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 Table of Contents  
Year : 2010  |  Volume : 23  |  Issue : 2  |  Page : 368

The Development of Competency-based Education for Mid-level Eye Care Professionals: A Process to Foster an Appropriate, Widely Accepted and Socially Accountable Initiative

The Fred Hollows Foundation New Zealand, Newmarket, Auckland, NewZealand

Date of Submission15-Jun-2009
Date of Acceptance04-May-2010
Date of Web Publication16-Aug-2010

Correspondence Address:
R du Toit
Private Bag 99909, Newmarket, Auckland 1149
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Source of Support: None, Conflict of Interest: None

PMID: 20853239


Introduction: The Western Pacific region has a dearth of appropriately educated eye care providers, training programs and large and increasing eye health needs.
Method: To ensure regional eye health needs would be met, an iterative process sought triangulations between the literature and consultations with local stakeholders from various fields. This information was used to develop competencies to meet quality standards for educational outcomes. A framework for social accountability was used to evaluate the proposed educational initiative, and the subsequent eye care service the graduates could provide.
Results: Current human resource development and deployment is inadequate to protect and restore ocular and visual health in the region. Some of these service needs could be met by task-shifting from conventional health professionals to appropriately trained mid-level personnel. A competency-based curriculum was developed to meet eye care needs and define this new cadre of mid-level professionals in relation to other professionals. This initiative met the relevance, equity, cost effectiveness and quality criteria for social accountability.
Discussion: The consultative process resulted in broad acceptance of the need for an appropriately educated mid-level cadre that could be recruited, educated, deployed, supported and retained in the Western Pacific region to supplement and substitute for established eye care professionals. This process also provided validation of the initiative prior to implementation, as being appropriate to the region, meeting educational standards and social accountability criteria for outcomes. It could be replicated in other regions that wish to develop such an education for new cadres of health care professionals.

Keywords: Education, curriculum, ophthalmology, competency-based, socially accountable

How to cite this article:
du Toit R, Palagyi A, Brian G. The Development of Competency-based Education for Mid-level Eye Care Professionals: A Process to Foster an Appropriate, Widely Accepted and Socially Accountable Initiative. Educ Health 2010;23:368

How to cite this URL:
du Toit R, Palagyi A, Brian G. The Development of Competency-based Education for Mid-level Eye Care Professionals: A Process to Foster an Appropriate, Widely Accepted and Socially Accountable Initiative. Educ Health [serial online] 2010 [cited 2020 Feb 20];23:368. Available from:


More than nine million people live in Western Pacific Island Countries and Territories (WPICT), ranging from an estimated six million in Papua New Guinea, to as few as a thousand in each of Nuie and Tokelau. Most (70 to 85%) are rural dwellers in remote communities separated by vast expanses of ocean or mountainous terrain. Provision of health care is challenging in these geographic circumstances. This is compounded by poorly resourced countries with low per capita government health spending, low ratios of doctors and nurses to population, and inadequate health infrastructure at every level. This is reflected in poor health indicators1.

Eye care in WPICT is no exception2,3. Most blindness and vision impairment in the region is due to cataract and uncorrected refractive error4-8. Conditions such as presbyopia and conjunctivitis also occur commonly, and although unlikely to have sight threatening outcomes9,10, may significantly affect quality of life11,12. Childhood blindness and diabetes eye disease may also significantly contribute to disability13-15. Yet, up to 80% of vision impairment is avoidable, i.e. can be treated or prevented16, by appropriately trained health personnel implementing cost-effective health interventions15,17.

Globally, there is a shortage of about 4.3 million health workers, leaving over a billion people with little or no access to health services. The greatest shortage is in poorest countries18. However, this is not just a problem of insufficient absolute numbers. Maldistribution of available health professionals frequently limits access to care, particularly for the poor and those living away from main population centres19-21. To assuage this workforce deficiency there has been a call for task-shifting22 away from conventionally accepted roles of health care professions: “Task-shifting involves the rational redistribution of tasks among health workforce teams. Specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health.”23

There is evidence that these lesser trained and qualified mid-level cadres are able to carry out tasks generally associated with more conventional professionals, such as physicians, and provide effective care when doing so20,23-25. They may also be more likely to live and work in locations and circumstances unattractive to conventional health professionals, especially if students are selected from areas of need20,26. An additional benefit of this strategy may be that such workers more readily relate to the communities they serve20,27.

