The effect of eye health system strengthening on the productivity of services: a before-and-after evaluation conducted in seven counties in Kenya

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Introduction: Health system strengthening is essential for achieving universal eye health coverage, yet evidence on the combined effect of simultaneous investments in infrastructure, human resource, equipment, and governance remains limited in low- and middle-income countries. This study evaluated the effect of a multi-component health system intervention on productivity of eye service in seven Kenyan counties. Methods: A before-and-after study was conducted using longitudinal program data from the Vision Impact Project (2021-2024), a partnership between Christian Blind Mission (CBM), Kenya's Ministry of Health, county governments, and implementing partners. The intervention comprised: eye unit establishment; training of core eye health workers; provision of ophthalmic equipment; and establishment of county eye health technical working groups. Data sources included pre-implementation situation analysis (2019), project monitoring data, Kenya Health Information System, Kenya national population census data, and structured facility surveys. Results: The number of facilities, providing eye care services, increased from 5 to 27 across seven counties between 2019 and 2024. The training of 72 core eye health workers addressed 48% of the total workforce deficit at baseline across counties. Of 53 purposively selected high-value equipment, 50 (94.0%) were fully operational, 49 (92.0%) were routinely used, and 33 (62.0%) were first acquisitions. 7 out of 8 secondary level facilities reported reduced patient referrals to higher-level facilities. Five counties showed increased Cataract Surgical Rates (CSR). Each county established a functional eye health technical working group (TWG), with the inclusion of county eye health coordinators into County Health Management Committees (CHMCs). Discussion: Concurrent investment in facility infrastructure, human resources, equipment, and governance strengthening was associated with improved productivity of services in most of the counties. Variability in outcomes underscores that health system strengthening efforts should be intensified to broader health system constraints to achieve universal eye health coverage in Kenya.

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