and extended hand-held occluder, consumables, and transport, etc. Tertiary care Advanced diagnostics, curative and rehabilitative services: Diagnostics, optical, non-optical, medical, surgical and rehabilitation intervention. Comprehensive eye examinations, detection and management of refractive errors, emergency care, advanced disease management, such as glaucoma, refractive, complex cataract, and retinal surgeries. Functional subspecialised optometry clinics: low vision, binocular vision, contact lens and keratoconus care, paediatric eye health, comprehensive ophthalmology services, and an established functional optical laboratory. Established electronic booking, telehealth and effective feedback systems. Clinical governance, eye health training hubs, and providing continuous support for secondary and primary levels. Tertiary/ academic hospitals Ophthalmic nurses, professional nurses, optometrists, ophthalmologists, ophthalmic medical officers, mobility and orientation trainers, dispensing opticians, psychologists, social workers, data capturers, eye care coordinators, occupational therapists, assistant nurses, and other allied and clinical health practitioners. Visual acuity charts, diagnostic set, tonometer, trial lens set, frames, slit lamp, visual field analyser, autorefractor and keratometer, lensometer, binocular vision kit, low vision care kit, contact lens kit, operating microscope, biometry, optical coherence tomography, and other advanced equipment, electronic booking devices and telehealth system, equipped optical laboratory equipment, consumables, and transport, etc. Source: WHO, 2 Burton et al., 1 Department of Health, 30 Health Professional Council of South Africa 36 Discussion Ensuring good eye health is a development challenge that requires sustained coordinated national leadership and political commitment. 1 , 4 Vision impairment is a major public health problem that significantly restricts an individual’s ability to function independently and imposes substantial social and economic burdens on affected individuals, communities, and health systems. 1 , 2 , 4 Despite most causes of VI being largely preventable or treatable with cost-effective interventions, 2,4 the burden of VI remains disproportionately high in low- and middle-income countries (LMICs), This article presents a context-specific, evidence-based model of care designed to address systemic gaps in VI-related service delivery within the public health sector of Limpopo province, South Africa. This VI model of care was informed by a critical review of existing global and national frameworks and a situational analysis of empirical evidence relating to gaps in access, service utilisation, and inequalities within the public health facilities across the province. This model of care aims to reduce avoidable VI, mitigate the effects of irreversible vision loss, and respond to the rising demand for ECS within Limpopo province. The model is purposely structured across the four interrelated levels of care comprising community, primary, secondary, and tertiary levels with cross-cutting health system enablers to ensure feasible and practical implementation within the province. Findings from the situational analysis showed a high burden of VI (61.5%), with a substantial proportion of individuals presenting with moderate-to-severe VI (57.3%) and blindness (22.7%)–and majority of causes were largely preventable. 15 , 16 This implies that most individuals seek ECS only when their VI has reached an advanced stage, impacting their daily functioning. This assertion is supported by the consistently low scores across all subscales of the National Eye Institute Visual Functioning Questionnaire-39, suggesting significant reductions in VRQOL across multiple functional domains among individuals with VI accessing ECS in the province. 18 Inadequate access to ECS and delayed presentation were noted as key contributing factors for high VI prevalence in this setting, 15 with the similar patterns widely reported in LMICs. 1 , 2 , 4 The Limpopo province is predominantly rural, characterised by dispersed and remote settlements, high poverty levels, and transportation challenges, all of which substantially limit access to hospital-based services. 23 Findings revealed discrepancies in VI classification among key eyecare practitioners. 15 , 17 This may be attributed to limited diagnostic capacity, varying levels of clinical involvement, including outdated classification systems. The inconsistency in VI classification among eyecare practitioners may lead to inaccurate estimations of the number of individuals with VI and who may benefit from VI-related services, such as refractive error correction, cataract surgery, and low vision and rehabilitation services. 1 , 2 , 11 Discrepancies in VI classification underscore the importance of adopting internationally standardised guidelines for classification to improve consistency in diagnosis and reporting, supported by continuous professional development and training, appropriate referral and feedback mechanisms. 1 , 2 The inclusion of the community level in the model of care helps to address contextual barriers in accessing ECS by providing decentralised preventive and promotive services in community settings such as early childhood development centres, schools, old-age homes, and primary health care clinics. This approach aims to promote culturally responsive eye health education and vision screening to enable early detection of vision-disabling conditions and strengthen referrals across the different levels of care. 1 , 2 , 33 Furthermore, awareness and knowledge about eye health, including available VI-related services, are important for individuals and their families to make informed health decisions and ensure timely uptake of services for improved health and eye outcomes. By integrating culturally responsive eye health education within existing community platforms, the model of care addresses the socio-cultural reliance on herbal remedies and traditional medicine and enhances service acceptability, supported by early referral. Early detection, particularly for mild VI, is important to prevent disease progression and reduce the burden of avoidable vision loss. The integration of ECS in school and clinic health settings and in programmes that target children, women, and the elderly may help to respond to the age-, cultural-, and gender-related disparities in VI distribution, promote equitable access and align with life-course approaches. 1 , 2 , 9 , 30 , 33 The strong association between VI and non-communicable diseases (NCDs) with VRQOL underscores the need to integrate ECS within existing NCDs health programmes. 16 , 18 By incorporating ECS within NCDs programmes at community and primary levels of care, the proposed model facilitates continuous eye health education and routine vision screening for individuals with systemic chronic conditions such as diabetes and hypertension. In this way, the model of care aligns with global 1 , 2 and provincial 24 efforts for integrated health services to improve access, promote early detection thereby reducing the impact of ocular complications associated with NCDs and enhance eye health outcomes. Uncorrected refractive error, cataracts, and glaucoma were the leading causes of VI and blindness in this study. 16 These findings are consistent with the national trends, 7 and reflect patterns observed across LMICs, 2 where, despite the availability of cost-effective interventions, service coverage remains suboptimal. In this setting, inadequate coverage appears to be driven by modifiable health system and behavioural factors, including workforce shortages, inadequate budget, limited availability of assistive devices and consumables, constrained surgical capacity, inconsistent referral practices, delayed presentation, and poor treatment adherence. 15 The proposed model of care incorporates the integration of optical, medical, surgical and rehabilitative interventions across primary-, secondary-, and tertiary-levels to strengthen ECS delivery at all levels of care. This is achieved through clearly delineated services provided at each level of care, strengthened multidisciplinary collaboration, and structured referral and feedback pathways to promote optimal continuity and coordination of services. The model incorporates the co-management of eye diseases by qualified optometrists, as well as initiating glaucoma treatment and subspecialty clinics at primary- and secondary-level of care, while reserving complex surgical and subspecialty cases for tertiary centres. This promotes access and efficiency while reducing unnecessary referrals to tertiary-level care. Furthermore, delayed presentation and detection of vision-disabling conditions, including glaucoma and poor adherence to long-term management plans, exacerbate the risk for irreversible blindness. In alignment with the national guidelines, the model incorporates surgical management of glaucoma to mitigate poor patient adherence to long-term medical treatment. 30 In addition, the model incorporates telehealth booking systems and electronic referrals to mitigate delays associated with outdated booking systems and fragmented referral practices. This is particularly relevant in rural and resource-constrained settings, where geographical barriers and long waiting times exacerbate preventable vision loss. 2 The absence of vision rehabilitation services reflects a critical gap in service delivery, particularly when one considers the substantial impact of irreversible vision loss on VRQOL. These deficiencies are consistent with reported limitations in the provision of vision rehabilitation services within the LMICs. 2 , 12 , 30 To address this gap, this model of care incorporates a phased-based approach that integrates low vision rehabilitation services with multidisciplinary collaboration in the primary-, secondary- and tertiary-levels of care. These services are age-, gender-, and culturally responsive and include psychological counselling, provision of assistive devices, mobility and orientation training, and referral for social and vocational support services, as well as referral to special schools for individuals with VI. The integration of rehabilitation services aligns with the current national and provincial health strategies aimed at strengthening and supporting long-term functioning, independence, and psycho-social well-being of individuals with VI. 24,30,33 This is consistent with global approaches for integrated comprehensive ECS. 2 , 9 , 12 The variations in referral practices among practitioners were largely attributable to the absence of standardised guidelines and protocols for disease management, lack of monitoring assessment protocols, outdated diagnostic equipment and referral systems that collectively compromise continuity of patient care. 15 , 17 Consequently, this may prompt patients to seek alternative or informal care such as unregulated medicines, which may worsen eye health outcomes. 2 , 37 – 40 The model of care incorporates a cross-cutting referral pathway, clinical governance and monitoring, and an electronic booking system across all levels of care to strengthen continuity of care and improve health outcomes. Workforce shortages and maldistributions of eye care practitioners, absence of other key cadres such as dispensing opticians and mobility orientation trainers, insufficient training capacity for ophthalmic nurses, inadequate replacement of staff following attrition or retirement, and ineffective staff retention strategies severely compromise ECS delivery. 15 This might be attributed to the province’s rural geographical setting, which may contribute to workforce attrition and urban migration, impacting the distribution of the available workforce. This underscores the need to re-evaluate eye care workforce retention strategies and practitioner-population targets with a clearly defined scope of practice for the eye care cadre based on the growing population and increased service demands, as well as expanded geographical coverage. The proposed model of care incorporates workforce development, including capacity building and training, particularly for ophthalmic nurses, recognition of the expanded scope of practice regarding diagnostics and therapeutics for optometrists, and inclusion of dispensing opticians and vision rehabilitation personnel within the public health sector through workforce profiling and cross-cutting health system enablers. In this regard, the model of care provides alignment of workforce requirements with service at each level of care, enabling task-sharing, decentralisation of ophthalmology services to secondary level hospitals within the province to reduce referrals and surgical backlogs to tertiary hospitals. 