Lesson 6: Introducing the Zrenya case study

In this step we introduce the Zrenya hypothetical case study, focusing on a
the fictional location that shares many of the common challenges faced by low and middle income countries.

Using the case study is optional, as you could instead use your own work setting. However, if you aren’t currently working in eye care, or are not sure that your local setting is appropriate, you may wish to use the case study instead.

We have provided a broad, descriptive framework for the case study. We recommend that you use it to apply and reflect on your learning from each week. It may provide the foundation from which to draw a parallel to your experiences or to learn from others in the forums. At key points throughout the course we’ll refer back to the case study in case you decide to use it.

The country
20 million inhabitants:
12% are over the age of 50 years
40% are 15 years and below
Sex ratio 0.98 males:females
Life expectancy at birth is 65 years
Density of 100 persons per km2
Birth rate: 28 births/1000 population
Infant mortality: 67 deaths / 1000 live births
Literacy: defined as 15 and above that can read and write – 51%.

40% of the population lives in cities
40% of the population lives below the poverty line
30% of the working age population is unemployed.

Mainly an agricultural economy with subsistence farming. A recent development has been to introduce large scale farming to grow green beans and bananas for export.

Health care
The Ministry of Health (MoH) is involved in strategic planning at a national level and in monitoring budgets and policies. However, health budget allocation and decision making has been devolved to district level
The MoH coordinates all human resource training and assignment for health services in the country. There is no government health insurance scheme.

National prevention of blindness committee has signed up to the VISION 2020 initiative and also has developed a national programme. There is a residency training programme for 4 ophthalmologists annually at the National University Hospital. There is no school of optometry in the country. There is a 4-year optometry training programme in a neighbouring country. There is ophthalmic nursing training within the national nursing school.

Zrenya district
Zrenya has a population of 1.2 million with similar indicators to the whole country.

Health facilities in the district: One general 25-bed secondary level hospital in the main town. Services provided at the hospital
include outpatients, obstetrics and gynaecology, surgical and medical departments. The eye unit is also based at the district hospital as part of the surgical department.

Eyecare in Zrenya: There is one government-funded 10-bed eye unit in the main district hospital. There are 3 smaller government hospitals with no eye-specific services 2 ophthalmologist and 3 ophthalmic nurses (one is trained in theatre practice).

Cataract surgical output is 500 surgeries per year. One private optometry practitioner (trained externally) is based in the main town who refracts and
dispenses spectacles. Spectacles have to be purchased and no subsidy scheme is available.

A non-governmental organisation (NGO) is involved in the community, working to support government services. It is independently funded and managed.

Epidemiological data on visual impairment

Prevalence of moderate/severe visual impairment (MVI/SVI <6/18 – 3/60) in Zrenya estimated at 5% = 60,000 people.

Prevalence of blindness (<3/60) 0.9% = 10,800.

Main causes of blindness: cataract (50%), trachoma (10%), childhood blindness (3%), glaucoma (14%), diabetic retinopathy (3%), corneal scar (non-trachoma) (5%), others (15%)

Main causes of MVI/SVI : cataract (30%); uncorrected refractive error (40%).
MVI = Moderate visual impairment
SVI = Severe visual impairment.

Eye unit activities

Output is 500 surgeries per year.


10 eye beds, shared hospital theatre, available 2 days a week for eye procedures.

4 complete cataract sets.

Irregular supply of consumables, mainly because the order is not processed on time and funding is erratic.

1 fixed and 1 portable slit-lamp, a direct and indirect ophthalmoscope, retinoscope and a complete refraction set.

Standard power intraocular lenses (IOLs) are used. Biometry for IOL facilities is not available.


3 outreach activities per year, which involves screening and operating in a rural setting. Hospital ambulances are available for use to travel to outreach.


Salaries are paid and consumables provided by the MoH, but not IOLs, which are purchased externally.

Patients pay a fee of $2 per hospital visit and have to buy their own medications.

Cataract surgery is free but the IOL and medicines cost $50.


An ophthalmologist is in charge of Zrenya eye care and sends annual reports to the MoH and the district medical officer.