A mixed methods approach was used to produce the ECCF, combining both data from existing resources and stakeholder consultations. Maximum efforts were made to ensure that viewpoints and perspectives from a variety of frameworks, occupational groups, and people from around the world were included in the development process of the ECCF because it is intended to be a tool that is universally applicable for the eye care workforce globally. The diverse viewpoints gained from the collaborative approach, further directed the development of the guiding principles, which serve to define the values and tenets of the framework. It is envisaged that these principles will be extended into the workforce where the ECCF is being implemented.
A popular method used to guide national workforce planning and development is to base workforce targets on worker-to-population ratios to calculate the number of eye care workers required per million population. (14–16) Planners can use this number to determine the workforce requirements by comparing how many eye care workers exist to how many are required. Whilst popular, the approach has limitations as it does not take into account factors such as the location and distribution of the current workforce, the population structure, disease epidemiology and the public demand, service regulations and importantly, quality standards. (6, 7, 17) Although competency frameworks do not directly calculate workforce targets, their strengths lie in emphasizing the quality of care and scope of practice required to address the eye care needs in the population.
Despite the fact the eye care sector is relatively mature in many countries, the adoption of competency frameworks is still novel. The use of the ECCF can be particularly beneficial in settings where the eye care workforce is still emerging or in instances where there is a labour supply shortage, and tasks need to be distributed efficiently and effectively to optimise access to care. (10, 15) This aspect was taken into account when developing the ECCF, whose key components encompassed the behaviours and tasks expressed over four levels of proficiencies. The TWG was instrumental in guiding and determining how the behaviours and tasks were described across the four levels of proficiency, to capture the scope of performance represented in the eye care workforce. The knowledge and skills included were not exhaustive, but rather a sample suggestive list for users of the ECCF to consider and further expand in their own contexts.
Although the Delphi technique was altered for this study, its underlying concepts and numerous consensus approaches remained the same. Anonymity, iteration, regulated feedback, statistical group response, and structured engagement are some of these foundational principles. The online survey approach assisted the removal of the inherent bias like dominance and group conformity (described as groupthink) noticed with face-to-face group meetings, despite the modified-Delphi study not being strictly anonymous.(19, 20)
The pilot process was valuable for testing the ECCF in a practical environment. Each site’s pilot experience was different, and each site applied the ECCF differently. The common result of each site identifying gaps within the current workforce documentation can be attributed to the comprehensive nature of the ECCF, which has been limited in previous workforce planning tools within eye care. The pilot highlighted the need for a guidance paper to make it easier for users to adapt and apply the ECCF in their settings by demonstrating how essential it is for the ECCF to be contextualised and tailored so that it is relevant to each setting. It was recommended that the learnings from the pilot process be converted to case studies, as it would be beneficial to show potential users on how they could apply the ECCF in their setting. A further recommendation would be to include these case studies within the guidance document that also shows users, a step-by-step process on how to adopt and adapt the ECCF for their individual settings. In addition, the pilot process gave a better understanding on how the ECCF can be used in addition to other existing approaches in workforce planning and development. It showed that the ECCF can be used successfully as a reference tool to not only improve workforce quality, but also to highlight the various competencies and activities required to provide high quality comprehensive eye care services that can be better integrated into the health system.
The development of the ECCF aims to facilitate eye care workforce planning and development by providing a comprehensive set of competencies and activities that encompass the diverse roles represented by eye care workers. This paper complements already published ECCF materials (6, 13) by presenting the thoroughness of the development process, and rationale for an accompanying guidance document. Given the lack of eye care workforce tools particularly for low-middle income resource settings and multi-disciplinary services (3), the ECCF can be a useful reference tool to assist in identifying gaps in current education programmes, workforce planning documentation, and frameworks used to describe the competencies for an occupational group within eye care. For the ECCF to be implemented successfully, a variety of stakeholders, including governments, the WHO, non-governmental organisations, and the private sector, will need to work together to invest in eye care workforce development, while also establishing stronger links between eye care education programmes, service providers, and regulatory bodies.
Limitations
Users of the ECCF should consider two key limitations when applying the framework. Firstly, an extensive range of eye care professionals from a variety of nations, including both high- and low-income settings, were represented among the study's stakeholders and participants. Despite this, there were still only small number of participants representing the East Mediterranean region throughout the modified-Delphi study which may result in some components of the framework irrelevant to the workforce in this region. Secondly, although the ECCF is targeted at both government and non-government institutions, a government setting was not selected for the pilot, as it would have been challenging to implement within the project timeframe. Given this limitation, it might be more difficult to understand how the framework can be applied in a government setting.