2 , 13 , 33 , 40 , 41 This approach will allow tertiary hospitals to focus on complex medical and surgical interventions such as refractive and glaucoma surgeries, as well as serving as a training centre, support, and clinical governance. Outdated equipment, substantial deficiencies regarding maintenance, and the inconsistent supply of consumables for optimal functioning were identified as limitations to comprehensive ECS delivery. 15 These factors influence eye care practitioners' ability to provide comprehensive and timely care for optimal patient outcomes. 42 Additionally, these factors contribute to the underutilisation of eye care professionals' skills and knowledge, resulting in inappropriate referrals, increased burden of VI, over-reliance on the already limited ophthalmology services, longer waiting times and diminishing patient trust in public health care facilities. To mitigate this, the model of care also incorporates a recommended minimum equipment list specific to each level of care for comprehensive eye examinations. 36 This aims to provide appropriate diagnostic and therapeutic care at each respective level of care. The inclusion of optical laboratories, assistive devices and technologies at the secondary and tertiary levels further addresses the well-recognised limitations regarding spectacle provision, refractive error coverage, and advanced technologies at these levels. 15 , 17 Fragmented national eye care leadership, inadequate governance, the absence of standardised service delivery models, and a lack of monitoring 15 undermine the integration of ECS into the health care system, worsening the burden of VI in the province. The proposed VI model of care provides a coherent framework for planning, accountability and financing of ECS supported by health information systems, governance and telehealth platforms. Integrating ECS into national and provincial planning with operational monitoring and evaluation systems and NHI-aligned financing structures will strengthen accountability and sustainability for effective service delivery. 2 , 33 This is particularly important in the Limpopo province, where fragmented and limited integration of policies and guidelines has previously been identified as a systemic barriers. 36 , 43 These reforms align with the WHO Health Systems framework, particularly service delivery, workforce, equipment, consumables and technologies, financing, and governance. 33 To this end, the model offers a structured pathway for decentralisation and integrated preventive, curative, and rehabilitative services across the continuum of care to address the epidemiological drivers of VI and structural health system weaknesses. The implementation of this model of care has the potential to reduce avoidable VI, improve VRQOL, and contribute meaningfully to UHC and SDGs related to health and well-being, equity, education, and disability inclusion. 2 , 4 , 9 Strength and limitations The strength of this study includes the development of a context-specific VI model of care grounded in established global frameworks, national and provincial priorities, complemented by empirical evidence from a situational analysis. This approach allowed for enhanced analytical understanding of ECS in the local context within the public health sector in the Limpopo province. In addition, the use of multiple data sources and drawing from the perspectives of diverse stakeholders strengthened the contextual validity to ensure relevance and feasibility of the proposed model of care. However, the study was conducted within public hospitals in a single province, which may limit the generalisability of the study findings to other provinces or to the private health sector within South Africa. In addition, while the VI model of care is theoretically and empirically informed, it is yet to be validated. Therefore, future research should assess the effectiveness, cost implications, and operational feasibility of the proposed VI model of care within the broader health system context within the Limpopo province. Conclusion This study developed a context-specific, evidence-based VI model of care to address persistent gaps in ECS delivery that profoundly impact the delivery of VI-related services within the public health system of the Limpopo province. The proposed model of care is particularly relevant within the South African context, where geographical, socio-cultural, economic, and health system barriers impact access, delivery and utilisation of comprehensive ECS. The model is grounded in global and national frameworks and informed by empirical evidence to provide a contextually appropriate strategy to integrate preventive, curative, and rehabilitative ECS across the community, primary, secondary, and tertiary levels of care to ensure continuity of care and optimal outcomes across the life course. Its implementation has the potential to reduce avoidable VI, improve VRQOL, and advance progress towards UHC. In addition, the VI model of care offers a scalable and policy-relevant framework that may inform eye health system strengthening in other low- and middle-income settings. Abbreviations VI: vision impairment ECS: eye care services VRQOL: vision-related quality of life LIMCs: low- and middle-income countries UHC: universal health coverage SDG: Sustainable Development Goals IPEC: integrated people-centred eye care WHO: World Health Organization NCDs: noncommunicable diseases Declarations Ethics approval and consent to participate Approval to undertake the study was granted by the University of KwaZulu-Natal Humanities and Social Science Research Ethics Committee (HSSREC/00004472/2022, Appendix A). Subsequently, gatekeeper permission was obtained from the Limpopo Provincial Department of Health (LP_2022-12-004, Appendix B), as well as from Pietersburg (Appendix C) and Mankweng hospitals (Appendix D), authorising the use of these facilities for data collection. All participants provided informed consent. To ensure confidentiality and protect participant identity, all hospital records and participants were assigned unique identification codes, thereby maintaining anonymity throughout the study. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available from the corresponding author, M.M.L., on request and in the reference list as: Leshabane MM, Rampersad N, Mashige KP. Perceptions of optometry coordinators on eye care services in public hospitals of Limpopo province, South Africa. Afr Vis Eye Health. 2026;85(1), a1075. DOI: https://doi.org/10.4102/aveh.v85i1.1075. Leshabane MM, Rampersad N, Mashige KP. Prevalence, causes and factors associated with vision impairment in Limpopo province. Afr Vis Eye Health. 2024;83(1):1-9. https://doi. org/10.4102/aveh. v83i1. 956. Leshabane MM, Rampersad N, Mashige KP. Optometrists’ perceptions of vision impairment services in public hospitals of Limpopo province. Afr J Dis. 2025 Jun 3;14:1559. https://doi.org/10.4102/ajod.v14i0.1559 Leshabane MM, Rampersad N, Mashige KP. Vision-related quality of life and associated factors in individuals with vision impairment. Afr J Pri Health Care & Fam Med. 2025 Feb 28;17(1):4765. https:// doi.org/10.4102/phcfm. v17i1.4765 Leshabane MM, Rampersad N, Mashige KP. Awareness, Knowledge, and Barriers for Vision Impairment Services in Public Hospitals of Limpopo Province, South Africa . J Vis Imp Blind. In press. Competing interests The authors declare that they have no competing interests. Funding The University of KwaZulu-Natal’s College of Health Sciences Scholarship funded the field work of this study. Authors’ contributions MML conceptualised the project, the design, and wrote the original draft. NR and KPM supervised the project, guided and reviewed all drafts to the final article. 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A critical analysis of the South African health policies and programmes with regard to eye health promotion. University of South Africa. South Africa. 2013. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 24 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor assigned by journal 13 Apr, 2026 Editor invited by journal 23 Mar, 2026 Submission checks completed at journal 21 Mar, 2026 First submitted to journal 21 Mar, 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-9080243","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":626371108,"identity":"2b263beb-1609-49f3-813d-9963500fb937","order_by":0,"name":"MODJADJI MARGARETH LESHABANE","email":"data:image/png;base64,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","orcid":"","institution":"University of KwaZulu-Natal","correspondingAuthor":true,"prefix":"","firstName":"MODJADJI","middleName":"MARGARETH","lastName":"LESHABANE","suffix":""},{"id":626371109,"identity":"6ee1b7a1-83d6-43e3-aecb-67ecf0b72592","order_by":1,"name":"NISHANEE RAMPERSAD","email":"","orcid":"","institution":"University of KwaZulu-Natal","correspondingAuthor":false,"prefix":"","firstName":"NISHANEE","middleName":"","lastName":"RAMPERSAD","suffix":""},{"id":626371110,"identity":"18ef8879-1566-41df-9c17-0f91264105a0","order_by":2,"name":"KHATHUTSHELO PERCY MASHIGE","email":"","orcid":"","institution":"University of KwaZulu-Natal","correspondingAuthor":false,"prefix":"","firstName":"KHATHUTSHELO","middleName":"PERCY","lastName":"MASHIGE","suffix":""}],"badges":[],"createdAt":"2026-03-10 07:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9080243/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9080243/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107568315,"identity":"60836b10-d38e-457c-a260-7703eae9ef5c","added_by":"auto","created_at":"2026-04-22 17:32:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38163,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the model development process\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9080243/v1/2264adce93f3d85abc2928c9.png"},{"id":108006028,"identity":"7b738d15-fd19-4e5d-9f73-af683574271c","added_by":"auto","created_at":"2026-04-28 12:52:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":154490,"visible":true,"origin":"","legend":"\u003cp\u003eAn integrated vision impairment model of care for integration within the public health system of Limpopo province.\u003c/p\u003e\n\u003cp\u003eECDC: early childhood development centres; VI: vision impairment; ECS: eye care services; VRQOL: vision-related quality of life.\u003c/p\u003e\n\u003cp\u003eSources: WHO,\u003csup\u003e2,9,34 \u003c/sup\u003eDepartment of Health\u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9080243/v1/34532448b575a3543e807e2a.png"},{"id":108008464,"identity":"395dd7b8-1208-49cf-999e-f7dbc4b420f3","added_by":"auto","created_at":"2026-04-28 13:06:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":496164,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9080243/v1/feeb4311-653d-40f9-976a-a8995dd6c341.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"An integrated model of care for vision impairment within the public health system of Limpopo province, South Africa","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGood eye health, wherein vision, ocular health, and functional vision are maximised, contributes to overall health and wellbeing, social inclusion, and quality of life.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Vision is among the most dominant human senses and plays a fundamental role in perception, communication, interpersonal, and social interactions.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eVision impairment (VI) is the leading cause of disability worldwide and a growing public health concern.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Vision impairment is associated with reduced vision-related quality of life (VRQOL), increased dependency, and substantial socio-economic burden for affected individuals, their families, and healthcare systems.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Vision impairment can be either congenital or acquired. Some of the risk factors for acquired VI include rapid population growth, an ageing population, and lifestyle changes.