Lesson 14: Strengthening diabetic eye disease services within the health system

A health system consists of all the organisations, people and actions concerned with promoting, restoring and maintaining health (WHO, 2007).

Each health system can be analysed through 6 building blocks: human
resources, information systems, medical products and technologies, financing, service delivery, and leadership and governance.

These six blocks are interconnected and good management of each block is
essential to establish a functional service and improve the availability, quality and access to services. A well-managed health system improves outcomes at the community level with services that are responsive to changing needs, efficient, productive and cost-effective.

The health system and diabetic eye disease

Those health system building blocks concerned with the long term prevention of blindness from diabetic retinopathy need to put in place clear health care standards to enable the effective management of both diabetes and diabetic eye diseases.

Diabetes health care standards

1. Prevention of type 2 diabetes: The Ministry of Health promotes strategies to reduce risk of type 2 diabetes by promoting healthy lifestyles, obesity reduction and prevention of smoking.
2. Identification of people with diabetes: The Ministry of Health develops and implements strategies to identify people with diabetes in the population.
3. Empowering people with diabetes: All persons with diabetes will receive a service which encourages good diabetes knowledge, management of diabetes and a healthy lifestyle.
4. Clinical care of people with diabetes: Clinical care for children, young people and adults should include:

• Rapid and effective treatment of diabetic emergencies
• Appropriate management during pregnancy
• Support to optimize control of the blood glucose
• Support to manage high blood pressure and other risk factors for developing complications.

Diabetic eye disease health care standards

5. Examination of the retina: The Ministry of Health promotes and develops services so that all people with diabetes receive an eye examination for diabetic retinopathy at least every 2 years.

6. Clinical care by an eye specialist for people with diabetic retinopathy: The Ministry of Health promotes and develops services so that all high-risk people receive ongoing care from an eye specialist.

7. Treatment for vision-threatening diabetic retinopathy: The Ministry of Health promotes and develops protocols and systems of care to ensure that all people with sight-threatening diabetic retinopathy receive appropriate and effective care to reduce their risk of visual loss.

Managing diabetes and diabetic eye diseases

Once the necessary health care standards are in place, some key activities also need to be put in place to ensure strong links between the management of diabetes and the management of diabetic eye diseases.

• Establishing a database of people with diabetes – links standard 2 with standard 5
• Establishing guidelines and protocols to direct people with diabetes to the required eye care services – links standard 2 with standard 6.
• Raising awareness and access to screening programmes – promotes acceptance of treatment and links standard 3 with standards 6 and 7.
• Providing timely quality interventions through a team approach – links standard 4 with standards 6 and 7.

Targeted action by eye health workers
Three groups need to be targeted by eye health workers to prevent blindness from diabetic retinopathy:

• The community
• People who are known to have diabetes
• People with vision-threatening diabetic retinopathy.

At the community level
Eye health workers should:

1. Promote a healthy lifestyle and the need for good nutrition and exercise
2. Test visual acuity in people aged 40 years and older
3. Carry out opportunistic fundus examination of patients in eye clinics.

People who known to have diabetes Eye health workers should:

1. Establish a database and local guidelines for diabetic eye disease
   management.
2. Set up a regular eye examination call and recall for each patient.
3. Undertake screening – visual acuity testing and retinal examination.
4. Promote the importance of good control of blood sugar.

People with vision threatening diabetic retinopathy

Eye health workers should:

1. Undertake early detection of the disease
2. Begin treatment as soon as possible
3. Counsel the patient and their family to succeed in achieving good glycaemic (blood sugar) control.

Constraints on managing diabetic eye disease

• Resource-constrained settings commonly face similar, fundamental challenges in managing diabetic eye diseases:
• A lack of access to trained eye health personnel
• Limited infrastructure and resources for treatment such as lasers and anti-VEGF therapy
• The cost-effectiveness of diabetic retinopathy screening programmes is influenced by compliance rates and good glycaemic control. These are directly linked with patient behaviour which is linked closely to their access to, and their awareness and acceptance of, health care services.

To address these challenges needs local planning and management of the interlinked blocks within the health system.