Task-shifting to a mid-level cadre of eye care providers has been advocated for many years28,29 and is practiced in varying degrees in both high30,31 and lower32-35 income countries. The education for such a cadre would ideally be based on recommendations for best practice36,37, appropriately equip graduates to perform their jobs within their environment and be socially accountable38-40.

This paper describes a widely consultative process undertaken to reach consensus about how best to meet eye care needs in WPICT. It describes the iterative process followed in: gathering information from the literature and from local stakeholders from various fields; developing a listing of appropriate competencies for a mid-level care of eye care personnel; and verifying the recommendations of this initiative against criteria for social accountability.


The Fred Hollows Foundation New Zealand, (FHFNZ) an international non-government developmental organization (INGO) working across WPICT, instigated this initiative to address eye care needs in the region. The process that was employed mirrored the "little steps" approach that argues for incremental improvement to foster sustainability. It further advocates that quality improvement projects in low income countries be integrated into local context, rather than summarily implementing an existing model without consultation or context specific adaptations and expecting high impact and immediate outcomes41.

The process commenced with information gathering from a selective literature review of eye and health care needs in the region and local stakeholder consultations. The process was iterative and at various points returned to the literature, most often prompted by additional information obtained from stakeholders. Similarly, stakeholders were consulted at various points to discuss or verify proposed options. Early involvement of stakeholders may foster a sense of ownership, acceptance of outcomes and encourage ongoing participation41.

Stakeholders from various fields were involved to provide different perspectives and ensure an initiative best-suited to this region38,41,42. FHFNZ staff met with representatives from Ministries of Health, the World Health Organization (WHO), academic institutions and professional bodies working in the most populous WPICT: Papua New Guinea, Fiji, Vanuatu, Solomon Islands, Samoa and Tonga. FHFNZ staff also attended the WHO ‘Consultation on Strengthening Specialized Clinical Services in the Pacific’ meeting. Groups of WPICT eye care personnel discussed how best to meet eye care needs during two workshops convened by FHFNZ: a Pacific regional workshop in Fiji and a subsequent workshop in Papua New Guinea, where Ministry of Health officials and other INGOs were also present. Throughout this process FHFNZ worked closely with a local ophthalmologist who had previously provided informal mid-level personnel eye care training.

The definition of competencies practitioners are to exhibit on graduation and in their future roles is held as the quality standard for educational outcome37. Information gathered during this process was thus used to define both broad and specific competencies.

The definition of competencies in and of itself, however, does not guarantee quality of education30, nor subsequent ethical and socially accountable practice38,43-46. Neither can this be guaranteed by processes such as a certification examination, which typically provide only limited verification of clinical knowledge47. Other measures of education quality may include student course evaluations, their success in attaining the qualification, and measures of the care they provide. The development, implementation and interpretation of such measures are, however, contentious48. In addition, such information would only be available some time after implementation of the course.

Thus prior to the implementation of this initiative, FHFNZ applied a framework for assessing the social accountability of both the educational initiative and the health care it allows its graduates to provide38,39. Criteria for social accountability: relevance, equity, cost effectiveness and quality38,39 were operationalized into questions addressing each area (Table 1).

Examples of questions for each area are listed below:

  • relevance: how can training be structured to address priority eye care needs in the region and reduce avoidable causes of vision impairment?

  • cost-effectiveness: how can training resources best be employed to enable the greatest impact on eye health?

  • equity: how can training be focused to ensure that everyone has access to high quality comprehensive eye care?

  • quality: how can training best be structured, and evidence-based data and appropriate technology be utilized, to ensure that populations can access comprehensive eye care, that meets their expectations and social and cultural needs?


Stakeholder input

Discussions with representatives of Ministries of Health, WHO and professional bodies included: consideration of demographic and epidemiological trends; socio-economic development; financial capacity; technical aspects of and likely advances in the provision of eye care; global health workforce trends; the appropriate mix of eye care team personnel; the skills each member would require; and how geographical coverage and accessibility in remote areas could be achieved and productivity promoted.

At the two workshops, issues surrounding accessibility of eye care and the shortage of trained eye care personnel in WPICT were identified, as were the implications for human resource recruitment, training, deployment and retention. An indigenous workforce of fewer than 15 doctors, 65 nurses and a handful of ex pat doctors provide most of the eye care in the public health care sector. There is a lack of formal training opportunities: in 2005, a low-output eye doctor training scheme in Papua New Guinea provided the only eye care education in the region that culminated in a recognized tertiary-level qualification. Short courses of two weeks to four months duration and on-the-job training of up to a year were intermittently available for training nurses in eye care.