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e The key determinants of VI include accessibility, affordability of eye care services (ECS), and the population\u0026rsquo;s awareness of VI-related conditions including knowledge of their prevention and management.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Vision impairment is the most prevalent disability in South Africa, accounting for 9.9% of all reported disabilities.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e The leading causes of VI in South Africa\u0026ndash;uncorrected refractive errors (UREs), cataracts, and glaucoma,\u003csup\u003e7\u003c/sup\u003e\u0026ndash;are largely preventable and/or treatable with cost-effective interventions such as spectacles and cataract surgery.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGiven the increase in global life expectancy, the prevalence of age-related ocular conditions is expected to rise exponentially.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e To mitigate this growing public health challenge, the World Health Organization (WHO) advocates for the integration of ECS into national health systems as a strategy to reduce avoidable VI and address the escalating demand for eye health care.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In this context, WHO\u0026rsquo;s Integrated People-centred Eye Care (IPEC) represents an optimal health-system approach, enabling coordinated and sustainable service delivery across the life course. The IPEC supports health systems in addressing demographic transitions and lifestyle-related risk factors affecting eye health, expanding the coverage and quality of ECS, and reducing inequalities in access to care and improving visual outcomes.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Preventing avoidable VI and mitigating the effects of irreversible vision loss contribute to poverty reduction and align with Sustainable Development Goals (SDGs), including those related to health, education, and economic productivity.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Improved ECS is a cost-effective strategy for maximising human potential and contributing to achieving some of the SDGs.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAdequate integration of eye health services within the health system is required to achieve the Universal Health Coverage (UHC) goal, reduce the prevalence of avoidable VI, improve access to comprehensive ECS and promote optimum eye health.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Comprehensive ECS spans four interrelated levels of care: promotive, preventative, curative, and rehabilitative services. Evidence indicates that comprehensive ECS are feasible, cost-effective, and associated with meaningful improvements in VRQOL and functional independence.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e.\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Notwithstanding these demonstrable benefits, substantial inequalities persist in the awareness, accessibility, and availability of comprehensive ECS, with disparities most pronounced in rural and underserved settings.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e In South Africa, the provision of ECS remains uneven, particularly within the public health sector, where systemic constraints disproportionately affect rural provinces such as Limpopo province.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eA multi-stage situational analysis was undertaken to examine the prevalence, causes and factors associated with VI,\u003csup\u003e16\u003c/sup\u003e optometrists\u0026rsquo; perceptions of VI-related services in public hospitals,\u003csup\u003e17\u003c/sup\u003e VRQOL and its associated factors among individuals with VI,\u003csup\u003e18\u003c/sup\u003e levels of awareness, knowledge, and barriers to accessing VI services,\u003csup\u003e19\u003c/sup\u003e as well as the perceptions of optometry coordinators regarding ECS in public hospitals in Limpopo province.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Collectively, the findings demonstrated a significantly high prevalence of VI, predominantly attributable to correctable causes. The provision of comprehensive ECS, particularly VI-related services, was reportedly limited, with contributing factors largely preventable or modifiable. Furthermore, VRQOL among individuals with VI attending public hospitals for ECS was relatively low. Awareness of the causes of VI and knowledge of the availability of VI-related services among affected individuals were limited, and the barriers restricting access to such services were largely avoidable.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis manuscript consolidates these findings to develop an evidence-based VI model of care for integration within the public health system in Limpopo province. The proposed model is intended to generate meaningful outcomes that strengthen ECS service delivery and enhance the health and well-being of individuals with VI attending public health facilities for ECS in Limpopo province. Its implementation is expected to reduce the prevalence of avoidable VI, mitigate the effects of irreversible VI, improve equity in service distribution, and strengthen the health system's capacity to respond effectively to the population's eye-health needs. Furthermore, the model seeks to improve VRQOL, educational attainment, workforce participation, and social inclusion, with particular emphasis on vulnerable groups, including the elderly, women, rural communities, and low-income populations. The model will be valuable to policymakers, eye care professionals, and Department of Health authorities for informing evidence-based planning, resource allocation, and effective management of ECS, while also serving as a foundation for future research.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study employed a sequential exploratory mixed-methods design, involving a critical review of relevant global and national health frameworks, complemented by a situational analysis that integrated quantitative and qualitative findings to provide a comprehensive, in-depth understanding of the phenomenon under investigation and to guide the model development.\u003csup\u003e20,21,22\u003c/sup\u003e This approach was purposefully selected to facilitate the development of a context-specific, evidence-based VI model of care suitable for integration in the public health system of Limpopo province, South Africa.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in public hospitals providing ECS in Limpopo province. The province is located in the northernmost part of South Africa. It borders Mozambique, Zimbabwe, and Botswana within the Southern African Development Community. As of 2020, the population in Limpopo province was approximately 5.9 million, making it the fifth most populous province in the country.\u003csup\u003e23\u003c/sup\u003e The province is divided into five district municipalities: Capricorn, Mopani, Sekhukhune, Vhembe, and Waterberg.\u003csup\u003e23,24\u003c/sup\u003e Each district municipality is served by one secondary-level hospital, which supports the primary-level hospitals, health centres, and clinics.\u003csup\u003e24\u003c/sup\u003e At the time of the study, ECS were provided in 38 public health facilities across Limpopo, including 30 primary-, five secondary-, two tertiary-level hospitals, and one health centre. Notably, the two tertiary-level hospitals and the single health centre were located within the same district. Eye care services are primarily delivered by optometrists, ophthalmic nurses, and ophthalmologists within the province. Optometric services were available in all 38 facilities, with a relatively even distribution of workforce, infrastructure, diagnostic equipment, and standardised clinical assessments. In contrast, ophthalmology services are available in only three hospitals: one tertiary- and two primary-level hospitals, across different districts. Patients access ECS either through self-referral, referral from outreach optometrists within district clinics and schools, or from medical doctors and other healthcare practitioners.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eModel development process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study used methodological guidance for developing a health system and service delivery model that encompasses three key stages, including identifying evidence, developing a model, and refining the model to ensure its relevance and feasibility.\u003csup\u003e25-28\u003c/sup\u003e The adapted process applied in this study is illustrated in Figure 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 1: Identifying evidence\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis stage involved the identification and critical appraisal of existing conceptual and policy frameworks relevant to the study context, complemented by the generation of context-specific data to inform model development.\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eExisting frameworks\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAccess to health services and the extent to which population health needs are met are strongly shaped by the service delivery model adopted within a given country. Service delivery models are, in turn, influenced by various structural and contextual factors, including the degree of health system decentralisation, geographical distance between communities and health facilities, the scope of services provided at different levels of the health system, and the quality of care delivered at the facility level.\u003csup\u003e29\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Integrated People-Centred Eye Care (IPEC) framework provides a robust conceptual rationale and practical guidance for the effective integration of eye care across health systems and societal structures. This includes integration at the community and primary health care level, supported by clearly defined referral pathways for comprehensive diagnosis, treatment, and ongoing management.\u003csup\u003e1,2\u003c/sup\u003e Additionally, the model is informed by relevant national health priorities outlined in relevant guidelines such as the National Guideline for the Prevention of Blindness,\u003csup\u003e30\u003c/sup\u003e\u0026nbsp; the guideline on refractive error screening for persons aged 60 years and older,\u003csup\u003e31\u003c/sup\u003e the district health system,\u003csup\u003e32\u003c/sup\u003e and the National Health Insurance (NHI) Act.\u003csup\u003e33\u0026nbsp;\u003c/sup\u003eThe design of the model also considered elements of global frameworks, particularly from the WHO, including the Health Systems\u003csup\u003e34\u003c/sup\u003e and UHC\u003csup\u003e9\u003c/sup\u003e frameworks. The integration of national and global evidence helped to ensure that key elements of the model support ECS that are coordinated, equitable, integrated, and sustainable to promote, restore, and maintain eye health. This alignment with global and national priorities underscores a best-practice approach to health system planning,\u003csup\u003e2,10\u003c/sup\u003e ensuring that the model is both contextually responsive and strategically positioned to advance public eye health in Limpopo province. Adoption of these guidelines would allow for individuals with, or at risk of, eye conditions to receive timely, integrated services that are people-centred, comprehensive, safe, effective, \u0026nbsp;efficient, acceptable, and well-coordinated within the health system that strongly emphasises the prevention and management of all eye conditions, including those that may not result in VI.\u003csup\u003e1,9,35\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003eData collection and analysis\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eA situational analysis of ECS in public hospitals of Limpopo province was conducted to determine the prevalence and causes of VI, assess VRQOL, and identify factors influencing the delivery of VI-related services.\u003csup\u003e15-18\u003c/sup\u003e Additionally, perspectives from various key stakeholders, including individuals living with VI, optometrists, and ECS coordinators, were explored to gain insights into their perceptions of VI-related service delivery, utilisation, and health system challenges.