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Evaluation Management Response
Management Response and Recommendations Action Plan
Evaluation Report Title: Strategic Evaluation of the “Strengthen National Capacities on Pediatric
Ophthalmology for Quality Child Eye Health in Bangladesh” (APC-GM-0010)
Date of Response: 17/04/2015
This management response was produced by Rifat Shahpar Khan, Programme Manager, Sightsavers
and recommendations action plan will be followed up by the Country Director.
 Overall Response (max 250 words)
Bangladesh Country Office acknowledges most of the findings in the evaluation report.
Sightsavers will consult these recommendations gradually during the next phase of project design
and may need to consider having its own strategy to deal with pediatric ophthalmology in future.
It is good to know that the evaluation recognises the contribution made by this short-term project
funded by the USAID/JSI, that has not only met most of its targets but was able to demonstrate a
referral pathway from CHWs to district ophthalmologist in project area and then to the tertiary facility
such as the NIOH. This was a good mean for early identification of children with eye health needs in
the community. The evaluation recognises that the project has led to some areas that could be
considered as lasting changes – including the i) the long-term pediatric ophthalmology subspecialty
fellowship training program initiated at NIOH, that is likely to continue into the future and produce a
stream of competent pediatric ophthalmologists to meet the future needs of the country and ii) the
development of pediatric ophthalmic guideline & protocol, which have created the scope to set
minimum standards in the area for Bangladesh.
This short-term project has also contributed to increase public sector partners’ capacities in
providing pediatric eye care unlike the BCCC project, that only worked with NGO hospitals. The
evaluation also confirmed its alignment with emerging eye health problem in children, retinopathy of
prematurity and has oriented obstetricians, pediatricians and neonatologists on its prevention and
timely treatment.
Evaluation Management Response
Findings and Evaluation Criteria Ratings we concur with (max 500 words)

The project was found effective as it achieved almost all of its targets. short-term training of a range
of cadres e.g. ophthalmologists, technicians, nurses and mid-level ophthalmic personnel in pediatric
eye care relevant to their level of competency. A large workforce of Community Health Workers
(CHWs) and teachers were trained as well in primary eye care (PEC), while a useful precedence
was set in orientation of other specialist health professionals e.g. obstetricians, pediatricians and
neonatologists in pediatric eye care issues. The training of CHWs could be aligned with the ten key
messages on child eye health, while training of teachers could be aligned with WHO school
screening guidelines and endorsed by relevant authorities.

Anecdotal evidence of an increase in outpatients and number of surgeries demonstrate efficiency of
the project. Although according to the evaluators it is difficult to attribute this to the short-term
training alone, the combined effect of orienting district ophthalmologists in pediatric eye care,
improving the soft skills of nurses and mid-level ophthalmic personnel, and training CHWs and
teachers in primary eye care has had a cumulative effect on the delivery of pediatric ophthalmic
services.

The project created impact by increasing the number of children screened and refracted. BJAKS
demonstrated a significant increase in both screenings and refractions. Marked increase in pediatric
outpatient attendances at the eye clinics in two out of three government district hospitals was seen.
One key impact of the project was the initiation of long-term subspecialty fellowship training in
pediatric ophthalmology at NIO&H. The protocol and guidelines for pediatric ophthalmology
developed are national resource documents and will help establish national standards for the
subspecialty services. The referral pathway from CHWs to district ophthalmologist has indicated the
potential for identification of children with eye health needs.

The long-term pediatric ophthalmology subspecialty fellowship training program at NIOH, a
government centre of excellence is likely to continue into the future and produce a stream of
competent pediatric ophthalmologists to meet the future needs of the country. NIOH capacities were
strengthened through management information system support on ped. ophthalmology.

The project has made a strategic entry point for school and community eye health in the districts and
took advantage of gains made through engagement with the Civil Surgeons. In the last five years
following the ending of the Bangladesh Childhood Cataract Campaign, there is a renewed intensity
of investment in child eye health by international NGOs, although the efforts are still fragmented and
progressing in the absence of appropriate stewardship mechanism from NEC to guide strategic
direction and there is lack of a revised child eye health strategy aligned with national needs.