Stakeholders from various fields concurred with published recommendations15-17: with effective eye health promotion, prevention and curative services, a significant proportion of ocular morbidity and vision-related disability in the region could be avoided or treated. It was further agreed that, if appropriately trained and deployed, a cadre of specialist mid-level eye care personnel could address much of the current and anticipated eye care need4-10,13-15. It was accepted that this would require formalized task-shifting from general nurses, optometrists, medical practitioners, and ophthalmologists22, with appropriate competency-based education, professional recognition, and workplace support following graduation26. Task-shifting would free the time of eye doctors and ophthalmologists to perform higher level functions such as cataract surgery and lazering of diabetic retinopathy.

Discussions with Ministry of Health representatives confirmed that remediations must not jeopardize other health and medical priorities. These should be in keeping with country health strategies and plans, encourage the retention of workers who would likely be lost to the system through migration and attrition, and avoid absorbing an inappropriately large proportion of nurses and doctors to the detriment of other health services. Thus this may, depending on the country’s situation, require that from the outset there is an expectation of rural service and that these mid-level personnel are not recruited exclusively from nursing staff. The scope of practice for non-nurse trained personnel will depend on the health systems and professional bodies within each country, and on selecting appropriate competencies to make up their education.

Stakeholders proposed situating the mid-level cadre largely within a nursing structure because non-nurse clinicians have not proven viable in many WPICT49. A newly created cadre of specialized non-nursing personnel would be unlikely to be incorporated into health systems of many WPICT. Nurse graduates could more easily fit into public sector schemes and nurse practitioner models of care50.

Representatives from regional tertiary academic institutions provided input into the academic requirements of a specialized eye care course. The nature of the educational qualifications required for specialized eye care personnel was discussed with human resources representatives from Ministries of Health and professional bodies. The nursing structure in most WPICT, whilst not recognizing eye care as a speciality area, makes some provision for rewarding the acquisition of a one-year post basic qualification with a salary increase.

Selective literature review

Appropriate education

There is little evidence-based information directly related to eye care and/or to mid-level eye care personnel in low income countries. Thus expert opinion, consensus statements and position papers were sought about eye health, services and utilization in the Western Pacific1-15,51; global trends in health human resources 18-26,28-30,32-34,49,50,52-54; strengthening health systems 25,55; commentary about eye health, providers and education 22,29,56-61; competencies and competency-based training 23,36,58,59,62-76 curricula for mid-level or allied eye health personnel77-80 professionalism20,23,46,53,64-66,69,70,81-83; and ethical/socially accountable medical education18,19,38,39,42,44-46,76,84-86.

Education and health care cannot be isolated from the health system, socio-cultural or economic context within which it occurs. Thus a wide range of stakeholders37 including health professionals, policy makers38, academics and representatives of health services42 can assist in defining competencies to help ensure that individuals are appropriately trained to perform their prospective jobs within their environment. Conventional health education with a curative, disease-oriented approach frequently lacks firm social mandates and may not equip its graduates to meet population health needs, especially those of resource-poor communities18,19,38.

Competency-based education

Many health care training programs in higher income countries, such as ophthalmology68 and optometry69, now base their curricula on competencies (“the ability to perform the activities within an occupation or function to the standard expected in employment70). Such competency-based education provides a measure of quality37 in that it can assist in clarifying, for both teachers and students, the expected learning outcomes. Thus the acquisition of a broad competency such as a professionalism may be facilitated throughout the course instead of being relegated to a hidden curriculum and potentially overlooked71,87. Specific competencies serve to align course content to the application of knowledge and skills88, allow for criterion-based assessment73 and focus on the expected outcomes after the course88 to enable students to learn to proficiently accomplish their expected tasks23,59,74. These advantages of competency-based education are equally applicable to low income countries36,37.

Further, these competencies characterize conventional health professions in high income countries. Professions such as optometry64,70 and ophthalmology65,66 may be defined by their legal scope of practice69 and by their professionalism in practice46. In contrast, mid-level eye care personnel have generally been identified by their relationship to other professionals or the location in which they work and not by their competencies81. However, defining new task-shifting cadres of mid-level health care personnel by what they do, and not who they are or where they work, may benefit the professionalism of a mid-level cadre23,83. It will facilitate the demarcation of professional boundaries. This may be important for a sense of professional identity, help secure status82, assist regulatory authorities and encourage recognition and respect from administrators and other health professionals20,53,83. Furthermore, competencies can be used to establish recruitment and evaluation criteria23.