\u003csup\u003e15,17,19\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData were collected through retrospective clinical charts review, quantitative surveys with optometrists and individuals with VI, and qualitative interviews with district optometry coordinators. Quantitative and qualitative data were collected simultaneously and independently analysed. The quantitative data were collected using validated instruments that generated numerical data, which were subsequently analysed to determine the prevalence and causes of VI, VRQOL, awareness, knowledge, and associated factors influencing ECS delivery and its utilisation.\u003csup\u003e16-19\u003c/sup\u003e In parallel, qualitative data were gathered using open-ended validated instruments and inductively analysed to capture the detailed experiences of key informants involved in ECS within the province.\u003csup\u003e15\u003c/sup\u003e Subsequently, the quantitative and qualitative findings were integrated to identify recurring patterns of VI, gaps in ECS delivery, referral pathways, continuity of care, and the impact of VI on VRQOL, health system constraints, and barriers to the delivery and uptake of these services. In this regard, data triangulation enhanced the analytical rigour and advanced understanding of the trends, patterns, and outcomes related to ECS in the province. The findings provided a comprehensive overview of the burden and causes of VI, including factors influencing the provision, access, and uptake of ECS in public hospitals of Limpopo province, to guide the development of an evidence-based model of care for integration within the public health system in the province.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 2: Developing a model\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eSynthesis of findings\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThis stage comprised the synthesis of study findings grounded on the empirical evidence from the situational analysis. This was further strengthened by peer debriefing and the integration of diverse perspectives from the research team to reduce potential bias arising from a single researcher\u0026apos;s interpretation. Both inductive and deductive strategies were applied to synthesise and triangulate the study findings. The synthesised findings were categorised into 9 themes comprising: 1) Prevalence and vision impairment categories, 2) Distribution of vision impairment, 3) Causes of vision impairment, 4) Factors associated with vision impairment, 5) Vision-related quality of life, 6) Eye care service delivery, 7) Eye care workforce, 8) Equipment, technologies and consumables, and 9) Leadership and governance. Table 1 illustrates the identified gaps in ECS delivery within public hospitals of Limpopo province identified from the synthesised findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe findings showed the substantial burden and unique distribution of VI across the different population strata attending public hospitals for ECS within the province. The majority of patients were classified with MSVI. There were discrepancies regarding the classification of VI across key service providers. The leading causes of VI were largely preventable or treatable. The risk factors, including ageing, presence of chronic conditions, rural residency, delayed presentation, limited eye health literacy, and poverty, showed that biological, social, and/or environmental determinants influenced vision outcomes. The VRQOL was relatively low. These findings reflected the inadequate coverage of ECS, poor eye-seeking behaviours, which may be influenced by inadequacies within the health system, individual socio-economic and cultural factors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMultifaceted barriers for ECS exist and include those within the health system and individuals. Eye care services in public hospitals were further restricted by workforce shortages, training gaps, weak retention strategies, and deficient continued professional development activities to meet population demands. Inadequate or outdated equipment limited the diagnostic accuracy and therapeutic intervention of eye conditions. The absence of updated national eye health policies and limited integration of eye health care further reflect systemic gaps in the health system. Collectively, these findings provide essential insights for the development of an equitable, comprehensive, people-centred eye care model aimed at reducing the burden of VI and improving the delivery of ECS for individuals utilising public hospitals in Limpopo province.\u003cstrong\u003e\u003cbr clear=\"all\"\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Synthesis of findings and identified gaps in eye care service delivery within public hospitals in Limpopo province.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1058\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSynthesis of findings\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIdentified gaps\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Prevalence and categories of vision impairment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eThe prevalence of VI was high (61.5%), with most cases presenting as moderate-to-severe VI (57.3%), followed by blindness (22.7%), and mild VI (20.0%).\u003csup\u003e16\u003c/sup\u003e This indicates that most individuals tend to seek ECS only when their VI has reached an advanced stage, resulting in functional limitations. There were discrepancies in VI classification among practitioners.\u003csup\u003e15,17\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003eInadequate community-based eye health education and screening services, and delayed eye health-seeking behaviour. Absence of standardised VI classification guidelines, limited and outdated diagnostic equipment, and gaps in clinical training.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Distribution of vision impairment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eVision impairment was prevalent among adults aged 50 years and older, adult females, and male children.\u003csup\u003e15\u003c/sup\u003e The age-related increase in VI observed in this study population aligns with trends found from the clinical chart reviews, indicating persistent unmet eye care needs.\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003eDelayed eye care-seeking behaviours.\u003c/p\u003e\n \u003cp\u003eGender-related and socio-cultural barriers to accessing ECS.\u003c/p\u003e\n \u003cp\u003eLimited integration of ECS and eye health education in schools, elderly programmes, and community-based programmes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Causes of vision impairment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eUncorrected refractive errors, cataracts, and glaucoma were the leading causes of VI, while glaucoma and cataracts were the main causes of blindness.\u003csup\u003e16\u003c/sup\u003e Additional adult-specific causes included oculocutaneous albinism, sequelae of eye trauma, retinal conditions, and complications of systemic diseases, whereas paediatric corneal diseases, complications of ocular surface diseases such as vernal keratoconjunctivitis, and retinal conditions. \u0026nbsp;Widespread use of herbal and/or traditional eye treatments was reported across all age groups.\u003csup\u003e15\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003eLimited access to comprehensive ECS, including refractive error correction, cataract surgeries, and glaucoma coverage, weak referral pathways and poor treatment adherence compounded by inadequate integration of eye care within the health system, workforce shortages, resource constraints, and prevailing socio-cultural barriers.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4. Factors associated with vision impairment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eVision impairment was associated with ageing,\u0026nbsp;non-communicable diseases, poor eye health literacy, poverty, and late presentation.\u003csup\u003e15,16\u003c/sup\u003e Limited access and affordability to comprehensive ECS, including refractive error correction and cataract surgery, further contributed to the burden of VI.\u003csup\u003e15,17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003eLimited integration for ECS within non-communicable diseases programmes, and inadequate decentralisation of ECS within the health system, worsened by socio-cultural barriers.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5. Vision-related quality of life\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eVision impairment was significantly associated with poorer VRQOL across all domains, including mobility, independence, emotional well-being, and role participation. Poorer outcomes were associated with severe levels of VI, particularly in the functional and mental health domains. Male gender demonstrated poorer scores in role-related and mental health domains.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003eInadequate integration of ECS within hospital multi-disciplinary teams, such as psychological and occupational therapy services, limited access to vision rehabilitation services, absence of gender- and age-responsive services, support for individuals with irreversible vision loss, and lack of mobility and orientation officers.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6. Eye care service delivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003ePublic-sector optometrists provided community education through radio stations, school health programmes, and clinic outreach; however, the use of herbal remedies remained common among individuals attending public hospitals.\u003csup\u003e15\u003c/sup\u003e Awareness of VI causes and knowledge of available VI-related services were suboptimal, reflecting gaps in eye health education, service provision, and population-level understanding, information usage, and socio-cultural responsiveness.\u003csup\u003e19\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCurative services were limited: Fewer than half of optometrists provided spectacle correction, only 9% offered limited low vision care, and optical interventions largely consisted of high-power spectacles.\u003csup\u003e17\u003c/sup\u003e Contact lenses and keratoconus care were available at one tertiary-level hospital. Medical interventions were co-managed by ophthalmic nurses, optometrists, and ophthalmologists. Cataract surgery services were offered at three hospitals, while advanced ophthalmology services were available at two hospitals.\u003csup\u003e15\u003c/sup\u003e These findings are reflected by substantial backlogs and long waiting times for ophthalmology services.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVision rehabilitation services were not available, and patient referrals for support varied by clinician discretion and patient preference.\u003csup\u003e15,17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003eAbsence of culturally responsive eye health education tailored to diverse population groups, lack of eye health education, persistent cultural beliefs, and delayed presentation contribute to the delay in detection and diagnosis of vision-disabling conditions exacerbated by limited refractive error, cataract surgery and glaucoma coverage, including poor treatment adherence. Other gaps include erratic supply of spectacles and consumables, limited access to specialised services (e.g. keratoconus and orthoptics care) and specialised diagnostic equipment. Absence and novelty of low vision rehabilitation services, and operational costs to sustain the services. Workforce shortages and the lack of standardised disease management and referral guidelines, as well as insufficient recognition of expanded optometry scope. Outdated case booking systems impede timely and coordinated service delivery.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7. Eye care workforce\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eThe eye workforce comprised primarily\u0026nbsp;optometrists (n=97), ophthalmic nurses (n=43), ophthalmic medical registrars (n=10), and ophthalmologists (n=3), distributed across the public hospitals.\u003csup\u003e15\u0026nbsp;\u003c/sup\u003ePractitioner-to-population ratios were below national targets, indicating severe workforce shortages, particularly ophthalmic nurses.