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

Action	Action 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 action	Action 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 action	Action 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 action	Action 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 action	Action 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 action	Action 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?