Strengthening patient referral systems and diagnosis and treatment services in Pakistan

Lady health worker visiting community members in Pakistan

Strengthening referral systems and diagnosis and treatment services in three hospitals in Pakistan has resulted in more than 50,000 diabetic patients being screened and treated for Sight-Threatening Diabetic Retinopathy in four years.

Sightsavers ‘Seeing is Believing’ project – “Strengthening Pakistan’s Response to Diabetic Retinopathy” – is designed to prevent visual impairment due to Diabetic Retinopathy (DR) through the early detection, regular follow-up and appropriate management of Sight-Threatening Diabetic Retinopathy (STDR).
While cataract remains the leading cause of blindness, non-communicable diseases such as DR and STDR are on the rise, and the International Diabetic Federation ranks Pakistan seventh globally for the number of diabetics in the population. Prevalence was estimated at 7 million for 2010 and was projected to increase to 11.5 million by 2025.

Sightsavers is working with three partner hospitals, in Karachi, Rawalpindi and Lahore, and has a focus on sensitising and screening known diabetics. The project has addressed both the demand for services in the community and improved treatment services at the hospitals.

Referral pathways are being strengthened by training a range of health workers involved in the identification, screening, diagnosis and treatment of patients at risk of DR and STDR. At primary level, Lady Health Workers (LHWs) – the key workforce of Pakistan’s health department at primary level – have been trained on diabetes, its effects on eye health and the importance of early screening and diagnosis of DR.

They have been encouraged to refer every suspected patient in their communities to appropriate health facilities for DR screening and 4,489 DM patients have been provided with DR services.

At the secondary level, General Physicians and Medical officers (MOs), Medical and Ophthalmic Technicians have been trained. They act as a bridge between communities and tertiary level health facilities where DR diagnosis and treatment services are available. Diabetic patients visiting private clinics and Basic Health Units, where these health workers are based, are now referred to tertiary hospitals.

Additionally, at tertiary hospitals, inter-departmental linkages have been developed between departments to ensure that all diabetic patients coming to hospital undergo DR screening. This has led to 10,436 DM patients being referred to DR clinics from other hospital departments.

Two ophthalmologists in partner hospitals have been trained in vitero retinal surgical skills and four on advanced laser treatment to ensure quality services are available to all patients.

Before the start of the project, primary health care workers, including the Lady Health Workers, had not been trained on the eye health complications that arise from Diabetes Mellitus (DM) and there were no formal referrals between ophthalmology and other hospital departments.

Community mobilisation has helped generate demand for the services. This has included the use of IEC materials that were developed and provide easy to follow instructions for adopting healthy lifestyles. These provide information on diabetes management as well as diet charts, that are customised according to patient’s economic status. These materials are distributed by LHWs at primary level and are available at secondary and tertiary level health facilities for all patients attending out-patient department. In addition, materials focusing on DR were developed and are given to every DM and DR patient and his family, to help them manage health issues and to avoid progression of diseases.

Interestingly, an analysis of the developing referral pathways showed they worked in different ways in the different hospitals. In two of the hospitals a high percentage of the referrals were from other hospital departments, but in the third hospital referrals from primary health care units were higher. Research is now underway to help understand how referrals pathways are working in the hospitals.

Overall 50,601 DM patients have been screened in DR clinics, with almost 30% of them arriving at the clinics as a result of the strengthened referral system.