\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003eLimited training of ophthalmic nurses, poor retention, attrition, and urban staff migration. outdated workforce targets, and underutilisation of optometrists\u0026rsquo; diagnostic and therapeutic scope.\u0026nbsp;Maldistribution of registrars, absence of vision rehabilitation specialists and dispensing opticians.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8. Equipment, technologies and consumables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eMost public-sector optometry clinics have the basic eye care equipment, including\u0026nbsp;diagnostic sets, Snellen visual acuity chart, tonometer, and trial lens and frame sets. There were substantial deficiencies regarding advanced equipment and the maintenance of equipment and the availability of consumables for their optimal functioning.\u003csup\u003e15,17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003eAbsence of advanced equipment and technologies and technologies, poor maintenance of eye care equipment, inadequate supply of consumables, and underutilisation of professional skills. These factors limit the range of clinical services that could be provided.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9. Leadership and governance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eEye care services were fragmented and inadequately integrated into existing health policies and limited guidelines within the health system.\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003eInadequate integration of ECS across government sectors, absence of defined service delivery models and standardised guidelines, inadequate financing, lack of accountability, and monitoring of the ECS delivery.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eVI: vision impairment; ECS: eye care services; VRQOL: vision-related quality of life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSources: Leshabane et al.\u003csup\u003e15-19\u003c/sup\u003e\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003eModel development\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe IPEC,\u003csup\u003e2\u003c/sup\u003e WHO Health Systems,\u003csup\u003e34\u003c/sup\u003e UHC\u003csup\u003e9\u003c/sup\u003e frameworks, together with relevant national and provincial health priorities,\u003csup\u003e30-33\u003c/sup\u003e complemented by evidence generated from the situational analysis, informed the model design. The model aims to ensure responsiveness to identified gaps in ECS delivery within the resource-constrained setting.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOverall, the model is organised into four interrelated levels of care: community, primary, secondary, and tertiary. In this way, the model ensures comprehensive service delivery across the continuum of care, designed to facilitate enhanced access, referral, and service integration. Figure 2 illustrates the context-specific integrated ECS delivery model within the public health system of Limpopo province.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe proposed model\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc207095924\"\u003e\u003cstrong\u003eInterrelated levels of care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLevel 1\u003c/em\u003e\u003cem\u003e\u0026ndash;\u003c/em\u003e\u003cem\u003eCommunity-level care\u003c/em\u003e: Prioritise health promotion and prevention. The core functions include raising awareness, improving eye health literacy, facilitating vision screening, early detection, and strengthening referral pathways. The services are delivered in community-based settings, such as clinics, schools, early childhood development centres, old-age homes, and community radio stations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLevel 2\u003c/em\u003e\u003cem\u003e\u0026ndash;\u003c/em\u003e\u003cem\u003ePrimary-level care\u003c/em\u003e: Prioritise diagnostics, curative and rehabilitative interventions. Eye care services are delivered in health centres and district-level hospitals. Services encompass vision screening, comprehensive eye examinations, refractive error correction, eye disease screening, early detection, management, and referral of priority conditions such as glaucoma, cataracts, keratoconus, diabetic retinopathy, and other retinal disorders. This level of care also addresses the initiation of glaucoma treatment and low vision care services, strengthens referral pathways, and includes an electronic and telehealth booking system.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLevel 3\u003c/em\u003e\u003cem\u003e\u0026ndash;\u003c/em\u003e\u003cem\u003eSecondary-level care\u003c/em\u003e: Prioritise advanced diagnostic, curative and rehabilitative interventions. Eye care services are provided at regional and/or secondary-level hospitals. Services include advanced diagnostic care, advanced management of multifaceted eye diseases including glaucoma, contact lenses and keratoconus care, orthoptics care, paediatric eye health, low vision rehabilitation services, telehealth bookings, spectacle production and supply, and provision of cataract and other minor eye surgeries (e.g., pterygium excision and eyelid repair, etc.). This level of care also addresses complex eye conditions that are inadequately addressed at the primary level, facilitates appropriate referral and feedback mechanisms with both the primary and tertiary levels to minimise the escalation of unnecessary referrals to the tertiary level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLevel 4\u003c/em\u003e\u003cem\u003e\u0026ndash;\u003c/em\u003e\u003cem\u003eTertiary-level care\u003c/em\u003e: Prioritise advanced diagnostics, curative, rehabilitative and complex interventions. Eye care services are delivered at academic and tertiary-level hospitals. Services include advanced diagnostic, refractive, medical, surgical, and vision rehabilitative interventions, complex refractive procedures, comprehensive ophthalmology services such as advanced cataract, glaucoma and retinal care, orthoptics care, paediatric eye health, spectacle production and supply, training and support for eye health services. Other services include capacity building, clinical governance, strengthened referral feedback, and specialist expertise to support lower levels of care.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk factors\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe developed VI model of care explicitly incorporates contextual risk factors influencing the burden of VI and access to ECS. The factors include poor access, poverty, an ageing population, rural residency, non-communicable diseases, low eye health literacy, cultural beliefs, and gender-related barriers. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth system enablers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCross-cutting health system enablers underpin all levels of care and further support service integration and continuity across all levels. These include leadership and governance, workforce training and retention, financing, equipment, consumables and technologies, including health information and telehealth systems. Strengthening these enablers is essential to ensure continuity of care and sustained support for preventive, promotive, curative, and rehabilitative services. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntegrated service domains across the continuum\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis model incorporates the WHO core ECS domains, encompassing preventive and promotive, curative, and rehabilitative services,\u003csup\u003e9\u003c/sup\u003e with the four component levels of care outlined in the South African national guideline.\u003csup\u003e30\u003c/sup\u003e Collectively, the model aims to strengthen service delivery and ensure a continuum of care from health promotion to specialised treatment and vision rehabilitation, as depicted below:\u003c/p\u003e\n\u003cp\u003e1) Preventive and promotive services are the primary point of entry at the community and primary-level of care, and include awareness creation, health education, eye health safety promotion initiatives, immunisation programmes, as well as maternal and child health services, vision screening, and referral. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2) Curative services are delivered across primary, secondary, and tertiary levels and include diagnosis and therapeutic management of eye conditions, refractive error correction, and surgical interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3) Vision rehabilitation services span primary, secondary, and tertiary levels. The services focus on minimising the impact of irreversible vision loss. Services include provision of assistive devices, counselling, functional training such as mobility and orientation training, and referral to other health or social services. Vision rehabilitation services may be accessed through preventative or curative pathways, reflecting continuous, life-course management of irreversible vision loss. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 3: Refining\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFeedback obtained from the previous stage guided iterative refinements to the model structure, terminology, and care pathways for better alignment and feasibility with the proposed implementation principles underpinning the South African national health policies. The findings were iteratively refined and systematically mapped onto the adapted frameworks and guidelines, ensuring contextual relevance through ongoing engagement with relevant literature and key stakeholders in the public health care system. Overall, the VI model of care depicts an integrated people-centred framework that links service delivery across the different levels of care, provides a coherent approach to strengthening eye care integration within the public health system of Limpopo province, supported by system-level capacity to address the burden of VI across the life course. Table 2 illustrates resources required for effective ECS delivery at different levels of care. Importantly, the information is valuable for policymakers, eye care professionals, and the Department of Health authorities for informing evidence-based planning, resource distribution, and effective management of ECS within Limpopo province.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRigour and trustworthiness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMethodological rigour was ensured through triangulation of multiple data sources, explicit and transparent alignment between empirical findings and model components, iterative model refinement supported by peer debriefing, and adherence to established frameworks for health system analysis and model development. The integration of context-specific epidemiological evidence, patient-reported outcomes, service delivery evaluations, and practitioners\u0026rsquo; perspectives underpinned the validity of the proposed model of care, positioning it as a robust, contextually grounded, and evidence-informed framework for strengthening ECS delivery within the public health system of Limpopo province. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eRequired resources for eye care service delivery at each level of care\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;within the public health sector of Limpopo province.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1030\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 386px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEye care services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorkforce\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimum equipment list\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 386px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreventive and promotive:\u0026nbsp;\u003c/strong\u003eEye health education, awareness, and eye safety promotion.\u003c/p\u003e\n \u003cp\u003eVision screening, early detection and referral of asymptomatic or symptomatic eye conditions to the nearest health centre or hospital (visual acuity threshold referral: distance presenting visual acuity less than 6/12, and/or near visual acuity less than N6 or 20/40).