Introduction
Diabetes mellitus (DM) is one of the most common non-communicable diseases globally. It affects over 415 million adults worldwide and is projected to increase to 640 million by 2040.1 Drifting from stereotypical concepts that DM is more prevalent in developed countries, it is now evident that 80% of patients with diabetes live in low-income and middle-income countries.2 DM is the most common cause of legal blindness in the working age group (20–64 years) presenting as the greatest health challenge in 21st century.3
Prevalence of diabetes in Pakistan is about 7.89%,4 with over 5.2 million people affected in year 2000 while 14 million are estimated to be affected by 2030.5 A quarter of these have potential threat from sight-threatening diabetic retinopathy (DR). The incidence of blindness is 25 times higher in people with diabetes than in the general population. One per cent of avoidable blindness worldwide is due to DR.6
Recommended guidelines for the prevention of vision loss due to diabetes include early identification and well-managed DM, an annual eye examination to screen for DR in people with diabetes and treatment for DR by an ophthalmologist as required (laser treatment, vitreoretinal surgery or anti-vascular endothelial growth factor injections when available).7
Childhood blindness (CB) is an important and avoidable public health problem in developing countries. A recent estimate showed that 19 million children are visually impaired; refractive errors being the the most common cause found in 12 million of these, which can be easily diagnosed and treated.8 Irreversible blindness made up 4% of these causes, which will have significant impact on the psychological and personal development of these children.6
There are four main components of healthcare system in Pakistan namely;
Community level—this is covered by female health workers (LHWs) who are responsible to offer preventive awareness and provide first aid in case of emergencies.
Primary level—at this level, basic health units (BHUs) and rural health centres are present across the country, where primary health services are offered. Majority of these centres are maned with medical doctors.
Secondary level—at this level, all specialties are available which treat referred cases from primary level and also accept walk in patients.
Tertiary level—these are teaching-level hospitals offering specialised services. The tertiary level not only treats the complicated cases but also undertakes teaching and training to graduate and postgraduates levels.
In Pakistan, the healthcare delivery system suffers at all levels due to economic burdens on the country in general and in the health sector in particular. The tertiary level has somehow managed to take the impact as it is well equipped with trained personnel and facilities. But it is the district level primary and secondary levels that suffer from severe administrative, managerial flaws in addition to lack of trained individuals. This has led the population in these areas to be deprived of proper healthcare thus increasing the burden of disease on the already burdened economy of the country. Therefore, there is a dire need of coordination between different healthcare programme at all levels of healthcare system. The main purpose of this programme was to provide health education at all levels particularly at the community and primary level to strengthen the referral pathways from community to tertiary level for DM, DR and CB in Hyderabad District, Pakistan. All the referrals were actively monitored by Sindh Institute of Ophthalmology and Visual Sciences (SIOVS), Hyderabad, Pakistan. We present the results of this community-based screening programme.