The six health system blocks: Governance, health financing, health personnel, medicines & technology, information systems, service delivery

Ormo case study: Assessing the health system

In this step, we see how the toolkit has been used to analyse the current situation for diabetic eye diseases in Ormo across the six interconnected health systems blocks - service delivery, human resources, technology, health information management systems, leadership and governance.

Activities in each block have been considered in three key areas:

  • Within the district health centres
  • Across the wider diabetic services
  • In the eye clinic.

All the key stakeholders in Ormo were involved in discussing and providing information. The brief answers they provided are outlined in the tables below. You can also download this as a PDF.

Service delivery

ActionAction in Ormo
Education about diabetes and the eye Health centres: Yes
Diabetic clinics: Yes
Eye clinics: No
Education about managing diabetes Health centres: No
Diabetic clinics: Yes
Eye clinics: Not actively
Screening for diabetes Health centres: Yes, in all health centres
Diabetic clinics: Yes
Eye clinics: Yes - only for high risk cases
Diagnosis of sight threatening diabetic retinopathy Health centres: Retinal imaging in two health centres
Diabetic clinics: No - symptomatic cases referred to eye clinic
Eye clinics: Opportunistic. Long waiting time - over 8 weeks for an appointment.
Treatment for sight threatening diabetic retinopathy
Options: Laser treatment, antiVEGF injections, vitreoretinal (VR) surgery
District health centres: Only referral
Diabetic clinics: Only referral
Eye clinics: Yes - lasers and antiVEGF. VR surgery - referred to national level

Human resources

Type of actionAction in Ormo
Category of health professional available to care for people with diabetes District health centres: Primary health workers, nurses
Diabetic clinics: Nurses, endocrinologists, physicians
Eye clinics: Ophthalmologists, nurses, ophthalmic clinical officers (OCOs)
Trained to educate people with diabetes about eye complications District health centres: No except in two health centres
Diabetic clinics: Inadequate
Eye clinics: Yes
Trained to undertake diabetic retinopathy screening/grading District health centres: Nurse screener/grader in two health centres
Diabetic clinics: None
Eye clinics: Opportunistic screening by ophthalmologists
Continuing training opportunities for diabetic retinopathy screening District health centres: Largely not available
Diabetic clinics: None
Eye clinics: Through external non-governmental organisation (NGO) partner.

Technology

Type of actionAction in Ormo
Biomedical tests
Options: HbA1C, Blood glucose, Blood pressure
District health centres: Blood glucose, Blood pressure
Diabetic clinics: Available – Blood glucose and HbA1C. Blood pressure
Eye clinics: Available – Blood glucose and HbA1C
Ophthalmic/retinal examination
Options: Slitlamp, Direct ophthalmoscope, Retinal imaging
District health centres: Retinal imaging in 2 centres
Diabetic clinics: None
Eye clinics: Slitlamp, Direct ophthalmoscope, Retinal imaging
Treatment
Options: Laser treatment, AntiVEGF injections, VR surgery
In district health centres: None
In diabetic clinics: None
In eye clinics: 2 lasers, Anti-VEGF (sometimes), VR only in capital city

Health information management systems

Type of actionAction in Ormo
Database of people with diabetes
Options: Name, Paper, Electronic
District health centres: Paper form in 2 health centres
Diabetic clinics: Paper
Eye clinics: Paper
Information recorded in databases
Options: Risk factors, Eye examinations, Level of DR, Follow up
District health centres: Level of DR in 2 health centres
Diabetic clinics: Risk factors, Follow up
Eye clinics: Risk factors, Eye examinations, Level of DR, Follow up
Available call and recall
Options: None, Systematic, Ad hoc mHealth messaging
District health centres: None
Diabetic clinics: None
Eye clinics: None
Statistics collected and monitored
Options: Numbers screened, Number referred to eye clinic, Numbers treated for STDR, Numbers not returning
District health centres: Numbers screened, Number referred to eye clinic
Diabetic clinics: Number referred to eye clinic
Eye clinics: Numbers screened, Number referred to eye clinic, Numbers treated for STDR
Nationally agreed indicators
Options: None, Number of STDR cases referred, Number of patients recalled for screening at regular intervals
District health centres: None
Diabetic clinics: None
Eye clinics: None
Communications methods with patients
Options: Personal record books, Information cards, mHealth: text messaging reminders using mobile phones
District health centres: Personal record books
Diabetic clinics: Personal record books
Eye clinics: Personal record books

Leadership and governance

Type of actionAction in Ormo
Main stakeholders in diabetes and DR services
Options: Government, INGO
District health centres: Government, INGO
Diabetic clinics: Government
Eye clinics: Government, INGO
Leadership for DR services
Options: Yes, no, clinical lead
District health centres: No
Diabetic clinics: No
Eye clinics: Clinician lead
Diabetes
Options: As a priority, Has a national plan, Programme with coverage
District health centres: As a priority
Diabetic clinics: As a priority
Eye clinics: As a priority
Guidelines for DR management
Options: None, Formulated but not used , Available and followed occasionally, Available and fully implemented
District health centres: Available and followed occasionally
Diabetic clinics: Available and followed occasionally
Eye clinics: Available and followed occasionally

Finances

Type of actionAction in Ormo
DR screening District health centres: 100% INGO funded in 2 health centres
Diabetic clinics: -
Eye clinics: 80% out of pocket for patient. 20% Government subsidy
Laser treatment District health centres: -
Diabetic clinics: -
Eye clinics: 80% out of pocket for patient. 20% Government subsidy
AntiVEGF District health centres: -
Diabetic clinics: -
Eye clinics: 80% out of pocket for patient. 20% Government subsidy
Eye clinics = Public and private clinics
INGO = International non-governmental organisation

A situation analysis also includes detailed discussions of the health system’s performance and an analysis of the implementation of health sector activities, budgets and finances. This supporting dialogue bring expert views and end user/community opinions together.

Once a situation analysis has been carried out, what else (other than plan the next steps) can be done with this information?

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This article is from the free online course:

Diabetic Eye Disease: Building Capacity To Prevent Blindness

London School of Hygiene & Tropical Medicine