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eCommunity radios, \u0026nbsp;schools, clinics, early childhood development centres, old age homes, and community centres\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eOphthalmic nurses, optometrists, primary health care nurses, school health nurses, community health care workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eVisual acuity charts \u0026nbsp;(distance and near), trial lens set, penlight torch, portable ophthalmoscope, portable tonometer, extended hand-held occluder, pinhole, consumables, and transport, etc.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 386px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurative and rehabilitative services:\u0026nbsp;\u003c/strong\u003eDiagnostics, optical, non-optical, medical and rehabilitative interventions.\u003c/p\u003e\n \u003cp\u003eVision screening, comprehensive eye examinations, detection and management of refractive errors, eye diseases, screening for glaucoma, cataract, diabetic retinopathy, and other retinal disorders, as well as referrals.\u003c/p\u003e\n \u003cp\u003eInitiation of glaucoma treatment, grading and monitoring the progression of non-emergency eye conditions such as cataract, pterygium, etc.\u003c/p\u003e\n \u003cp\u003eStaggered introduction of specialised optometry clinics: binocular vision, contact lens and keratoconus care, low vision care services.\u003c/p\u003e\n \u003cp\u003eElectronic case bookings, referral of eye emergencies, surgical, and advanced care to the secondary level of care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eHealth centres\u003c/p\u003e\n \u003cp\u003ePrimary-level hospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eOphthalmic nurses, optometrists, mobility and orientation officers, assistant nurses, psychologists, medical practitioners, social workers, data capturers, occupational therapists, and other allied and clinical health practitioners.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eVisual acuity charts, trial lens sets, ophthalmoscope and retinoscope, tonometer, slit lamp, visual field screener, autorefractor and keratometer, lensometer, low vision care starter kit (optical and non-optical assistive devices), telehealth and electronic booking devices, penlight\u0026nbsp;torch, extended hand-held occluder, trial contact lenses, and binocular vision kit, such as prism lenses, consumables, and transport, etc.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 386px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdvanced diagnostic, curative and rehabilitative interventions:\u0026nbsp;\u003c/strong\u003eDiagnostics, optical, non-optical medical, surgical, and rehabilitation interventions.\u003c/p\u003e\n \u003cp\u003eComprehensive eye examinations, detection and management of refractive errors, eye diseases, glaucoma and diabetic retinopathy management, cataract surgeries, including other minor surgical cases (e.g., pterygium and eyelid repair) and referral of eye emergency cases to tertiary-level care.\u003c/p\u003e\n \u003cp\u003eComprehensive low vision care, referral for complex cases, and advanced surgical and vision rehabilitation cases to the tertiary level.\u003c/p\u003e\n \u003cp\u003eProvide referrals and feedback mechanisms between primary- and tertiary-level.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaggered introduction of subspecialty clinics, such as ophthalmology outreach services, contact lenses and keratoconus care, orthoptics clinics, paediatric eye health.\u003c/p\u003e\n \u003cp\u003eAn electronic case booking, telehealth system, and an established functional optical laboratory.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eRegional hospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eOphthalmic nurses, ophthalmologists, ophthalmic medical officers, optometrists, dispensing opticians, mobility and orientation officers, assistant nurses, psychologists, social workers, data capturers, occupational therapists, eye care coordinators, and other allied and clinical health practitioners\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eVisual acuity charts, ophthalmoscope and retinoscope, tonometer, trial lens set and frames, slit lamp, visual field tester and analyser, autorefractor and keratometer, lensometer, low vision care kit, binocular vision care kit, trial contact lenses and keratoconus care kit, binocular vision kit, operating microscope, biometry, optical coherent tomography and other advanced equipment, telehealth and electronic booking devices, equipped functional optical laboratory, penlight\u0026nbsp;torch, and extended hand-held occluder, consumables, and transport, etc.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTertiary care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 386px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdvanced diagnostics, curative and rehabilitative services:\u0026nbsp;\u003c/strong\u003eDiagnostics, optical, non-optical, medical, surgical and rehabilitation intervention. Comprehensive eye examinations, detection and management of refractive errors, emergency care, advanced disease management, such as glaucoma, refractive, complex cataract, and retinal surgeries.\u003c/p\u003e\n \u003cp\u003eFunctional subspecialised optometry clinics: \u0026nbsp;low vision, binocular vision, contact lens and keratoconus care, paediatric eye health, comprehensive ophthalmology services, and an established functional optical laboratory.\u003c/p\u003e\n \u003cp\u003eEstablished electronic booking, telehealth and effective feedback systems.\u003c/p\u003e\n \u003cp\u003eClinical governance, eye health training hubs, and providing continuous support for secondary and primary levels.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eTertiary/ academic hospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eOphthalmic nurses, professional nurses, optometrists, ophthalmologists, ophthalmic medical officers, mobility and orientation trainers, dispensing opticians, psychologists, social workers, data capturers, eye care coordinators, occupational therapists, assistant nurses, and other allied and clinical health practitioners.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eVisual acuity charts, diagnostic set, tonometer, trial lens set, frames, slit lamp, visual field analyser, autorefractor and keratometer, lensometer, binocular vision kit, low vision care kit, contact lens kit, operating microscope, biometry, optical coherence tomography, and other advanced equipment, electronic booking devices and telehealth system, equipped optical laboratory equipment, consumables, and transport, etc.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSource: WHO,\u003csup\u003e2\u003c/sup\u003e Burton et al.,\u003csup\u003e1\u0026nbsp;\u003c/sup\u003eDepartment of Health,\u003csup\u003e30\u0026nbsp;\u003c/sup\u003eHealth Professional Council of South Africa\u003csup\u003e36\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEnsuring good eye health is a development challenge that requires sustained coordinated national leadership and political commitment.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Vision impairment is a major public health problem that significantly restricts an individual\u0026rsquo;s ability to function independently and imposes substantial social and economic burdens on affected individuals, communities, and health systems.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Despite most causes of VI being largely preventable or treatable with cost-effective interventions,\u003csup\u003e2,4\u003c/sup\u003e the burden of VI remains disproportionately high in low- and middle-income countries (LMICs),\u003c/p\u003e \u003cp\u003eThis article presents a context-specific, evidence-based model of care designed to address systemic gaps in VI-related service delivery within the public health sector of Limpopo province, South Africa. This VI model of care was informed by a critical review of existing global and national frameworks and a situational analysis of empirical evidence relating to gaps in access, service utilisation, and inequalities within the public health facilities across the province. This model of care aims to reduce avoidable VI, mitigate the effects of irreversible vision loss, and respond to the rising demand for ECS within Limpopo province. The model is purposely structured across the four interrelated levels of care comprising community, primary, secondary, and tertiary levels with cross-cutting health system enablers to ensure feasible and practical implementation within the province.\u003c/p\u003e \u003cp\u003eFindings from the situational analysis showed a high burden of VI (61.5%), with a substantial proportion of individuals presenting with moderate-to-severe VI (57.3%) and blindness (22.7%)\u0026ndash;and majority of causes were largely preventable.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e This implies that most individuals seek ECS only when their VI has reached an advanced stage, impacting their daily functioning. This assertion is supported by the consistently low scores across all subscales of the National Eye Institute Visual Functioning Questionnaire-39, suggesting significant reductions in VRQOL across multiple functional domains among individuals with VI accessing ECS in the province.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Inadequate access to ECS and delayed presentation were noted as key contributing factors for high VI prevalence in this setting,\u003csup\u003e15\u003c/sup\u003e with the similar patterns widely reported in LMICs.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e The Limpopo province is predominantly rural, characterised by dispersed and remote settlements, high poverty levels, and transportation challenges, all of which substantially limit access to hospital-based services.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Findings revealed discrepancies in VI classification among key eyecare practitioners.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e This may be attributed to limited diagnostic capacity, varying levels of clinical involvement, including outdated classification systems. The inconsistency in VI classification among eyecare practitioners may lead to inaccurate estimations of the number of individuals with VI and who may benefit from VI-related services, such as refractive error correction, cataract surgery, and low vision and rehabilitation services.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Discrepancies in VI classification underscore the importance of adopting internationally standardised guidelines for classification to improve consistency in diagnosis and reporting, supported by continuous professional development and training, appropriate referral and feedback mechanisms.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe inclusion of the community level in the model of care helps to address contextual barriers in accessing ECS by providing decentralised preventive and promotive services in community settings such as early childhood development centres, schools, old-age homes, and primary health care clinics. This approach aims to promote culturally responsive eye health education and vision screening to enable early detection of vision-disabling conditions and strengthen referrals across the different levels of care.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Furthermore, awareness and knowledge about eye health, including available VI-related services, are important for individuals and their families to make informed health decisions and ensure timely uptake of services for improved health and eye outcomes. By integrating culturally responsive eye health education within existing community platforms, the model of care addresses the socio-cultural reliance on herbal remedies and traditional medicine and enhances service acceptability, supported by early referral. Early detection, particularly for mild VI, is important to prevent disease progression and reduce the burden of avoidable vision loss. The integration of ECS in school and clinic health settings and in programmes that target children, women, and the elderly may help to respond to the age-, cultural-, and gender-related disparities in VI distribution, promote equitable access and align with life-course approaches.