Lesson 13: Planning to strengthen DR

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In this step you begin to use a toolkit to take a practical approach to the 3 key steps of planning district-level diabetic retinopathy (DR) service:

  • Step 1. Undertake a detailed situation analysis to provide a clear understanding of the need, the available resources and present service provision.
  • Step 2. Establish key priorities for action and a strategy to accomplish them. What is feasible to change or improve and how it can be done?
  • Step 3. Monitoring implementation of the planned action.

Planning DR services in Ormo district

The toolkit uses our hypothetical case study of Ormo as its reference. You can also download a template of the tool kit and use it for your own setting.
What we know already about diabetes and DR services in Ormo Strengths.

  • An active strategy is in place for non-communicable diseases (NCDs)
  • The Ministry of Health leadership is interested in addressing diabetes management through healthy diet education, free insulin and metformin (medicine to reduce blood sugar levels).
  • An international non-governmental organisation (INGO) is working in partnership with health providers to develop DR services
  • Ormo tertiary hospital has some imaging and treatment facilities
  • 2 district hospitals with screener/graders and referral to the tertiary hospital.
  • The diabetes clinic is within the same premises as the eye unit.


  • Only a weekly retina clinic and there is no dedicated DR management clinic.
  • An 8-week waiting list to attend the eye clinic.
  • No active detection of DR is taking place at the tertiary hospital and only symptomatic patients are referred.
  • Most patients arrive with sight-threatening DR
  • Blood sugar testing has a fee as well as treatment for DR.
  • There is no dedicated educational programme for diabetes.


  • Support for nurse-led diabetes education.
  • Strengthen collaboration between the eye unit and the diabetes clinic and improve the referral scheme.
  • Strengthen treatment by increasing number of retina clinics per week.

To make a difference, planning must identify and involve all the key stakeholders in the health system. In Ormo, the stakeholders are the Ministry of Health, the local consultant ophthalmologists, the local endocrinologist, the public health expert for Ormo, the INGO working in partnership with the tertiary hospital and representatives from the local health centre and diabetes society.

Step 1: Situation analysis
The purpose of a situation analysis is to provide an evidence-informed basis for:

  • Responding to the health needs and expectations of the population
  • Formulating future strategic directions.

Using a tool kit to document a situation analysis provides a basis for participatory and inclusive dialogue and an analytical framework to examine the impact of past decisions and keep the focus on the most relevant and important issues. It can also be used when the plan is implemented to represent the impact of the plan across the health system and in the population being served.

The first part of this tool kit addresses two key questions:

  • A. How big is the need for DR services in a given population, and
  • B. What is the existing situation for DR services across the six health system blocks?

A. How big is the need for eye services?

In the community, we serve, how many people need the two main services required to address diabetic retinopathy?

  1. Case detection: How many people with diabetes need to be screened at a
    regular defined interval?
  2. Treatment: How many people with diabetes have sight-threatening
    retinopathy and need treatment?

1. Case detection in Ormo
Use the information below to calculate the number of people with diabetes in Ormo. Remember, everyone with diabetes will need to be screened.

Tips: The question marks “???” indicate where to make the calculation. Use the formula provided to do the calculation.

2. Treatment in Ormo

Use the information below to calculate how many people with diabetes in Ormo will need treatment for sight-threatening diabetic retinopathy (STDR).

Information source: From surveys in similar low- and middle-income countries we can estimate that 10% of people with diabetes in Ormo will have sight-threatening diabetic retinopathy.

B. What is the existing situation for DR services

Output indicators provide a measure of what is being done at present and can be obtained from the eye clinics serving the population.