Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

The eye care workforce and task sharing

Too few eye-care workers, unevenly distributed, is a central reason why avoidable blindness persists, especially in rural areas [S8] [S10]. WHO names both task shifting and more human resources for eye health as tools to improve access [S8]. Task shifting works when it comes with training, supervision, clear roles and a supportive policy environment [S3] [S5] [S11].

Key points - Sierra Leone had only 6 ophthalmologists for the whole country, while 91.5% of its blindness was estimated to be avoidable [S3]. - In a randomised non-inferiority trial, nurse-administered intravitreal injections gave visual outcomes non-inferior to physician injections at one year [S2]. - Trained non-ophthalmologists and general physicians using portable cameras showed good agreement with reference standards for diabetic retinopathy screening [S9]. - Enhanced, skills-based supervision improved primary eye care knowledge and vision-testing skills compared with routine supervision [S1]. - Incentives, financial and non-financial, help start task shifting and improve rural recruitment and retention, particularly of mid-level eye-care professionals [S8].

Evidence last checked: 2026-10-18 (PubMed abstracts).

Red flags: signs that need urgent action

• A new cadre without a post: in Sierra Leone, unimplemented policy left ophthalmic community health officers posted at the wrong level, dissatisfied with certification and without career paths [S3].
• High staff attrition: 24% of Tanzanian primary health workers were lost within a year, 44% among clinical officers [S1].
• Task shifting without referral capacity: a community health worker programme in India tripled referrals but did not detectably reduce corneal ulcers [S4].
• No competency framework or incentives for community workers [S11].
• Uneven workforce distribution and inadequate funding in national frameworks [S10].

Recognise it: workforce gaps and cadres

• Rural and underserved areas have the greatest burden of blindness and the least access [S8].
• Restricted scope of practice: in Kenya only optometrists, ophthalmologists and ophthalmic clinical officers may refract [S7].
• Cadres used for task sharing include ophthalmic community health officers [S3], nurses [S2], community and allied health workers [S11], community cadres [S6], community health workers [S4] and primary health workers [S1].
• Tasks shifted successfully include health education, visual acuity screening, portable fundus photography, referral navigation and digital data management [S11].

Confirm it: is task shifting working?

• Measure outcomes, not only activity: nurse injections were tested against a three-letter non-inferiority margin, with 2077 injections and 3 ocular adverse events recorded [S2].
• Measure skills directly, for example the ability to describe and demonstrate vision testing [S1].
• Track the downstream effect: referrals rose (incidence rate ratio 3.57) without a detectable change in corneal ulcer incidence [S4].
• Track uptake: cadres motivated people to attend diabetic eye screening, with examination rates about six times higher than before [S6].

Manage it: building the workforce at each resource tier

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Tier A (community and primary care)

• Train community health workers and primary care staff in health education, vision testing and referral [S6] [S10] [S11].
• Recruit community workers from the communities they serve; cultural familiarity helped overcome distrust, mobility and language barriers [S11].
• Use job aids and supportive supervision [S5].

Tier B (district eye unit)

• Supervise primary workers with skills-based methods rather than routine visits [S1].
• Use mid-level and allied staff for screening and imaging under supervision [S9] [S11].
• Link non-eye health workers to optometrists by telemedicine for refraction, as proposed by Kenyan opinion leaders [S7].

Tier C (specialist centre and national planners)

• Delegate high-volume procedures where evidence supports it; task shifting injections to nurses can relieve the burden on ophthalmology departments [S2].
• Create posts, career paths and certification before training a new cadre [S3].
• Use in-service training, on-site clinical supervision and mentoring, periodic supportive supervision, job aids and pre-service education [S5].
• Combine task shifting with recruitment and retention incentives tailored to local motivation [S8].
• Include human resources among national strategic pillars; Indian experts reached consensus on task shifting, quality indicators and better referral systems [S12].

Refer when

Pitfalls

• Training a cadre without policy, posts or advancement [S3].
• Expecting referrals alone to change disease outcomes [S4].
• Neglecting supervision and retention [S1] [S8].
• Assuming results from high-income settings transfer directly; the nurse injection trial was in Norway [S2].
• Leaving community workers without digital tools or integrated referral systems [S11].

Evidence notes

• Thin evidence: only two randomised trials on task shifting itself [S2] [S4], one from a high-income setting; most sources are reviews, qualitative work or expert opinion.
• The search returned no global workforce density data, so numbers of ophthalmologists or optometrists per population are not given.
• Task shifting of cataract or trichiasis surgery is not covered by these sources.
• Not covered by these sources: workforce ratios and targets, training curricula and licensing.

Related articles

• Integrating eye care into primary health care
• Global eye health: blindness and vision impairment

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.