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Lessons from the Boresha Macho eye health programme in Tanzania

Edwin Maleko, March 2023

The three-year Boresha Macho programme has been a game-changer for eye health in the Singida and Morogoro regions of Tanzania. I’ve been involved with the project throughout its lifespan and seen for myself the impact it has had within communities.

Although the programme, funded by donations from the UK public and match funding from the UK government through UK Aid Match, has now ended, it formed strong foundations that governments and partners are now building on. Health budgets and resourcing have already been increased and Sightsavers is currently supporting a review of professional training curriculums.

It has made a huge difference in growing the number of eye health workers, making services more accessible and gender-inclusive, reaching marginalised groups and demonstrating the importance of data. But most of all, it has had a wonderful ripple effect, as each person who accesses eye health services becomes an ambassador for eye health.

Upendo examines a patient's eyes during an eye test.

The Boresha Macho project

In Singida, an inclusive eye health programme has made eye care services more affordable, sustainable and equitable.

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Building the eye health workforce

When the programme started, we first addressed the eye health human resource aspect, making sure that all districts we work with had qualified human resources. The programme helped to roll out the World Health Organization Primary Eye Care manual in Tanzania, supporting the Ministry of Health to customise it to reflect the national context, and provided training for 533 primary eye care staff. We also strengthened eye health facilities at all levels, and we aligned with the World Health Organization’s six ‘building blocks’ by making sure that we addressed the issue of service delivery to the community.

The trained staff help provide eye health services at lower health facilities as well as referrals to patients who need cataract operations. Tanzania is one of few countries in Africa to implement the eye care manual and this is thanks to the UK Aid Match support.

Improving accessibility

With the UK Aid Match programme, we helped decision-makers understand the importance of accessibility and accessible infrastructures. The programme was one of the first to pilot Sightsavers’ accessibility audit toolkit. Before this project, we did not have any interventions that considered accessibility. So we started to train the regional health management teams on accessibility audits. We used the audit tool in 14 facilities to identify whether the buildings were accessible and whether staff could communicate in an accessible way.

After this, we renovated two buildings, which are now used as model facilities for the government to copy. Whenever they build any eye health infrastructure or building, they now know they need to consider what’s required so that the building can be accessible. As a result of this, the disability unit at the prime minister’s office has asked us to work with them to help the government develop its own accessibility audit tool. This has all come about through the programme.

We have also helped the prime minister’s office to implement the National Disability Act by supporting the training of disability committee members at village level.

“The prime minister’s office has asked us to help the government develop its own accessibility audit tool.”

Upendo talks to a patient during an eye test.
Upendo, an assistant doctor who specialises in eye surgery at the Singida Referral Hospital, has been able to help many people through the programme. ©Sightsavers/Michael Goima

Reaching remote communities

At Sightsavers, we do a lot of community outreach work. With Boresha Macho, we conducted 60-70 community outreach events – and whenever we go to rural areas for eye screening and surgical camps, we help a lot of people. The area that we work in is very remote. In terms of the average household income, many people struggle just to pay for transport to access health care, let alone the costs of the care itself. So community outreach is vital, and the programme has had a significant impact.

Demonstrating the importance of data

In Tanzania, most of the regions are not able to share eye health data. But the two regions we have been working in, Singida and Morogoro, have demonstrated it is possible for the ministry of health to receive quality eye health data from the district regional level and even lower-level facilities. For three consecutive years the two regions have been outstanding in terms of sharing quality data. This helps with policy lobbying for budget allocations and lobbying for human resource for eye health – not only in the two regions but also in other regions.

Ensuring gender inclusion

To make sure women were not excluded from the programme, we worked in partnership with Tanzania Gender Network to provide training, develop training manuals and liaise with social welfare officers working at district and regional levels.

It was especially important for us to consider the accessibility of operations. Around 56% of the people who benefited from the programme are women, but in terms of cataract surgery, the number is 46%. Why? Because if a woman accepts cataract surgery, she may need around two weeks to recover. Who will take care of the children? That is the challenge. To tackle it, we need to change community behaviour, so that men can be more responsible in taking care of their children and doing domestic work.

While there is still work to do in this area, it was encouraging to see that during the programme, the number of women who accepted cataract surgery increased from our previous project where it was just 36%. So we’ve seen an increase, and seen the benefit of working with women’s groups through social welfare officers.

“We’ve seen an increase in the number of women who accepted cataract surgery through the project.”

An eye surgeon operates on a patient in hospital. Another member of clinical staff stands next to them wearing scrubs.
In the future, changes in social attitudes around childcare and domestic tasks will hopefully enable more women to access cataract surgery. ©Sightsavers/Michael Goima

Beyond Boresha Macho

The programme has led to a lot of positive change throughout Singida and Morogoro, but there is still plenty of work to be done to improve eye health across Tanzania. Firstly, we need to look at the link between primary eye care and primary health care. Eye health should be well integrated into primary care facilities because that is where people on low incomes go whenever they get any eye issues.

We need to train more people. We need to integrate eye health with insurance to make sure eye health services are covered. We need to ensure eye health financing is in place, and that it is sustainable.

We also need to work on raising awareness of the importance of eye health. In Singida and Morogoro, 80% of the residents are farmers. Their farming depends on rainfall, and with climate change, now they’re farming once a year for a period of three months. That money will go to pay for school fees, to build a house, and to buy food. So when it comes to eye health, many people think, “I will not die if I have eye conditions. I can just live the way I am.” To address this, we need to address the challenge of their household income through economic empowerment programmes.

It is also important that we integrate eye health into education – especially early childhood development – to make sure we’re raising awareness at all levels.

The Boresha Macho programme allowed us to make great progress in improving eye care in Tanzania. UK Aid Match has helped make this possible and changed lives across the country for the long term. I’m so proud to have been involved, and I’m hopeful that the progress made so far will continue.

Nowah wears optometry glasses during an eye test at her school in Liberia.

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Edwin Maleko is a programme manager at Sightsavers, based in Tanzania.

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