Integrating Diabetic Retinopathy Into Mainstream Health System in Bangladesh

Diabetes is a non-communicable chronic disease associated with abnormally high levels of the glucose in the blood. One of the many complications of diabetes is Diabetic Retinopathy (DR), which results in vision problems in persons suffering from diabetes for many years.

DR is the fifth leading cause of global blindness, affecting an estimated 1.8 billion people and responsible for 4.8% of all causes of blindness. According to International Diabetes Federation (IDF) Atlas, Bangladesh is a least developed country (LDC) with a disproportionately high proportion of people having diabetes. Among all people living with diabetes in the 48 LDCs, about 40% live in Bangladesh, which makes it one of the top 10 countries suffering from diabetes. In Bangladesh, approximately 6.1% of the population aged 20-79 years has diabetes, with approximately 46% of these undiagnosed. According to International Diabetes Federation Diabetes Atlas (5th Edition), in 2011 there were approximately 8.4 million people in the age bracket 20-79 suffering from diabetes in Bangladesh, and this number is projected to double to 16.8 million by 2030. Diabetic Retinopathy (DR) and Diabetic Macular Edema (DME) are common complications of diabetes that can result in vision loss - the estimated number of people with DR in Bangladesh is about 1.8 million (21.3% of the diabetic persons).

From a patient perspective there is little or no integration between the eye health sector and the diabetes sector. In Bangladesh, care for diabetes-related eye disease is available in very few tertiary level health facilities. There is currently no eye health care available for people with diabetes or those suffering from DR, at the community clinics, primary health care centers or secondary health care centers (The Fred Hollows Foundation, 2015).

An effective referral system is a 'critical component of quality clinical care'. When utilized optimally, it can solve more public health problems in less time by directing cases through an appropriate channel.

DR Screening is very important, because early stages of the disease lack symptoms - when symptoms occur the disease already requires treatment. DR Screening centers may have to refer persons in a timely and effective manner to a DR treatment center. Early detection and timely referral are critical for timely interventions to prevent further deterioration of vision. In the case of DR, an effective referral system is crucial for the success of the disease management. This is because knowledge, awareness and perceived benefit of receiving DR Management services among persons with diabetes is very low, the world over, and more so in Bangladesh. Therefore, in order to make sure that DR Management is effectively integrated into mainstream public health in Bangladesh, it is vital to address one of the most challenging components of DR management, which is, strengthening referral system for persons having DR. If a person with diabetes is not made aware about possible consequences of negligence of eye problem, is not properly counseled to undertake DR treatment and is not made aware of the existing DR referral pathway, the person will in all probability forego treatment, since the perceived benefit of DR treatment is low among persons who lack symptoms.