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Planning DR services: Where to begin?

It is only after a situation analysis that a realistic and practical development DR programme suited to the local health system can be started.
If you look at the situation in India, there is no organized or systematic program to look at the complications in diabetes, specifically in relation to the eye complications in diabetes. And people come to a clinic, an eye clinic, and when they come in, they get examined more like an opportunistic screening. The other important thing is that the government of India, the Ministry of Health, has initiated a non-communicable diseases program at the national level. But at the moment, complications of the eye in diabetes is not included in this program.
And therefore, we needed to undertake a situational analysis to look at the gaps that exist and to try and set up a systematic screening program for diabetic eye disease and retinopathy in India. It was a considerable undertaking where we picked random people with diabetes and providers of diabetic services. And what we did was conduct 859 interviews, which included 195 service providers, 664 persons with diabetes spread across 11 cities in India, being the most populated cities across the country. The skills of people who provided these services, the available equipment, and the infrastructure that was available to provide services for diabetic eye disease and retinopathy were targeted as part of this endeavor.
We also looked at the persons with diabetes, we look at what their perceptions about complications of diabetes were, where they went for their treatment, did they comply with the treatment guidelines, and how frequently did they come to get their examinations for the eyes done. When we look at the gaps, we could look at the patient level gaps, as well as the provider level gaps, because we needed to develop a program based upon the findings of the situational analysis. When we look at the patient level, we found that 75% of people with diabetes were aware that diabetes can have an effect on the eyes. But 45%, when they first came to an eye clinic, were already visually impaired.
So they had lost a significant proportion of their vision when they actually came to an eye clinic. We also found that the clients are most concerned about blindness and vision impairment amongst all the complications of diabetes. But despite that, they did not come to an eye care provider. When you look at the provider’s site, we found that 75% of the diabetic clinics, they did not have a vision chart to examine the vision. And only 20% of the physicians actually examined the fundus of a person with diabetes when they actually come to them for treatment. And therefore, this was a critical finding.
We also found that the equipment that was available, the infrastructure, and the skills for screening and managing diabetic retinopathy, there were big gaps there. And therefore, the situational analysis helped us to develop a plan to address these gaps and run a program in the country. The primary goal was to reduce avoidable blindness and vision impairment due to diabetic retinopathy in India. To look at this particular goal, we identified some objectives. The primary objective was to look at developing an integrated model of care for diabetes and its complications, specifically the eye complications, and to look at embedding this in the government health system.
This is because the government health system is the only one which can provide services in the rural and remote areas reaches the poor and the disadvantaged populations. And therefore, we looked at that as a critical primary objective. Another objective was to see that we build the capacity of the eye care teams, which includes the ophthalmologist, the ophthalmic assistants and technicians, nursing staff in the non-communicable disease clinics, general physicians who treat diabetes, and also empower persons with diabetes to be able to manage their diabetes, along with the carers of persons with diabetes who can assist them in managing the diabetic state.
We looked at preventing sight-threatening diabetic retinopathy through these interventions and building capacity at different levels to try and see that we could reduce the rates of sight-threatening diabetic retinopathy. So these were the major objectives. There were a number of other secondary objectives, but these were the critical objectives that we had in mind.

Planning in healthcare is a process that starts by establishing a clear picture (the baseline) of the existing situation. That is, the magnitude of the need and the available resources to address that need (human and infrastructure resources). It is only after this situation analysis that a realistic and practical development programme suited to the local health system can be started.

Diabetes and diabetic retinopathy in India

“India is the diabetes capital of the world!” was the title of a recent Times of India article. Looking beyond the alarmist headlines, we know that one in five of the 382 million people living with diabetes are in India and that the prevalence of diabetes in some parts of urban India is as high as 20% in people aged over 20 years (Murthy et al. 2016). And, as we learned in week one, diabetic retinopathy (DR) complications affect 18–34% of people with diabetes.

The increasing diabetes prevalence and longer lives of people with diabetes mean that the Indian health system faces a major challenge in managing an exponentially increasing risk of sight threatening complications amongst people with diabetes.

Based on this epidemiological evidence:

  • What do you think needs to be done to manage the growing challenge of diabetes in India?
  • Should existing initiatives by non-governmental organisations (NGO) be strengthened to deliver diabetic retinopathy services?
  • How best can the existing health system infrastructure be strengthened for sustainable detection and treatment of sight threatening diabetic retinopathy?

In the video on this step, Professor GVS Murthy from the Public Health Foundation of India describes a large and comprehensive situation analysis carried out to assess the need for and resources available to deliver diabetes and diabetic retinopathy services in India. The study’s findings are being used to inform a comprehensive and integrated district model of screening and management of DR in the government health system.

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Diabetic Eye Disease: Building Capacity To Prevent Blindness

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