The existence of defined competencies, “knowledge, skills, attitudes and personal qualities that an individual needs to be effective in a wide range of jobs and various types of organizations72, are considered a quality standard for outcomes of medical education37. The curricula available for mid-level or allied eye health personnel77-80 are not competency-based. The role of mid-level eye care personnel may include competencies from ophthalmology68, optometry69 and ophthalmic nursing75.

Accountable education

There is consensus that education for health professionals should also be both ethically and socially accountable38,40,44-46. It needs to be responsive and have a focus on continually improving quality by embracing changing circumstances, expectations and health care needs of individual patients and of society, new information and technologies85,86. It is thus important that education programs, their graduates, and the health care these graduates provide meet certain standards of social accountability38,39.

Competency and curriculum development

Based on the published information and stakeholder consultations FHFNZ staff developed draft competencies for mid-level eye care personnel. These were based on regional eye care needs, the role that this cadre could be expected to fulfill1-15,51, competency standards for nursing, medical, optometric and ophthalmic personnel developed in high income countries23,36,58,59,62-76 and curricula from mid-level eye care personnel77-80. A draft of these competencies was presented for group discussions during the workshops, and the feedback used to further modify the competencies. The competencies were submitted to the regional eye workers’ association (PACEYES) for approval.

Specific competencies were grouped into six areas to address curative and preventive/promotive aspects of the significant eye care needs in this region (Annex 1). In addition, core generic/broad competencie71,58,67,76 were developed to cut across the entire course. These include public health perspective, systems-based practice, collaboration, working in teams, patient-centred care, interpersonal and communication skills, information and communication technology, quality improvement, practice-based learning and professionalism, evidence-based eye care. The inclusion of behavioural and social sciences into the traditional curative curriculum provoked the most debate. Given the available evidence of best practice37,67,89 and eye care needs in the region13-16, these were retained.

Evaluation of social accountability

FHFNZ used the best evidence available – the information from a selective literature review and the stakeholders to evaluate this initiative against the criteria proposed for social accountability38,39 (Table 1). Both the educational outcome and eye health service delivery were assessed against the criteria of relevance, cost-effectiveness, quality and equity. While this occurred informally throughout the initiative, a final evaluation of the initiative verified that the purpose, function and education of this new cadre of mid-level eye care personnel would meet the criteria for social accountability46. The information used as proof of verification of each criterion is summarized in table 1.

Table 1: Criteria for social accountability28 applied to the purpose, function and education of a new mid-level cadre of eye care workers for the Western Pacific region

After consultations with academic institutions, the competencies were included in a curriculum for a full-time, tertiary-level, qualification-earning course to convert general nurses, and those with a suitable non-nursing tertiary education and work experience, into mid-level eye care professionals. The curriculum was applied to one-year courses delivered by The Pacific Eye Institute (Suva, Fiji) and Divine Word University (Madang, Papua New Guinea), with an adapted version at The National Institute of Health Science in Dili, Timor-Leste. The training at these institutions is delivered in partnership with FHFNZ, Ministries of Health and the academic institutions, which approved these curricula and continue to oversee their implementation and award the qualifications: Postgraduate Diploma in Eye Care (Fiji School of Medicine and Divine Word University) and Diploma in Eye Care National Institute of Health Science. All graduates receive, as part of their scholarship package, equipment to use while learning and to allow them to implement these competencies at their workplaces.


Service and survey data2-5,7,8 and stakeholder consultations confirm there is a great need for comprehensive, capable and accessible eye care in the Western Pacific region. Current services are insufficient to protect and restore ocular and visual health. In part this is because of an inadequate workforce—too few, inappropriately trained and poorly deployed.

The strengths of this initiative designed to address the inadequate workforce within a broader health systems approach, include the comprehensive process that was used to ensure social accountability, quality, appropriateness and widespread accord. Current best practice regarding eye care and global workforce trends, and also education and competencies of health and eye care personnel was identified1-15,18-30,32-39,41,42,44-46,48-50,52-86 and triangulated with information from stakeholders from various fields.

