Lesson 15: Case study

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Introducing a hypothetical case study: Ormo district

In this step, we introduce a hypothetical case study, Ormo district in a country called Gula. This is a fictional location with similar socioeconomic challenges to those shared by many real low- and middle-income countries.

We use Ormo district throughout the course to illustrate key points about the ways health systems are working to address the growing burden of visual impairment from diabetic retinopathy. You may prefer to use your own country’s setting instead and we welcome this approach as well.


  • Gula has 10 million inhabitants distributed across 5 main districts.
  • Approximately 30% of the population is younger than 20 years old.
  • Life expectancy at birth is 72 years.
  • The literacy level is 75%.
  • 53% of the population now live in its 5 main cities and 200 smaller towns.
  • 17% live below the poverty line.

The economy is based on tourism, exporting agricultural produce and some mining. With good political stability, there has been a recent influx of ICT companies which are growing strongly and providing new jobs in business processing and call centres.

Gula health system

The government of Gula recognises the strategic value of health and prioritises the achievement of Universal Health Coverage (WHO, 2017). However, many years of under-investment means there are major challenges with infrastructure.

As in most countries, Gula health services are structured across 3 levels – primary, secondary and tertiary. Primary level care is provided in the community and is the first point of contact for many people. Secondary level health care is provided by medical specialists after a referral from the primary level and further highly specialised care, often over a period of time, is provided at the tertiary level care after a referral from the primary or secondary levels. The government subsidises health services and citizens pay rates proportional to their income.

About 15% of the population has private insurance. Some hospitals
partner with international non-governmental organisations (INGOs) to subsidise patient treatment. Procurement of medical equipment is devolved to each district and health services vary across the five different districts.
There are two medical schools for undergraduate-level training. All the 20
ophthalmologists in the country were trained abroad but there is a mid-level ophthalmic training programme in the capital city.

Non-communicable diseases (NCDs), Cardiovascular disease, diabetes and cancers are a growing challenge in Gula, along with obesity. In 2009, NCDs accounted for 75% of deaths in Gula.

Risk factors for NCDs in the adult Gula population

The government has created a national NCD unit within the Ministry of Health. It has an operational policy, strategy and action plan to reduce harmful use of alcohol and tobacco, promote physical activity and promote healthy diets.

Last year, the government introduced a new policy to make insulin and metformin (a medicine used to treat type 2 diabetes) available to everyone with diabetes free of charge at public hospitals and clinics.

Health care in Ormo district

Ormo has a population of 1.4 million people and has similar health indicators to the rest of the country. There are nine secondary level district hospitals and one tertiary level main hospital which also provides clinical training as part of the Gula national medical school. Ormo is regarded as having one of the better eye care services in the country. The available eye care human resources are:

  • 4 ophthalmologists
  • 8 ophthalmic nurses, 2 of whom are trained as screener/graders
  • 6 Optometrists
  • 5 clinical assistants

Health services for diabetes and diabetic eye disease in Ormo

An initiative to develop a DR screening programme started 2 years ago with the support of an INGO and the NCD working group at the Ministry of Health. Two district hospitals have installed retinal cameras, operated by the two screeners/graders recently trained by the INGO.

The tertiary hospital has a diabetes clinic which runs daily out-patient services within the hospital facilities. They provide HbA1C testing for blood sugar control and a range of other biochemical tests which are provided to only high-risk patients or to those willing to pay privately.

People with diabetes and any eye complaints are referred by the diabetes clinic to the weekly retinal clinic run by the eye department and there is usually a 4 week waiting period for an appointment.

The retinal clinic has some facilities for retinal imaging, laser, and occasionally anti-VEGF, treatment. There are no vitreo-retinal surgery facilities in the district and all patients are referred to Gula’s capital city, 300 miles away.

In total, across the whole district, last year:

  • 4,500 retinal examinations were carried out at the main hospital and the two district hospitals with the support of the INGO.
  • 155 people with vision-threatening diabetic retinopathy were treated with lasers at the main hospital.
  • 20 people with vision-threatening diabetic retinopathy were treated with anti-VEGF at the main hospital.

“The diabetic patients that we see in the eye clinic, have poorly controlled diabetes and already have visual complaints, often due to sight-threatening diabetic retinopathy. We urgently need to get the messages out on diabetes control and also early detection of DR”.

Reading this information, what are the key strengths and weaknesses of diabetic eye care services in Ormo district? What opportunities for development or threats to the current provision of services do you see?