Diabetic retinopathy: a growing challenge in Pakistan

Pakistan is on the brink of a diabetes epidemic and the country has the fourth-highest global rate of diabetes prevalence. The rate is growing significantly: by 2045, Pakistan will have more adults living with diabetes than the United States.

Changing lifestyles, dietary patterns and reduced physical activity have all contributed significantly to the rising prevalence of diabetes and pre-diabetes. If not diagnosed and managed early, diabetes causes multi-organ complications. One of the conditions related to long-standing and uncontrolled diabetes is diabetic retinopathy. This eye condition can cause blindness and/or severe vision impairment in people as it affects blood vessels in the retina.

According to the National Diabetes Survey of Pakistan (2016/2017), 27.4 million people over the age of 20 (26.3% of this age group) are affected by diabetes – four times higher than in the 1998 survey. Population-based studies suggest that about a third of all diabetics will be affected by diabetic retinopathy. Over time, almost all diabetic patients develop complications.

To prevent vision loss and irreversible blindness, patients with advanced diabetic retinopathy require early diagnosis and treatment. As a starting point, screening of all diabetics for diabetic retinopathy is recommended to prevent blindness and severe vision impairments. This challenge is enormous and the public health system in Pakistan is unable to address it due to limited resources, poor governance and a lack of monitoring  (as stated in a 2016 report analysing the health care system in Pakistan).

Over the past decade, Sightsavers and other international organisations have implemented projects to combat diabetes-related blindness in Pakistan and develop a replicable approach for long-term sustainability. The key focus of these projects was to develop diabetic retinopathy services and establish a referral pathway that ensured early diagnosis, treatment and management.

These projects have collected significant data to develop future programme strategies. For example, services that were introduced through these projects were not accessible to the most marginalised people as they were only established at a a tertiary level of care. This meant that health care facilities were only located in Pakistan’s main cities. Not only were there financial barriers for patients who had to travel, but this added extra burdens for women. It became difficult for women who needed specialist care or treatment to travel without a male relative accompanying them.

Both these factors discouraged patients from attending early screenings, so they only received treatment when their eyesight was at a sight-threatening stage. It became apparent that it was important to provide diabetic retinopathy screening services nearer to communities to prevent irreversible vision loss.

What we’ve learned

• A multi-disciplinary team approach and strong inter/intra-departmental links are key to the successful implementation of diabetic retinopathy services.
• Strong coordination between diabetes mellitus screening outlets and diabetic retinopathy clinics paves the way to a strong referral pathway.
• For better outcomes, a high level of compliance is needed. This can be achieved through patient counselling, following up with patients using automated SMS reminders, and providing a one-stop service for diabetic retinopathy care that provides all essential diabetes-related services under one roof.
• Pakistan faces many challenges in addressing the rising burden of diabetes and its related complications. This is compounded by increasing health costs that pose a financial risk to affected individuals and their families, especially if they are poor.
• Due to the unavailability of diabetic retinopathy services at a primary health care level, poor communities and people living in rural areas face challenges in accessing treatment. There is a pressing need to introduce diabetic retinopathy services at the primary and secondary levels in the health care system. This will ensure integrated, people-centred health care and universal coverage that leaves no one behind.
• The recently approved Integrated People-Centred Eye Care (IPCEC) plan 2021-2030 provides an opportunity to introduce diabetic retinopathy services from the primary level. The plan proposes that a comprehensive model of cost-effective, equitable and quality diabetic retinopathy services should be integrated into all levels of the existing health system.

Based on the learnings from previous projects and operational research, Sightsavers has developed a three-year project that aims to combat blindness caused by diabetic retinopathy. One aspect of the project involves bringing services closer to the communities in Naushahro Feroze District in Sindh province. The project will also focus on providing diabetic retinopathy services by establishing referral pathways, supplying the required equipment and training community workers.

Ensuring the project is sustainable seems challenging because of the changing priorities of donors and the government of Pakistan in post-pandemic scenario. Nevertheless, the diabetes epidemic in Pakistan needs immediate attention. A coordinated effort by donors, government and local partners can help us create a lasting impact on the lives of millions of people.