Abstract / Summary
Primary eye care (PEC) is increasingly recognised as essential for improving access to eye health services in low‑income settings. The 2019 World Report on Vision emphasised integrating eye care into primary health care (PHC). In Sierra Leone, where vision impairment remains a major public health problem and specialist services are limited, the Ministry of Health and Sanitation adopted the WHO PEC training manual in 2020. However, previous studies have largely focused on training outcomes and service-delivery effects of PEC programmes, while evidence on implementation processes and the health-system factors that influence successful integration remains limited. We conducted a mixed‑method study across four districts in Sierra Leone, including 57 in‑depth interviews with PHC workers trained using the WHO PEC manual, ophthalmic specialists, health managers and NGO partners, alongside a survey of 32 PHC facilities. Interviews were transcribed and analysed thematically. Facility survey data were analysed descriptively to assess infrastructure, the availability of equipment and medicines, and eye care data systems. PEC training was well received, with PHC workers reporting increased confidence, improved knowledge, and enhanced ability to identify, manage and refer patients. Positive changes included improved patient counselling, reduced harmful practices, and more appropriate referrals, with perceived reductions in pressure on secondary services. However, implementation was constrained by limited supervision, insufficient refresher training, insufficient equipment and medicines, poor infrastructure, workforce shortages and low referrals uptake due to cost and travel barriers. Facility surveys confirmed substantial gaps in essential supplies, electricity, water and integration of eye care records within the health management information system. Standardised PEC training can strengthen PHC workers’ competencies and support the delivery and access of basic eye care closer to communities in Sierra Leone. However, training alone is insufficient; effective integration requires strengthened supervision, refresher training, referral systems, workforce capacity, infrastructure, supply chains and routine data systems.