Training Alone Is Not Enough: What Sierra Leone’s Eye Health Experiment Reveals

Vision impairment remains one of the most stubborn and under-addressed public health problems in low-income countries, and Sierra Leone sits squarely at the sharp end of that burden. With specialist eye services concentrated in a handful of facilities and a largely rural population scattered across difficult terrain, most people who develop blinding or disabling eye conditions simply never reach the care they need. In an effort to change this, the country’s Ministry of Health and Sanitation adopted the World Health Organization’s primary eye care training manual in 2020, betting that the fastest route to better eye health runs through the thousands of community-level health workers who form the first point of contact for nearly every patient. A new mixed-methods study published in BMC Public Health now offers one of the most detailed looks yet at whether that bet is paying off, and the answer is a nuanced one: the training works, but training alone is not enough.

The research, led by Sapana Basnet of the international development organization Sightsavers together with colleagues from Sightsavers offices in Nigeria and Sierra Leone and the Ministry of Health and Sanitation, set out to fill a gap that has long frustrated eye health advocates. Previous studies of primary eye care programmes have tended to measure what is easiest to count: how many workers were trained, how many patients were seen, how many referrals were made. Far less attention has been paid to the messier question of implementation, meaning the health-system conditions that determine whether a training programme actually changes practice on the ground. The 2019 World Report on Vision from the World Health Organization emphasized that integrating eye care into primary health care is essential for expanding access, but the evidence base for how to do that well has remained thin, particularly in fragile health systems.

To build that evidence, the team conducted the study across four districts of Sierra Leone, combining two complementary strands of data collection. The first was a series of 57 in-depth interviews with the people closest to the reform: primary health care workers who had been trained using the WHO primary eye care manual, ophthalmic specialists, health managers, and partners from non-governmental organizations. The second was a structured survey of 32 primary care facilities, designed to assess the physical and logistical foundations on which any eye care service must rest, including infrastructure, the availability of equipment and medicines, and the systems for recording and reporting eye care data. The interview transcripts were analysed thematically, while the facility survey data were summarized descriptively. Ethical approval was granted by the Sierra Leone Ethics and Scientific Review Committee in October 2021, and all participants gave informed consent.

The qualitative findings paint an encouraging picture of what good training can achieve. Primary health care workers reported that the WHO training increased their confidence, improved their knowledge, and enhanced their ability to identify, manage, and refer patients with eye problems. This is no small thing in a setting where, before the programme, many frontline workers had received little or no formal instruction in eye conditions and were often unable to distinguish conditions they could treat from those requiring urgent specialist attention. Workers described tangible changes in their day-to-day practice: better counselling of patients about their conditions and their treatment, a reduction in harmful traditional practices that can worsen eye disease, and more appropriate referrals to secondary-level facilities when cases exceeded their competence.

Perhaps the most strategically significant finding was the perception among participants that the strengthened primary eye care services were reducing pressure on secondary facilities. In health systems theory, this is precisely the mechanism through which primary care integration is supposed to work: by resolving simple conditions, such as conjunctivitis, minor injuries, or allergic eye disease, at the community level, the trained workers filter the patient stream so that scarce ophthalmic specialists, cataract surgeons, and operating theatres can concentrate on the complex cases that genuinely require them. In a country like Sierra Leone, where the cataract surgical rate, a standard indicator of surgical service delivery, has historically been far below the levels needed to clear the backlog of avoidable blindness, freeing up specialist capacity is a meaningful gain. The study’s participants, including ophthalmic specialists themselves, reported observing this relief effect, suggesting that the training is producing system-level benefits rather than merely individual ones.

