A tale of two sectors

Optometrist Boikhutso Mmereki speaks to OT  about delivering eye care in the public and private sectors in Botswana, and the need for a change in approach

A tale of two sectors

Landlocked between four countries in southern Africa, Botswana’s economy is frequently listed as Africa’s fastest growing. despite this new-found prosperity, people living in the country face a number of challenges when it comes to accessing healthcare services, particularly those based in the more sparsely populated and hard-to-reach regions.

Eye care in particular is acknowledges as an area of unmet need, with figures from Vision Aid Overseas (VAO) estimating that 730,000 people have refractive error and over 21,000 people are blind.

In partnership with Addenbrooke’s Abroad, the charity has established a vision centre in the Sekgoma Memorial Hospital in Serowe, funded by a Seeing is Believing grant from the Standard Chartered Bank. As one of 19 vision centres currently supported by VAO in Africa, the facilities aim to provide communities with a walk-in eye examination service, the opportunity to purchase affordable spectacles and referrals into specialist care, if required.

As the centre’s first optometrist, Boikhutso Mmereki joined the clinic in July 2014, having practised within the private eye care sector in Botswana for three years previously.

As the sole optometrist in the centre, the optometrist works closely with five ophthalmologists, five nurses and an optical technician. Talking about her new role within the public sector, Ms Mmereki explained: “It is very challenging and since I started it has certainly got a lot busier.”

Sharing details of an ‘average’ working day, Ms Mmereki told OT that most patients are referred into the clinic having seen an ophthalmologist first. “Our internal referral pathway is the reverse to what would be observed in the UK,” she said, explaining, “because there was not an optometrist at the hospital before [I arrived], around 90% of patients attend to see the ophthalmologist first.”

Six months into her role, demand is so high that appointments now have to be scheduled in advance, with her seeing around 10 patients a day.

An onsite glazing facility with a technician means that spectacles can be made to prescription quickly, and Ms Mmereki highlighted that her role still sees her act as both the optometrist and the dispensing optician. 

Emerging public sector 

Ms Mmereki is one of only five optometrists working within the public sector across the whole of Botswana.

As an emerging area for eye health, the country’s Ministry of Health, which is responsible for overseeing the quality and distribution of healthcare throughout the country, first began recruiting optometrists in 2011. 

Recruitment has been slow, with remuneration being much lower compared to the benefits that are available in the private sector. “Many of my friends ask me why I would work in the public sector when I could get more in private practice,” Ms Mmereki told OT, “but I love my job so much more than I have done for the last three years,” she added. 

"As I learnt about how I could help change a person's quality of life by providing them with eye care, I became eager to return home and share that with my people"

For Ms Mmereki, it is the lack of knowledge about eye care and its importance, combined with unaffordability, which makes the provision of optometry in the public sector, and its growth, so important.

“Many people simply don’t know about optometry or can’t afford to be seen in the private sector,” she explained. “For those living in remote areas, it seems that they just accept not being able to see properly as part of life. But as optometrists are recruited into the public sector to reach these people, we can help them take control of their lives again.” 

An optometrist at heart

Speaking honestly, the optometrist admitted that she herself did not know what clinical practice entailed until she began browsing course prospectuses prior to studying in the UK.

Ms Mmereki told OT: “When I first started looking at university courses, I didn’t really understand what optometry was and I certainly didn’t know what it was as a child growing up in Botswana. But, as I began to research on the subject, I was drawn to the course.”

After learning more, Ms Mmereki enrolled at Glasgow Caledonian University, where she graduated with a BSc in Optometry in 2011.

While initially Ms Mmereki was unsure about her desire to return to Botswana, throughout the course of her studies “it became undebatable that I would return,” she explained. “As I learnt about how I could help change a person’s quality of life by providing them with eye care, I became eager to return home and share that with my people,” Ms Mmereki added.

Returning to Botswana three years ago, Ms Mmereki worked in various practices in the private eye care sector, where few vacancies exist, yet still the public sector remains heavily understaffed.

For Ms Mmereki it was “the challenge” that attracted her to the public sector. “I thought it would expose me to a much greater range of patients, so I could grow in my career,” she said.

“The private sector is limited in the services it can provide and it mainly involves refraction and dispensing. Here, I can treat patients to the best of my ability rather than referring them,” she added.

Since July, Ms Mmereki has been mainly clinic-based. However, the optometrist recently provided eye care to people living in remote areas surrounding Serowe through an outreach programme she has established.

As the only optometrist working on the programme, appointments are pre-booked for Ms Mmereki’s visit, allowing her to see 15 to 20 people daily, dispensing frames, sunglasses and ‘ready readers’ from a sample collection she carries with her.

Speaking passionately about her desire to extend the programme, she already intends to visit hospitals in other remote areas in the near future, with this expected to expand further.

Also on Ms Mmereki’s agenda from April – when the hospital’s next financial year begins and her position has been budgeted for – is joining the hospital’s school health programme “to help raise awareness of eye care with children.”

Public sector future

Reflecting on optometry in the public sector in Botswana, Ms Mmereki admitted that she could not predict what the future may hold. “It could go both ways.”

“We could see a growth in the number of optical professionals working within the public sector, but we will need to see an increase in the remuneration being given at the moment which is substandard,” she added.

Speaking passionately, Ms Mmereki explained that from this month she will collate statistics for the number of patients tested and spectacles dispensed across the public sector. “The government needs to see and understand the benefits which providing eye care in the public sector brings and then maybe this will bring change,” she said.

“They need to take care of the optometrists in the public sector as, at the moment, they cannot attract professionals in and therefore things can’t change for the good if they remain as they are at the moment.”

Relishing the challenges that working in the public sector brings and reflecting on its possibilities, Ms Mmereki added: “I’m just crossing my fingers and hoping that change will come.” 

A UK perspective

Optometrist and AOP head of professional development, Karen Sparrow, shares her experiences of eye care in Botswana

It is three years since my first fact-finding visit to Botswana. Although I have travelled to several countries in Africa, I didn’t know much about this small country nestled against the northern border of South Africa until I arrived. What I found was a wonderfully warm and welcoming, well-equipped hospital and surprisingly good roads, as well as an emerging national eye care system.

I was sent on behalf of Vision Aid Overseas (VAO) to work with Addenbrooke’s Abroad in looking at delivering enhanced accessible eye care services across the country, especially in the more rural and remote areas away from the capital, Gaborone. Addenbrooke’s Abroad had already implemented diabetic retinal screening, but had an ambitious plan to support children’s vision screening and refraction services across the country, funded by a three-year ‘Seeing is Believing’ grant from the Standard Chartered Bank.

I have made several trips to Botswana since, but one of the most rewarding was revisiting the vision centre last October and seeing how far it had come from the bare room that I first saw in 2011. The vision centre is now a busy and bustling eye care centre, with a full-time optometrist and optical technician, serving the local community all year round. There is a queue of patients outside from 7.30am every morning.

During my last visit, I helped deliver a development workshop where staff from 12 hospitals across Botswana developed their own referral pathways from case finder to ophthalmologist, via nurse and optometrist. It was inspiring to see their enthusiasm and teamwork in the workshop and their commitment to high quality patient care.

VAO is supporting this programme until spring 2016, and I look forward to seeing patient centred eye care services develop further, as well as watching a sustainable vision centre grow even more successful, delivering spectacles to the local community and beyond.