Blindness and visual impairment prevention

Nepal tackles diabetic retinopathy

October 2017

Chronic diseases are on the rise. There are now an estimated 422 million adults with diabetes globally. Among its serious complications, people living with diabetes can suffer vision loss. Often by the time a person notices a problem with his or her vision, the damage is irreversible.

Diabetic retinopathy, which contributes to 2.6% of blindness in the world, can be a challenging disease for many countries to manage, because doing so involves two different parts of the health system, that which cares for patients with diabetes and that which cares for patients with vision loss. A lack of coordination can lead to people missing out on essential services, enduring long waits or traveling far from home to receive care.

To help countries better ensure timely diagnosis and access to treatment for diabetic retinopathy, WHO developed the Tool for Assessment of Diabetes and Diabetic Retinopathy or “TADDS” in 2015. Among the first countries to make use of this new tool was Nepal, where the Ministry of Health had been concerned by the increase in diabetes and diabetic retinopathy, and wanted to use TADDS to make sure it was taking the appropriate actions in response.

Mr Sailesh Kumar Mishra, National Programme Coordinator of the Apex Body for Eye Health in the Ministry of Health said “At the time Nepal had taken a step forward by listing noncommunicable diseases as a priority health concern, but it was lacking the specific health policies, plans and programmes to address diabetes and diabetic retinopathy in particular. TADDS has helped move us in the right direction.”

The assessment was made possible through the direct assistance provided by the WHO Country Office in Nepal to the Ministry of Health; the Office supported the field work, monitored the progresses and provided effective and timely feedback to the WHO HQ in Geneva.

TADDS was used to collect data and information about the current situation in the country, including the level of coordination – or lack thereof – across the two services, the extent to which data are shared, and the ways that patients are educated on how to manage their diabetes and prevent vision loss from diabetic retinopathy.

The findings of the assessment were not surprising. There had been insufficient collaboration between the diabetes management and eye care sectors, making it difficult for health care providers to know when and how they should be working together. There were also some areas where disease management guidelines needed to be updated to reflect current best practice. It was also clear that patients needed to be better educated about how to manage diabetes and diabetic retinopathy.

With support from WHO, a national policy discussion was held in 2016 based on the report during which immediate actions were defined for the Ministry of Health and its partners, including patient associations, to rectify shortcomings in the system.

Since then, the Government of Nepal has been making good progress. A National Strategy for the Integration of Diabetic Retinopathy Eye Care Services into the Public Health System and several clinical guidelines for managing diabetic retinopathy have been developed in part based on WHO guidance and are about to be approved. Diabetic retinopathy has also been included in the National Eye Health Policy which is also nearing completion.

Work has been done too to build the capacities of health care workers, with diabetic retinopathy included in curriculum developed for primary care assistants who focus on noncommunicable diseases. In fact the Ministry of Health is promoting a new model for its workforce in communities which supports better integration and referrals in primary eye care, with diabetic retinopathy one of the key issues addressed.

To complement these ongoing efforts, the Ministry of Health has initiated public awareness campaigns targeted at people with diabetes on the importance of having their eyes checked regularly for any sign of vision loss.

Mr Mishra noted “We now know best where to place our energies, so that people with diabetes get the eye care they need to prevent any unnecessary loss of vision. And we have been able to do this because we made sure we had the buy in of all the stakeholders involved.”

The Ministry of Health is expecting to conduct the TADDS assessment again in two years. This will help monitor the progress of specific actions, and make sure that future work continues to address the most important needs.

Experiences from countries like Nepal in implementing TADDS and other similar WHO tools for glaucoma, refractive errors and vision rehabilitation will help to inform WHO’s World report on vision which is currently under development, and scheduled for release in late 2018.