Yet the facility survey data reveal the other side of the story, and it is a sobering one. The audits of the 32 primary care facilities confirmed substantial gaps in the essential supplies that trained workers need in order to act on their new knowledge. Equipment and medicines for eye care were frequently unavailable, meaning that a worker who could correctly diagnose a condition might still have nothing with which to treat it. The gaps extended to basic infrastructure: many facilities lacked reliable electricity and safe water, conditions that constrain almost every aspect of primary care delivery, from sterilizing instruments to examining an eye under adequate light. In technical terms, the study found a mismatch between the cognitive capacity built by training and the material capacity of the facilities in which that training was supposed to be deployed, a mismatch that implementation scientists recognize as one of the most common failure modes in health system reform.

The data systems told a similar story of partial integration. Eye care records had not been fully incorporated into the national health management information system, the routine reporting architecture through which the Ministry of Health tracks disease burdens, service volumes, and resource needs. Without eye care indicators flowing through the health management information system, managers cannot see how many patients are being treated at primary level, cannot identify districts with unmet need, and cannot make the case for budget allocations with hard numbers. The study also identified weaknesses in the referral pathway itself: even when workers made appropriate referrals to secondary facilities, many patients did not complete the journey, deterred by the direct and indirect costs of travel and by geographic barriers. A referral that is clinically correct but practically unaffordable delivers no health benefit, and the study found that low uptake of referrals was a persistent constraint on the programme’s impact.

Workforce and supervision gaps compounded these problems. The study found that supervision of trained workers was limited, meaning that newly acquired skills could erode without reinforcement and that workers had few opportunities to seek guidance on difficult cases. Refresher training was insufficient, a well-known vulnerability of one-off training models, since clinical knowledge decays without periodic reinforcement and since the WHO manual covers a broad range of conditions that a community health worker may encounter only rarely. Chronic workforce shortages in the primary care cadre meant that some trained individuals were stretched across too many responsibilities, leaving little room in a busy clinic day for systematic eye examination. Each of these constraints is individually manageable; together, they form a web of systemic friction that can quietly undo the gains of a well-executed training programme.

The authors’ conclusion is carefully worded but clear in its implications. Standardized primary eye care training can strengthen the competencies of primary health care workers and support the delivery of basic eye care closer to communities, which is a genuine and valuable achievement in a country where vision impairment remains a major public health problem. But training alone is insufficient. Effective integration of eye care into primary health care, they argue, requires simultaneous investment in strengthened supervision, refresher training, functioning referral systems, workforce capacity, infrastructure, supply chains, and routine data systems. This framing aligns with the broader logic of universal health coverage and with the Sustainable Development Goal agenda, both of which treat the health system as an interdependent whole rather than a collection of vertical disease programmes. The study was funded by Irish Aid, which had no role in the design, analysis, or writing, and the authors declared no competing interests.

For policymakers in Sierra Leone and in the many countries watching this model, the study offers a practical roadmap. The training component has proven its worth and can be scaled with confidence; the WHO manual provides a standardized, internationally validated curriculum that workers embrace. The next phase of investment should target the enabling environment: reliable drug supply for common eye conditions at peripheral health units, basic equipment provision, electricity and water at facility level, supervision structures that include eye health content, scheduled refresher training, affordable transport or fee waivers for referred patients, and the technical work of embedding eye care indicators into the health management information system. None of these measures is glamorous, and none will generate headlines on its own. But the Sierra Leone experience demonstrates that they are the difference between a training programme that changes what workers know and a health system that changes what patients can see.

Subject of Research: Integration of primary eye care into the primary healthcare system in Sierra Leone

Article Title: Integration of eye health into the primary healthcare system in Sierra Leone: a mixed-methods study

Article References: Basnet, S., Jolley, E., Ibrahim, N., Gondoe, T., Harrison-Williams, L., Smart, N., Mustapha, J., & Schmidt, E. (2026). Integration of eye health into the primary healthcare system in Sierra Leone: a mixed-methods study. BMC Public Health. https://doi.org/10.1186/s12889-026-29893-7

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29893-7

Keywords: primary eye care, primary health care, Sierra Leone, health systems strengthening, WHO training manual, vision impairment, universal health coverage, health management information system, referral systems, Sightsavers, BMC Public Health, mixed-methods study