Lesson 4: Strengthening health systems

Strengthening health systems for diabetic eye disease treatment

Before starting a screening programme for diabetic eye disease in any setting it is essential that treatment is readily available and able to undertake the additional workload that screening is likely to generate. Treatment to prevent sight loss from diabetic eye disease needs to be given early. This means the health system has to be prepared to coordinate each patient’s journey across the complete care pathway through:

  • Case finding (screening).
  • Referral
  • Patient counselling. That is informing people with diabetes who are diagnosed with diabetic eye disease about their options and supporting them to make the decision that is right for them
  • Treatment and long-term follow-up.

Every step is essential and this has implications for both the patient and the health service. In resource-poor settings, drawing on the experiences of established diabetic eye disease programmes from other settings may be useful but it remains essential to produce locally appropriate guidance and models of service delivery.

What is required?

According to the World Health Organization, “A good health system delivers quality services to all people, when and where they need them.”

The whole health system needs to be involved to offer integrated care for diabetes and eye health. This means all the organisations and agencies whose purpose is to improve health in a country: government health services, as well as those, delivered by not-for-profit providers and them private, for-profit sector – at the community or at primary, secondary/district or tertiary level.

A framework of activities to manage diabetic eye disease

As we saw in our analysis of the health system in Ormo District in week 1, the six building blocks of any health system are:

  • Leadership and governance
  • Health workforce
  • Technology, equipment, infrastructure, and medicines
  • Health financing
  • Health management information systems
  • Service delivery.

The six building blocks of a health system

To establish successful screening and treatment services for diabetic eye disease, the following framework of activities must be carried out in each of the six building blocks at the local or national level.

Leadership and governance

  • Establish evidence-based, clinical protocols and guidelines for diabetic eye disease at the national level and at the hospital level provides training for people to use them correctly.
  • Provide good management to bring together the key resources for local service provision, including human resources, finances, hardware and coordinating the process aspects of care at the point of service delivery to obtain the best results.
  • Provide leadership and support team-building – including forging links with other sectors or other health departments, for example, endocrinology, antenatal clinics and information technology services.

Health workforce

  • Train staff at every level of the health service to be competent in comprehensive eye examination and ensure availability of appropriate treatment or referral to higher levels to ensure a continuum of care
  • Ensure sufficient numbers of patient counsellors, supported by appropriate educational materials for people with diabetes
  • Employ technicians to protect, maintain and repair equipment such as retinal cameras and lasers
  • Facilitate teamwork and task shifting to ensure good management adequate vision testing, retinal imaging and patient support
  • Create access to sub-speciality training in medical and surgical retina

Technology, equipment, infrastructure and medicines

  • Invest in fundus cameras, lasers, indirect ophthalmoscopes and vitrectomy machines to ensure trained personnel have the appropriate tools to provide a good service.
  • Ensure services can afford well-maintained stocks of medications. Consider the need for affordable anti-VEGF injections.
  • Provide telemedicine models for screening remote populations.

Health financing

  • Make affordability of medication for diabetes a priority for all people with diabetes
  • Provide insurance packages or other financing schemes for eye care which include treatment options for, diabetic retinopathy.

Health management information systems

  • Implement electronic patient records. The ability to track data from screening to follow up can be developed as technology in health improves.
  • Ensure good record keeping and information retrieval systems. This is a cornerstone for the provision of good care for the patient and managing patient expectations.
  • Monitor rates of uptake of screening, treatment and follow-up.

Service delivery

  • At the tertiary level put dedicated retinal clinics, with well-trained teams, in place.
  • Implement robust referral pathways from diabetes and antenatal clinics
  • Put systems in place to encourage follow-up, e.g. SMS message reminders
  • Empower and inform people with diabetes with relevant health education activities at all health care levels.

In summary: To overcome barriers to effective provision of diabetic eye care services, it is helpful to be responsive to the community and their needs. For example, by holding clinics at times that suit working people such as weekends and evenings or by screening for diabetic retinopathy in doctors’ clinics. Everyone providing eye care, at whatever level they work, can gain knowledge and skills to reduce visual loss from diabetic eye disease.