In context of coordination and coherence, the evaluation states that the project has demonstrated
several points of synergy. Of particular note are the linkages developed with obstetricians,
pediatricians and neonatologists and this is an area that needs to be nurtured further to enhance
overall awareness about child eye health. The training of teachers and CHWs were complimentary
to each other as both were part of the local communities and therefore more effective in awareness
raising and referrals.
Evaluation Management Response

Although it is early to claim a scaling up in the post-project period, there are some potential options
for scalability. For instance, subspecialty fellowship training at NIO&H, training of CHWs in PEC and
teachers in vision screening can be scaled-up. More recently, the Little Doctors program of the
Ministry of Health provides an invaluable opportunity to integrate vision screening to reach children
in primary schools. National stewardship is required to guide future development of the subspecialty
of pediatric ophthalmology and coordinate the efforts of stakeholders and organisations so that they
are mutually reinforcing and not competitive or duplicative.

The evaluation team found that the one month observership training in pediatric ophthalmology
could be more useful/effective to someone who has undergone a full 18 months of subspecialty
training. However, at the time the project was developed, this subspecialty training did not exist in
Bangladesh. We concur with this finding and will be careful in future while designing any project.
 Findings and Evaluation Criteria Ratings we question (max 500 words)

The rationale to develop or strengthen district eye services for childhood eye surgery was unclear.
There is generally no anaesthesia service for eye care at district level, and the major workload of the
district eye unit revolves around general ophthalmology. The development of child eye health
services at district level could have focused on identification of children with eye problems,
correction of refractive errors, treatment of minor eye ailments, and refer others to subspecialty
services at tertiary hospitals. There are issues in light of the competencies and what district
ophthalmologists can realistically deliver on pediatric ophthalmology.
Our response:
 The USAID funds through both WL & then JSI was utilised for improving linkages between the
stakeholders incliuding the following for better pediatric eye care: district based government
hospitals, CHW, district based ophthalmologists so that the early identification and referral pathways
could improve.
 However, the development of district hospitals’ capacities with equipment etc. was done based on a
situation analysis done by an external consultant back in 2011, (and this component was funded by
Sightsavers back in 2011, not USAID). We agree with the Evaluator (i.e. Dr H Awan) this was not an
appropriate and effective action as indicated in the 1st two sentences (i.e. ‘The rationale to develop
or strengthen district eye services for childhood eye surgery was unclear. There is generally no
anaesthesia service for eye care at district level, and the major workload of the district eye unit
revolves around general ophthalmology.’). As this component was not actually funded by USAID
funded projects the first part of the findings by the Evaluator (Dr Awan) is really useful for us, but it
should not be perhaps connected to the evaluation of this USAID funded components, as the action
in italic above precedes the project(s) funded by USAID. –.
 The schoolteachers were trained in primary eye care while the need in school eye health is more on
vision screening and eye health promotion.
Our response:
We do not concur with this recommendation as the project focus was on child eye care, not just on
refractive error. Teachers identified all children with different types of eye problems and referred
them to doctors/ophthalmologists for examination/services including for refractive error services.
Evaluation Management Response

