Avoid Blindness in people at risk of vision loss due to diabetes, by strengthening the health system
Long-term Outcome: Eye health services are integrated within diabetes management to offer comprehensive care for people at risk of vision loss due to diabetes
Pakistan is a populous country with the current estimated population to be over 180 million. The overall health status in Pakistan has improved since 1990 although at a much slower pace in relation to its neighbouring countries. Major social determinants of health such as poverty, gender inequality, low levels of literacy and lack of public service facilities are some of the contributing factors to disease burden and pose challenges to the health system. Pakistan continues to spend less on health than other countries at similar levels of economic development.
Addressing health care needs in a developing country like Pakistan is a multidimensional challenge with implications at different levels. The health system in Pakistan is characterised by a mixed system with a combination of public and private provision of services to the population. In such a scenario, presenting projects that have been tested for being comprehensive, integrated into existing systems and value for money to public and private partners provides opportunity for successful replication and scalability. In addition, countries like Pakistan need low cost technology solutions to increase coverage of services to remote parts of the country and closer to the communities. This will result in increased access to quality services for people.
According to a survey conducted in 2013 by the World Health Organisation (WHO), non-communicable diseases such as cardiovascular morbidity, diabetes, cancer and mental disorders are on the rise in addition to prevalence of blindness being nearly 1% in Pakistan. Disability from blindness profoundly affects poverty, education and overall quality of life.
During the General Assembly High-Level Meeting on Non-Communicable Diseases in 2014, Pakistan highlighted that the country had made strategic interventions in such areas as governance, infrastructure, generation of resources through taxes, and surveillance based on the WHO framework. It is evident that Pakistan’s health-care programmes have taken a cost-effective approach, emphasising on early detection and improved access to medicine and technology. This is being done through the primary health care (PHC) facilities and their network of grass-root level volunteers and Lady Health Workers and the People’s Primary Health Initiative. Pakistan is pursuing a comprehensive health plan in cooperation with the private sector which provides many opportunities for stakeholders to pilot innovative approaches to delivering comprehensive services for the prevention and early intervention of non-communicable diseases such as diabetes and blindness.
The last National Action Plan for Prevention and Control of Non-Communicable Disease and Health Promotion in Pakistan (2010) highlights that disease prevention and health promotion are the most effective interventions for solving Pakistan’s healthcare crisis. This very much applies to both diabetes and provision of eye care services.
Diabetes is an emerging global epidemic. According to the International Diabetes Federation (IDF) Diabetes Atlas 6th Edition, 2014 update, the prevalence of diabetes in Pakistan is about 6.8% in the adult population (22-79 years). It is estimated that above 6.9 million people in Pakistan have diabetes and that there are another 3.5 million undiagnosed people (aged 20-79) with diabetes. Diabetes accounted for 3% of total deaths in 2013. Diabetic retinopathy is the leading cause of blindness and visual impairment resulting from diabetes in adults. Diabetic retinopathy (DR) is a complication of diabetes that affects the blood vessels of the retina. It is amenable to timely and cost-effective treatment. Both younger and older-onset diabetic people are at risk of developing another sight-threatening manifestation of DR, namely macular oedema, a swelling of the central part of the retina.
Background
Since 2008, the FHF program in Pakistan has implemented a comprehensive eye care project that includes detection of diabetic retinopathy (DR) in persons known to have diabetes, and assessment and treatment of diabetic retinopathy within endocrinology units and specialised diabetic retinopathy eye care units. In adopting a comprehensive approach, the project provided support for workforce development, equipment and infrastructure, set up clinical data systems, initiated service delivery and also strengthened other components of the health system such as leadership and governance. Tertiary level care was established and enhanced across Pakistan at centres of excellence and teaching hospital eye units for detection and treatment of diabetes-related eye disease in the public and private sectors and linkages were established with endocrinology units. Detection of diabetic eye disease has been incorporated within routine care for the persons with diabetes and treatment is provided at the eye units. In parallel, the National Program for Eye Health provided equipment to treat DR at the district level, while FHF supported training of the district ophthalmologist to assess the need for and deliver laser photocoagulation. This combination of inputs ensures that a continuum of diagnosis and clinical management for diabetes and diabetes-related eye disease is available at facilities that provide secondary and tertiary level care.
