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Planning services in low resource settings

In this interview with Dr Mathenge, we discuss the challenges faced in Africa and the approaches that can be used to address them.
Daksha Patel: So Ciku could you highlight what is a typical pathway that a person with diabetes navigates in a low resource centre.
Wanjiku Mathenge: I don’t think there is a typical pathway. I think I would describe it as a series of Ds. As soon as a patient gets this diagnosis, it sounds like doom and death to them, and it takes a long time for them to accept that they have diabetes. And after they come to that realisation and acceptance, they then have to start taking new medications– the second D is drugs. And it’s hard to access the drugs– some of them may not be available at the nearest pharmacy, and where they are available, they may not be affordable. And with a diagnosis also comes a new diet, the third D.
And this diet that is recommended for people living with diabetes is usually more expensive than the normal food that the family eats, and this has budgetary implications for the family. It has logistical implications. Do they prepare two meals every time? And this can be very difficult for the patients to navigate through. And finally, they’re told that you have to see a lot of doctors, because it’s not just diabetes. There’s the complications of diabetes, and they’re told you have to see a foot doctor, a heart doctor, a kidney doctor, an eye doctor. So much as ophthalmologists, we want the eye checkup to be up there.
It’s really very low on the list of the Ds that this patient has to navigate through.
Daksha : At a health system level, what are the major concerns when it comes to the treatment of diabetic retinopathy?
Wanjiku: At the health system level, there are many challenges. So the first one is just the people to deal with the disease. There is a shortage of practitioners who can deal with diabetic retinopathy. We may have ophthalmologists, but they may not have the skills that they need to provide the treatments. But I don’t think there’s anywhere where there is enough ophthalmologists. We need to get in more retinal specialists, and we need to put in more skills at the training level to get every new ophthalmologist coming out with some skills.
In terms of the stuff that’s needed to treat the patients, the lasers, the diagnostic equipment, the OCTs, the cameras, all this costs a lot of money, and it’s very difficult for a hospital to accept to buy a piece of equipment that’s just for the eyes that costs so much. And something like an OCT, which is becoming an integral part of the care for DR is really expensive.
Then the financing. So the cost of all this treatments, whether it is the procedures for diagnoses or the medicines that the patient needs, the laser procedures, all that cost a lot. It costs a lot for the hospital to procure and stock up with those consumables, and that cost is passed on to the patient. But the other thing is just the massive number of specialists that are needed to take care of the patient, whether it’s the retinal specialist, whether it’s the other comorbidities, because a lot of times when patients come to me, for example, with diabetic retinopathy, their sugars are out of control, their renal function is bad.
And this has major implications on a hospital having those specialists all available in one place. So those are some of the challenges that the health system is experiencing. Everybody is struggling to get the right model for their environment and for their patients to do diabetic retinopathy, and there are several models out there that are being tried out. One of the simplest things to try is just to link up with the diabetes clinic where your eye clinic is located. And that’s usually where people start, and amazingly, even that has not been modeled in an efficient way.
So just getting the diabetologist just within your facility to send the eye patients, how that flows, what happens once you find they have disease, that’s one of the models that people are working on. Another model that I have seen in Kenya is where there’s a mobile van that’s equipped with lasers and sterile facilities for giving injection that’s driven to where people with diabetes have gathered together, probably screened by a local ophthalmologist and the specialists will then go there and provide all the treatments. And I think this model is working well because they get access to a highly specialised ophthalmologist and all treatments are done in one location. How often this can be done, again, is a challenge.
One of the models we are trying in Rwanda is where we go to the natural hub for people with diabetes, so the Diabetes Association in our situation, and we go there once a month, and we just screen everybody who presents there. And because it’s an ophthalmologist going down there, we go with all the equipment, we make a diagnosis on the spot, and we advise on what treatment is needed. We are not able to provide the treatment at their association clinic, but we provide transport for the patients to then come back to our hospital and access the treatment.
Besides the treatment models, there are other things people are trying, so we are running through the College of Ophthalmology of East Africa a short skills course where existing ophthalmologists come for one week to Rwanda, and in that week, we train them on how to give injections, how to do laser, how to do a good indirect examination, and it makes it possible for them to then go and give those basic treatments when they get home. We are also trying to integrate CPD so that ophthalmologists provide CPD for general practitioners. And during those sessions, educate them on what are the referral protocols that exist out there.
All these different things we’re doing to try and make sure that the person with diabetes is getting the right care at the right time. But I don’t think there’s one model that fits and works everywhere.
Daksha: As a key decision maker in a low resource setting, what are the priorities for establishing services to prevent blindness from diabetes in the next decade?
Wanjiku: I think if we are to win this battle against diabetic retinopathy, we need to prioritise several things, and the first one has to be at the patient end of things. We need to educate the people living with diabetes to be aware that the eyes are part of the complications that they will have to deal with. And just the culture of regular eye checkups is something that needs to be ingrained into them. We need to educate their carers, their diabetologists, their general practitioners so that they too are encouraging the patients to come for regular eye checkups.
As you know, if we get them early, we can stop all those blinding stages, which are the ones that cost a lot of money. So I think education will be really important. And that’s one end. On the other hand, we need to have the service centres that can provide the care that they need. There’s no need of us educating them and raising awareness if there is no one to provide service at the other end. So we do need to have, like I said, at least one facility in each country that can provide specialised care at all levels of diabetic retinopathy, from the laser, all the way to VR surgery.
And the tricky part will be now how you link those two ends, and I think everybody’s still trying to get those models. But I would prioritise those two things.
Daksha: Thank you very much.

A programme to manage diabetic retinopathy (DR) should include the following:

  • A good understanding of the current and projected prevalence of DR, to make it possible to plan services for prevention, screening, and treatment
  • Clinical guidelines with a simple classification system, recommended examination intervals, and suggestions for treatment
  • A way of finding patients with diabetes and DR
  • Retinal examination methods that take into account available equipment and human resources
  • Creation or identification of laser treatment centres for timely treatment
  • An education and prevention programme that reaches the whole population
  • Advocacy to secure the support of the authorities, educators, general practitioners, endocrinologists, and so on.

Long-term sustainability, using cost recovery or subsidies

One of the challenges in managing DR is that it requires partnerships with many different health care workers – both to find people with diabetes and to provide the eye care they need. DR programmes have to forge alliances with physicians, podiatrists, dieticians, pharmacists and all the other health workers and policy makers involved in the care of patients with diabetes. to encourage their patients to have annual eye examinations. DR programmes must return the favour by encouraging their patients to maintain good control of their diabetes and blood pressure and by reaching out to other health workers. It is by building and maintaining networks and alliances amongst health care professionals that we can prevent blindness from DR.

There is no single solution to DR that can be applied to every community worldwide. The best results will be achieved by developing programmes at district level that take into account local conditions and resources.

There is one single message: Diabetes and diabetic eye disease are everybody’s business. We must not leave it just to the specialists, in diabetes or in retinal disease. In future, every single health worker will have to contribute to preventing, detecting, and managing diabetes and its complications, including diabetic retinopathy.

Excerpt adapted from Hall, A. (2011). Recognising and managing diabetic retinopathy Comm Eye Health, 24(75), 05 – 09

In this interview with Dr Mathenge, we discuss the challenges faced in Africa and the approaches that can be used to address them. Health providers need to work actively to strengthen local diabetic eye care services. As you watch this video consider your view on Dr Mathenge’s vision of having at least one centre of excellence in every low resourced country to manage the complex treatment of DR?

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Diabetic Eye Disease: Building Capacity To Prevent Blindness

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