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe strong association between VI and non-communicable diseases (NCDs) with VRQOL underscores the need to integrate ECS within existing NCDs health programmes.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e By incorporating ECS within NCDs programmes at community and primary levels of care, the proposed model facilitates continuous eye health education and routine vision screening for individuals with systemic chronic conditions such as diabetes and hypertension. In this way, the model of care aligns with global\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e and provincial\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e efforts for integrated health services to improve access, promote early detection thereby reducing the impact of ocular complications associated with NCDs and enhance eye health outcomes.\u003c/p\u003e \u003cp\u003eUncorrected refractive error, cataracts, and glaucoma were the leading causes of VI and blindness in this study.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e These findings are consistent with the national trends,\u003csup\u003e7\u003c/sup\u003e and reflect patterns observed across LMICs,\u003csup\u003e2\u003c/sup\u003e where, despite the availability of cost-effective interventions, service coverage remains suboptimal. In this setting, inadequate coverage appears to be driven by modifiable health system and behavioural factors, including workforce shortages, inadequate budget, limited availability of assistive devices and consumables, constrained surgical capacity, inconsistent referral practices, delayed presentation, and poor treatment adherence.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe proposed model of care incorporates the integration of optical, medical, surgical and rehabilitative interventions across primary-, secondary-, and tertiary-levels to strengthen ECS delivery at all levels of care. This is achieved through clearly delineated services provided at each level of care, strengthened multidisciplinary collaboration, and structured referral and feedback pathways to promote optimal continuity and coordination of services. The model incorporates the co-management of eye diseases by qualified optometrists, as well as initiating glaucoma treatment and subspecialty clinics at primary- and secondary-level of care, while reserving complex surgical and subspecialty cases for tertiary centres. This promotes access and efficiency while reducing unnecessary referrals to tertiary-level care.\u003c/p\u003e \u003cp\u003eFurthermore, delayed presentation and detection of vision-disabling conditions, including glaucoma and poor adherence to long-term management plans, exacerbate the risk for irreversible blindness. In alignment with the national guidelines, the model incorporates surgical management of glaucoma to mitigate poor patient adherence to long-term medical treatment.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e In addition, the model incorporates telehealth booking systems and electronic referrals to mitigate delays associated with outdated booking systems and fragmented referral practices. This is particularly relevant in rural and resource-constrained settings, where geographical barriers and long waiting times exacerbate preventable vision loss.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe absence of vision rehabilitation services reflects a critical gap in service delivery, particularly when one considers the substantial impact of irreversible vision loss on VRQOL. These deficiencies are consistent with reported limitations in the provision of vision rehabilitation services within the LMICs.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e To address this gap, this model of care incorporates a phased-based approach that integrates low vision rehabilitation services with multidisciplinary collaboration in the primary-, secondary- and tertiary-levels of care. These services are age-, gender-, and culturally responsive and include psychological counselling, provision of assistive devices, mobility and orientation training, and referral for social and vocational support services, as well as referral to special schools for individuals with VI. The integration of rehabilitation services aligns with the current national and provincial health strategies aimed at strengthening and supporting long-term functioning, independence, and psycho-social well-being of individuals with VI.\u003csup\u003e24,30,33\u003c/sup\u003e This is consistent with global approaches for integrated comprehensive ECS.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe variations in referral practices among practitioners were largely attributable to the absence of standardised guidelines and protocols for disease management, lack of monitoring assessment protocols, outdated diagnostic equipment and referral systems that collectively compromise continuity of patient care.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Consequently, this may prompt patients to seek alternative or informal care such as unregulated medicines, which may worsen eye health outcomes.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan additionalcitationids=\"CR38 CR39\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e The model of care incorporates a cross-cutting referral pathway, clinical governance and monitoring, and an electronic booking system across all levels of care to strengthen continuity of care and improve health outcomes.\u003c/p\u003e \u003cp\u003eWorkforce shortages and maldistributions of eye care practitioners, absence of other key cadres such as dispensing opticians and mobility orientation trainers, insufficient training capacity for ophthalmic nurses, inadequate replacement of staff following attrition or retirement, and ineffective staff retention strategies severely compromise ECS delivery.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e This might be attributed to the province\u0026rsquo;s rural geographical setting, which may contribute to workforce attrition and urban migration, impacting the distribution of the available workforce. This underscores the need to re-evaluate eye care workforce retention strategies and practitioner-population targets with a clearly defined scope of practice for the eye care cadre based on the growing population and increased service demands, as well as expanded geographical coverage. The proposed model of care incorporates workforce development, including capacity building and training, particularly for ophthalmic nurses, recognition of the expanded scope of practice regarding diagnostics and therapeutics for optometrists, and inclusion of dispensing opticians and vision rehabilitation personnel within the public health sector through workforce profiling and cross-cutting health system enablers. In this regard, the model of care provides alignment of workforce requirements with service at each level of care, enabling task-sharing, decentralisation of ophthalmology services to secondary level hospitals within the province to reduce referrals and surgical backlogs to tertiary hospitals.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e This approach will allow tertiary hospitals to focus on complex medical and surgical interventions such as refractive and glaucoma surgeries, as well as serving as a training centre, support, and clinical governance.\u003c/p\u003e \u003cp\u003eOutdated equipment, substantial deficiencies regarding maintenance, and the inconsistent supply of consumables for optimal functioning were identified as limitations to comprehensive ECS delivery.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e These factors influence eye care practitioners' ability to provide comprehensive and timely care for optimal patient outcomes.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e Additionally, these factors contribute to the underutilisation of eye care professionals' skills and knowledge, resulting in inappropriate referrals, increased burden of VI, over-reliance on the already limited ophthalmology services, longer waiting times and diminishing patient trust in public health care facilities. To mitigate this, the model of care also incorporates a recommended minimum equipment list specific to each level of care for comprehensive eye examinations.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e This aims to provide appropriate diagnostic and therapeutic care at each respective level of care. The inclusion of optical laboratories, assistive devices and technologies at the secondary and tertiary levels further addresses the well-recognised limitations regarding spectacle provision, refractive error coverage, and advanced technologies at these levels.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFragmented national eye care leadership, inadequate governance, the absence of standardised service delivery models, and a lack of monitoring\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e undermine the integration of ECS into the health care system, worsening the burden of VI in the province. The proposed VI model of care provides a coherent framework for planning, accountability and financing of ECS supported by health information systems, governance and telehealth platforms. Integrating ECS into national and provincial planning with operational monitoring and evaluation systems and NHI-aligned financing structures will strengthen accountability and sustainability for effective service delivery.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e This is particularly important in the Limpopo province, where fragmented and limited integration of policies and guidelines has previously been identified as a systemic barriers.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e These reforms align with the WHO Health Systems framework, particularly service delivery, workforce, equipment, consumables and technologies, financing, and governance.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e To this end, the model offers a structured pathway for decentralisation and integrated preventive, curative, and rehabilitative services across the continuum of care to address the epidemiological drivers of VI and structural health system weaknesses. The implementation of this model of care has the potential to reduce avoidable VI, improve VRQOL, and contribute meaningfully to UHC and SDGs related to health and well-being, equity, education, and disability inclusion.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrength and limitations\u003c/h2\u003e \u003cp\u003eThe strength of this study includes the development of a context-specific VI model of care grounded in established global frameworks, national and provincial priorities, complemented by empirical evidence from a situational analysis. This approach allowed for enhanced analytical understanding of ECS in the local context within the public health sector in the Limpopo province. In addition, the use of multiple data sources and drawing from the perspectives of diverse stakeholders strengthened the contextual validity to ensure relevance and feasibility of the proposed model of care. However, the study was conducted within public hospitals in a single province, which may limit the generalisability of the study findings to other provinces or to the private health sector within South Africa. In addition, while the VI model of care is theoretically and empirically informed, it is yet to be validated. Therefore, future research should assess the effectiveness, cost implications, and operational feasibility of the proposed VI model of care within the broader health system context within the Limpopo province.