Through interventions at project sites and lessons learnt from implementation, it is however evident that demand from patients for early detection of sight threatening retinopathy and its subsequent treatment is less than optimal, even though services are now made available at the district level. Further, it is clear that successful components of projects must be brought to scale if we are to be proactive in addressing the huge burden of undiagnosed diabetes and undetected diabetes-related eye disease in a community.
Hence, this proposed project has a strong focus on testing the effectiveness of various components along the care pathway, such as detection of diabetes-related eye disease at a community and primary health care facility level to optimize the problem of vision loss in defined populations of persons known to have diabetes, as well as the large group of still undiagnosed persons with diabetes. The other areas of focus include strengthening of mechanisms for referral and follow-up care, particularly at the primary health care level, where clearly gaps in both health promotion and in early detection remain. Together with available services at the secondary and tertiary levels of care, this will constitute a holistic model of care for provision of eye health services for people with diabetes as a part of diabetes management within the existing heath care system comprising of both public and private sectors in Pakistan. The project will compare mechanisms for public and private sector referral and follow-up care, comparative assessments of the applicability of low cost technology in addition to testing applicability of teleophthalmology for provision of integrated care to people with diabetes.
Through previously supported projects in Pakistan, FHF has learnt that to provide accessible and comprehensive diabetes management services that include early detection of complications, an effective approach is to target improving health awareness and access to services. Therefore it is imperative that underlying assumptions must be explored systematically through operational research embedded within a proposed program. We propose to deliver a program where eye health is integrated within a model of care for diabetes. The intention is to test effectiveness, efficiencies and sustainability of component programmatic interventions and low cost technologies for diagnostics, and assess the contribution of each, where possible, to strengthening some or all of the core pillars of the health system.
According to the International Diabetes Federation (IDF) Diabetes Atlas 6th Edition, 2014 update, the prevalence of diabetes in Pakistan is about 6.8% in the adult population (22-79 years). It is estimated that above 6.9 million people in Pakistan have diabetes and that there are another 3.5 million undiagnosed people (aged 20-79) with diabetes. Diabetes accounted for 3% of total deaths in 2013. Diabetic retinopathy is the leading cause of blindness and visual impairment resulting from diabetes in adults. Diabetic retinopathy (DR) is a complication of diabetes that affects the blood vessels of the retina. By 2030, at least 1.8 million people in Pakistan will be afflicted by sight threatening diabetic retinopathy, which is about the same as the 1.7 million in 2014 who are blind from all causes.
Situational Analysis:
Care for diabetes-related eye disease is available at tertiary level across Pakistan at centres of excellence and teaching hospital eye units for detection and treatment in the public and private sectors however these are inaccessible and costly for many people living in districts.
Although the National Program for Eye Health provided equipment to treat DR at the district level and FHF supported training of the district ophthalmologist to assess the need for and deliver laser photocoagulation, there are no referral mechanisms from primary level and subsequently to the tertiary facilities for specialised care.
Through previous FHF projects, it is evident that demand from patients for early detection of sight threatening retinopathy and its subsequent treatment is less than optimal, even though services are now made available at the district level.
Eye care is currently not integrated into routine care for people with diabetes who attend public endocrinology clinics located within each district or in the private sector facilities.
There is no health education or awareness raising about diabetes and its potential effects on the eye at the community nor the primary health facility level.
Lady Health Workers (LHWs) who are the first point of contact to the health system for urban poor and rural households are not trained to provide any diabetes relevant health promotion or conduct a risk assessment.
Although testing for diabetes is mandated in the public health system, detection of diabetes (and diabetes-related eye disease) does not occur routinely at the Basic Health Unit facilities.
There is limited evidence on the effectiveness of various approaches to manage DR in a holistic manner from community to tertiary level in the Pakistan context.
Main Problems:
High rates of diabetes and undiagnosed diabetes in Pakistan.
Limited evidence on the current knowledge, attitudes and practices of people in the community, and health care workers, towards diabetes mellitus and diabetic retinopathy.
Eye care services are currently not available, accessible, and affordable for people at risk of vision loss due to diabetes, or integrated into routine care at the community or Basic Health Unit level resulting in vision loss that is avoidable.
Where eye care services are available for people at risk of vision loss due to diabetes, there are no referral pathways.
