Integration of Refractive Services Provided by Optometrists into the Portuguese National Health Service

Introduction: Refractive error is a public health concern and even with relatively simple and cost-effective interventions it remains usually outside national health services (NHSs) not ensuring universal health coverage. This study aimed to generate evidence about the availability and accessibility of refractive services in Portugal and to present a plan for more efficient services. Methods: A situation analysis of the Portuguese existing refractive services within the NHS was conducted based on three health systems building blocks: service delivery access, service coverage, and workforce. A strengths, weaknesses, opportunities, and threats analysis was performed based on existent evidence to identify internal and external factors that can facilitate or hinder the integration of refractive services within the NHS. The number of eye care personnel to be integrated in the NHS was calculated considering the minimum ratios recommended by national and international technical reports. Results: Portugal has no specific services to address refractive errors within the NHS. Treatment of refractive error occurs at the level of eye care general services. There are 39 NHS eye care services, all hospital-centred and divided into three large groups, according to technical differentiation, the technology required, and workforce capacity. The workforce available is composed of ophthalmologists and orthoptists, together with nurses and other general paramedical assistants. 3 Portuguese municipalities have more than 1 NHS eye care service, 35 have 1 NHS eye care service, and 240 municipalities (in the mainland) have none. In 2021, 52% of the hospitals providing eye care services did not meet the recommended response times. Centralization of eye care services in urban areas, undifferentiated referral systems, and a shortage in the workforce per inhabitant was observed. Conclusions: Portuguese NHS has all the requirements to reorientate refractive care from the current hospital-based model to primary care. The country also has a trained and qualified workforce to address this condition. Evidence demonstrates that the provision of refractive services at primary care is efficient and effective and translates into an opportunity to identify other visual conditions.