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study developed a context-specific, evidence-based VI model of care to address persistent gaps in ECS delivery that profoundly impact the delivery of VI-related services within the public health system of the Limpopo province. The proposed model of care is particularly relevant within the South African context, where geographical, socio-cultural, economic, and health system barriers impact access, delivery and utilisation of comprehensive ECS. The model is grounded in global and national frameworks and informed by empirical evidence to provide a contextually appropriate strategy to integrate preventive, curative, and rehabilitative ECS across the community, primary, secondary, and tertiary levels of care to ensure continuity of care and optimal outcomes across the life course. Its implementation has the potential to reduce avoidable VI, improve VRQOL, and advance progress towards UHC. In addition, the VI model of care offers a scalable and policy-relevant framework that may inform eye health system strengthening in other low- and middle-income settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVI: vision impairment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eECS: eye care services\u003c/p\u003e\n\u003cp\u003eVRQOL: vision-related quality of life\u003c/p\u003e\n\u003cp\u003eLIMCs: low- and middle-income countries\u003c/p\u003e\n\u003cp\u003eUHC: universal health coverage\u003c/p\u003e\n\u003cp\u003eSDG: Sustainable Development Goals\u003c/p\u003e\n\u003cp\u003eIPEC: integrated people-centred eye care\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e\n\u003cp\u003eNCDs: noncommunicable diseases\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval to undertake the study was granted by the University of KwaZulu-Natal Humanities and Social Science Research Ethics Committee (HSSREC/00004472/2022, Appendix A). Subsequently, gatekeeper permission was obtained from the Limpopo Provincial Department of Health (LP_2022-12-004, Appendix B), as well as from Pietersburg (Appendix C) and Mankweng hospitals (Appendix D), authorising the use of these facilities for data collection. All participants provided informed consent. To ensure confidentiality and protect participant identity, all hospital records and participants were assigned unique identification codes, thereby maintaining anonymity throughout the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author, M.M.L., on request and in the reference list as:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLeshabane MM, Rampersad N, Mashige KP. Perceptions of optometry coordinators on eye care services in public hospitals of Limpopo province, South Africa. Afr Vis Eye Health. 2026;85(1), a1075. DOI: https://doi.org/10.4102/aveh.v85i1.1075.\u003c/p\u003e\n\u003cp\u003eLeshabane MM, Rampersad N, Mashige KP. Prevalence, causes and factors associated with vision impairment in Limpopo province. Afr Vis Eye Health. 2024;83(1):1-9.\u0026nbsp;https://doi. org/10.4102/aveh. v83i1. 956.\u003c/p\u003e\n\u003cp\u003eLeshabane MM, Rampersad N, Mashige KP. Optometrists\u0026rsquo; perceptions of vision impairment services in public hospitals of Limpopo province. Afr J Dis. 2025 Jun 3;14:1559. https://doi.org/10.4102/ajod.v14i0.1559\u003c/p\u003e\n\u003cp\u003eLeshabane MM, Rampersad N, Mashige KP. Vision-related quality of life and associated factors in individuals with vision impairment. Afr J Pri Health Care \u0026amp; Fam Med. 2025 Feb 28;17(1):4765.\u0026nbsp;https:// doi.org/10.4102/phcfm. v17i1.4765\u003c/p\u003e\n\u003cp\u003eLeshabane MM, Rampersad N, Mashige KP.\u0026nbsp;Awareness, Knowledge, and Barriers for Vision Impairment Services in Public Hospitals of Limpopo Province, South Africa\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eJ Vis Imp Blind. In press.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe University of KwaZulu-Natal\u0026rsquo;s College of Health Sciences Scholarship funded the field work of this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMML conceptualised the project, the design, and wrote the original draft. NR and KPM supervised the project, guided and reviewed all drafts to the final article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article is partially based on the author\u0026rsquo;s thesis entitled \u0026lsquo;The development of a vision impairment model of care in the public hospitals of Limpopo province, South Africa\u0026rsquo; towards the degree of Doctor of Philosophy in the Discipline of Optometry, University of KwaZulu-Natal, South Africa, with supervisors Dr N Rampersad and Prof KP Mashige.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBurton MJ, Ramke J, Marques AP, Bourne RR, Congdon N, Jones I, Tong BA, Arunga S, Bachani D, Bascaran C, Bastawrous A. The Lancet Global Health Commission on global eye health: vision beyond 2020. Lancet Glob Health. 2021 Apr 1;9(4):e489-551.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. World report on vision. WHO. 2019. 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DOI: https://doi.org/10.4102/aveh.v85i1.1075.\u003c/li\u003e\n\u003cli\u003eLeshabane MM, Rampersad N, Mashige KP. Prevalence, causes and factors associated with vision impairment in Limpopo province. Afr Vis Eye Health. 2024;83(1):1-9.\u003c/li\u003e\n\u003cli\u003eLeshabane MM, Rampersad N, Mashige KP. Optometrists\u0026rsquo; perceptions of vision impairment services in public hospitals of Limpopo province. Afr J Dis. 2025 Jun 3;14:1559.\u003c/li\u003e\n\u003cli\u003eLeshabane MM, Rampersad N, Mashige KP. Vision-related quality of life and associated factors in individuals with vision impairment. Afr J Pri Health Care \u0026amp; Fam Med. 2025 Feb 28;17(1):4765.\u003c/li\u003e\n\u003cli\u003eLeshabane MM, Rampersad N, Mashige KP. Awareness, Knowledge, and Barriers for Vision Impairment Services in Public Hospitals of Limpopo Province, South Africa\u003cstrong\u003e. \u003c/strong\u003eJ Vis Imp Blind. In press. \u003c/li\u003e\n\u003cli\u003eCreswell JW. 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[21/01/2026]. https://knowledgehub.health.gov.za/system/files/elibdownloads/2023-04/DHP_and_M_Framework_and_Guidelines_25Aug_DG.pdf\u003c/li\u003e\n\u003cli\u003eRepublic of South Africa. National Health Insurance Act No. 20 of 2023. Cape Town. Government Gazette No. 50664, 16 May 2024. [cited 22/01/2026]. https://www.gov.za/documents/acts/national-health-insurance-act-20-2023-english-afrikaans-16-may-2024.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies. WHO. 2010 [cited 15/08/2025]. https://iris.who.int/server/api/core/bitstreams/a4b7c7f8-9084-4d76-b512-fa5a7597ec06/content\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Eye Care in the Health System: A Guide for Action. WHO. 2022 [cited 15/08/2025]. https://www.who.int/publications/i/item/9789240050068. \u003c/li\u003e\n\u003cli\u003eHealth Professions Council of South Africa. Clinical guidelines for basic, general, and comprehensive eye examinations. Professional Board for Optometry and Dispensing Opticians. [homepage on the Internet]. [cited 15/10/2025]. Available from: https://www.hpcsa.co.za/Content/upload/professional_boards/odo/guidelines/Clinical_guidelines_for_comprehensive_eye_examinations_19092023.pdf.\u003c/li\u003e\n\u003cli\u003eOlusanya BA, Ashaye AO, Owoaje ET, Baiyeroju AM, Ajayi BG. Determinants of utilization of eye care services in a rural adult population of a developing country. Middle East Afr J Ophthalmol. 2016 Jan 1;23(1):96-103.\u003c/li\u003e\n\u003cli\u003eShrestha, G. S., Sigdel, R., Shrestha, J. B., Sharma, A. K., Shrestha, R., Mishra, S. K., \u0026amp; Joshi, S. N. (2018). Awareness of eye health and diseases among the population of the hilly region of Nepal. J Ophthal \u0026amp; Vis Res, 13(4), 461.\u003c/li\u003e\n\u003cli\u003eBlanchet K, Gilbert C, de Savigny D. Rethinking eye health systems to achieve universal coverage: the role of research. Br J Ophthalmol. 2014; 98(10):1325-8. doi: 10.1136/bjophthalmol-2013-303905.\u003c/li\u003e\n\u003cli\u003eCicinelli MV, Marmamula S, Khanna RC. Comprehensive eye care - Issues, challenges, and way forward. Indian J Ophthalmol. 2020; 68(2):316-323. doi: 10.4103/ijo.IJO_17_19.\u003c/li\u003e\n\u003cli\u003eNaidoo KS, Govender-Poonsamy P, Morjaria P, Block S, Chan VF, Yong AC, Bilotto L. Global mapping of optometry workforce. Afr Vis Eye Health. 2023 Oct 27;82(1):850.\u003c/li\u003e\n\u003cli\u003eFrempong EA, Van Staden DW. Accessibility of and barriers to the use of eye health services in Kumasi Metropolis, Ghana. Afr J Prim Health Care Fam Med. 2024 Jun 25;16(1): e1-e8. doi: 10.4102/phcfm. v16i1.4270.\u003c/li\u003e\n\u003cli\u003eSithole HL. A critical analysis of the South African health policies and programmes with regard to eye health promotion. University of South Africa. South Africa. 2013.\u003c/li\u003e\n\u003c/ol\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"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-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"eye care services, vision impairment, vision-related quality of life, health system, integration, eye health outcome, referral, vision impairment model of care","lastPublishedDoi":"10.21203/rs.3.rs-9080243/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9080243/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eVision impairment (VI) remains a significant global public health challenge, with a disproportionate burden in resource-constrained settings where access to comprehensive eye care services (ECS) is limited. In South Africa, fragmented delivery and inequitable access to ECS hinder effective prevention and management of VI, particularly in rural provinces such as Limpopo. This study aimed to develop a context-specific, evidence-based VI model of care for integration within the public health system of Limpopo province.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn exploratory mixed-methods design was employed. The model of care was developed in three distinct stages. Stage 1 involved identification and critical appraisal of relevant global and national health frameworks, complemented by a situational analysis comprising retrospective chart reviews, interviews-administered questionnaires to optometrists, district optometry coordinators, and individuals with VI. Stage 2 involved synthesis of findings to inform model development, guided by relevant global and national health frameworks. Stage 3 focused on iterative refinement of the model through peer debriefing and alignment with national and provincial health priorities.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA context-specific model was developed, grounded in empirical evidence and aligned with global and national frameworks. The model comprises four interrelated levels\u0026ndash;community, primary, secondary, and tertiary care\u0026ndash;designed to improve access, utilisation, referrals, integrating preventive and promotive, curative and rehabilitative ECS across the health system continuum with consideration of contextual risk factors and health system enablers. Iterative refinement of the model enhanced its contextual relevance, implementation feasibility and alignment with existing policies to address the increasing burden of VI and improve eye health outcomes. In this regard, the model addresses fragmented delivery and persistent gaps in access, availability, utilisation, and equity of ECS in the public health sector across the province.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe proposed VI model of care provides a contextually responsive framework to enhance the integration of comprehensive ECS, improve access to care, and maintain continuity of care, thereby reducing the burden of avoidable vision loss in Limpopo province.\u003c/p\u003e\u003ch2\u003eContributions:\u003c/h2\u003e \u003cp\u003eThe study provides a practical framework to inform policy, planning and implementation to improve ECS delivery and strengthen integration in resource-constrained public health settings.\u003c/p\u003e","manuscriptTitle":"An integrated model of care for vision impairment within the public health system of Limpopo province, South Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 17:32:06","doi":"10.21203/rs.3.rs-9080243/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"174146409236478097223568808198011453294","date":"2026-04-24T11:06:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T09:05:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T14:11:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-23T04:04:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-21T11:35:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-21T11:30:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0d34c4d6-1204-4848-ba79-decf4c6be243","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T17:32:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 17:32:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9080243","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9080243","identity":"rs-9080243","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}