The evaluation team noted that there were some operational gaps. For instance, there were very
limited services available for low vision care and there were no orthoptists19. Both are essential for a
comprehensive pediatric ophthalmology subspecialty service.
Our response:
While we agree there were very limited LV services available, this was actually not a focus of this
short-term project. We actually could not focus on LV given the practical reality and the overall lack
of capacity of partner hospitals.
Evaluation Management Response
Recommendations Action Plan
(The following actions have been taken by Sightsavers, BCO from both the findings section and recommendation due to
their relevance)
Evaluation Recommendations
(A)
Accepted/
Rejected
(B)
Priori
ty
High/
Medi
um/
Low
(C)
If “Accepted”, Action plan for
Implementation or if “Rejected”,
Reason for Rejection
(D)
Responsi
bility
(E)
Timeline
(F)
Country
Director
2016/17
- 2018
Country
Director
2016/17
- 2019
Recommendations for Sightsavers
Accepted
1
2
High
Develop an integrated child eye health
approach in a pilot district that derives synergy
from on-going health initiatives and builds on
existing governance structures for health,
education and child rights
Extend administrative and technical support to Accepted
the Association of Pediatric Ophthalmologists
and Strabismologists, to establish a secretariat,
hold periodic national conferences and
symposia, and attend and participate in
international meetings of the American
Association for Pediatric Ophthalmology and
Strabismus
Advocate with NEC to take a lead in
this area.
Explore the possibilities of developing a
joint proposal with other INGOs
addressing eye care to avoid
duplication and better programming;
while keep a focus on designing new
child eye health project in context of the
WHO 6 building blocks (subject to
availability of funds) following situation
analysis and in alignment with social
inclusion & education project
High
Advocate with NEC to take a lead in
this area and coordinate with the INGO
Forum on eye care. Explore integrating
this in new project design if funding is
available and include scope of
participation in both national and
international conferences as well.
Evaluation Management Response
Evaluation Recommendations
(A)
3
Accepted/
Rejected
(B)
Priori
ty
High/
Medi
um/
Low
(C)
If “Accepted”, Action plan for
Implementation or if “Rejected”,
Reason for Rejection
(D)
Responsi
bility
(E)
Timeline
(F)
Accepted
High
Work with the DGHS’ ‘Little Doctor’
program to explore possibility of better
integrating eye health education
Country
Director
2015 2018
Foster networking between the Bangladesh
Association of Pediatric Ophthalmologists and
Strabismologists, Bangladesh Pediatric
Association and Bangladesh Society of
Neonatal and Pediatric Intensive Care to
identify joint areas for priority action
Accepted
Medi
um
Advocate with NEC & NIOH to take
lead in this, and coordinate with the
INGO Forum on eye care.
Country
Director
2015/16
- 2019
Appropriate human resources to deliver
pediatric ophthalmic services should be
developed according to an overarching
national strategy, being mindful of
accreditation, deployment and career
Accepted
High
Advocate with NEC to take a lead in
this area and coordinate with the INGO
Forum on eye care
Country
Director
2016 2019
Derive maximum synergy from the ‘Little
Doctors’ programme to obtain access to
universal child eye health promotion amongst
children and institutionalise vision screening by
children
Recommendations for National Eye Care of DGHS
1
2
Evaluation Management Response
Evaluation Recommendations
(A)
Accepted/
Rejected
(B)
Priori
ty
High/
Medi
um/
Low
(C)
If “Accepted”, Action plan for
Implementation or if “Rejected”,
Reason for Rejection
(D)
Responsi
bility
(E)
Timeline
(F)
Advocate with NEC to take a lead in
this area and coordinate with the INGO
Forum on eye care
Country
Director
2016 2019
development pathways, and feasibility for
institutionalising training programmes should
be kept foremost
3
4
5
Accepted
High
Accepted
High
Advocate with NEC to take a lead in
this area; and work with other INGO
Forum members.
Country
Director
2015 2019
Accepted
The governance structure and stewardship for
pediatric ophthalmology needs to be
strengthened, and one possible way might be
to set up Task Forces under the auspices of
NEC. These Task Forces, with membership
from the professional association of pediatric
ophthalmologists and strabismologists, national
High
Advocate with NEC to take a lead in
this area and coordinate with the INGO
Forum on eye care
Country
Director
2015 2019
Consideration needs to be given to developing
cadres to deliver low vision and orthoptic
services. This may require a national
consultation with other non-project
stakeholders to formulate a unified national
strategy for developing human resources in
these areas.
Define minimum standards of service delivery
of child eye health services for district health
care, and develop the capacities of district
ophthalmologists for improved refraction in
children
Evaluation Management Response
Evaluation Recommendations
(A)
and international NGOs and training
institutions, jointly formulate a coordination
mechanism, articulate minimum standards for
subspecialty services and develop a national
strategic plan for child eye health. Future
partnership support by NGOs and international
partners should be directed towards achieving
the various components of the strategic plan
for child eye health
Additional Actions (G):
Accepted/
Rejected
(B)
Priori
ty
High/
Medi
um/
Low
(C)
If “Accepted”, Action plan for
Implementation or if “Rejected”,
Reason for Rejection
(D)
Responsi
bility
(E)
Timeline
(F)