A task-shifting approach to mid-level eye care personnel was proposed to assist in assuaging the need for eye care in WPICT. Given the identified benefits of the definition of competencies37, both specific and generic competencies for this cadre were identified. These were incorporated into curricula that aim to produce mid-level health professionals with values, attitudes, knowledge and skills in eye care that will enable them to provide ethical and socially accountable service. Additionally, these competencies can be used to advocate for professional recognition as specialized eye care providers, define the role of these personnel both in eye care and in relation to others in the health care team, inform policies and planning, aid recruitment and calculation of reimbursement packages, evaluate workplace performance, and identify strengths and weaknesses when planning continuing professional development and career advancement73,37,35.

Grouping of competencies according to local eye health need or worker interest and capability also offers an opportunity to design a modular education and workplace system that accommodates a cohort of complementary workers within the mid-level cadre. As the need for particular competencies and cadres fluctuates with time, education courses need to be able to respond in a flexible and integrated manner85. If widely endorsed and adopted across the Western Pacific region, the mid-level eye care competencies could enhance retention of workers as they migrate across national borders. Harmonization of competencies may also help maintain the quality of courses and graduates38,85.

This initiative further employed a widely consultative process involving educators, eye care personnel, and those from the wider health field. Wide consultation was intended to help design an initiative that would prepare mid-level eye care personnel able to provide quality eye care appropriate to the context of their health systems. The competencies within the proposed educational initiative and the subsequent eye care that graduates would provide were further honed by evaluating them against a framework of social accountability, considering relevance, equity, cost effectiveness and quality38,39. This process culminated in the approval by the profession, health systems and the academic institutions in the region. This process, incorporating the operationalisation and application of this social accountability framework38,39 as a component of the development of an educational program for mid-level health personnel, appears to be unique40.

Limitations of this process include that communities, the end users of eye care services, were not directly consulted about their needs and priorities. Obtaining a representative view of all communities in WPICT would have been nearly impossible – in Papua New Guinea alone about 800 languages are spoken. Instead, information from eye care personnel and from surveys of quality of life51 and access to services2,3 was used to identify patient needs. Communities in WPICT are likely to accept the concept of specialized mid-level eye care personnel, since much of the general health care in remote areas in this region is provided by non-physicians50,90. Further the course includes competencies to enable graduates to work in partnership with their communities to adapt eye care services to meet local needs and expectations.

In this region initiatives are often suggested by ‘experts’ and implemented from the top down, and extensive consultations are not the norm. A top-down approach can lead to the creation of less appropriate interventions, weaken any sense of local program ownership, and hamper subsequent implementation41,91. The extensive consultative process we used was time and resource intensive. Yet, respectful consultations with a wide range of stakeholders and basing this initiative on best practice, resulted in a remarkably smooth process and a largely uncontroversial and widely accepted outcome. It also fostered a sense of ownership. Further, it is consistent with the incremental approach recommended for sustainability of quality improvement initiatives41. This widely endorsed process92 may also ensure that the skills level and contribution of mid-level personnel is recognized as sufficient and significant by the health system and other health care professionals35,60, so that they do not try to limit the extent of task-shifting that occurs20.

To bring about lasting change, the process still cannot be considered complete. As mid-level personnel are recruited, educated and deployed, ongoing evaluation and negotiation will be required with health systems in each WPICT. The goal will be to ensure nomination of suitable candidates, within a careful plan for human resources to meet eye care needs, while considering other health priorities: that competencies are adjusted to meet changing eye health needs and priorities; that infrastructure, equipment, professional recognition, policy and legislation are in place; that there are effective systems for workplace mentoring, supportive supervision and continuing professional development; and that any other required improvements or adjustments can be made28,60,61.


Mid-level personnel can potentially make a valuable contribution to unmet global health needs22. The process described here, which culminated in the establishment of training courses for Western Pacific mid-level eye care personnel, was carefully structured and widely consultative. The iterative nature of gathering information from both stakeholders and the literature further strengthened this process. It also helped ensure the competencies appropriate to the eye care needs in the region and the integration into the wider health system. This initiative addresses the three components of Vision 2020–The Global Initiative to Eliminate Avoidable Blindness: human resource development; infrastructure development; and disease control15,93. In addition, evaluation against a framework of social accountability allowed the assessment of both the educational outcome and the eye care the graduates could provide, prior to implementation of the initiative38. As such, this process could be replicated in other regions that may be interested in developing an appropriate and socially relevant competency-based education for new cadres of health care professionals.


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Appendix: Competencies for a cadre of mid-level eye care personnel


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