HKI helps streamline vision screenings for people with Diabetes in Indonesia

Diabetic Retinopathy screening

This is a post from Helen Keller International, our 10GA Eye Health Investor, on their work in Indonesia tackling diabetic retinopathy.

Annual eye exams for people with diabetes is not routine practice in Indonesia (like it is in countries like the United States), and the process to access care is time-consuming and convoluted. In 2000, the number of people with diabetes in Indonesia was estimated at 8.4 million; with this number expected to almost triple by 2030.1

Typically, people with diabetes make monthly visits to a primary health centre where vital signs are checked, blood is drawn, and a general practitioner is consulted. If concerns are raised, the GP refers the patient to a district hospital for a consultation with an endocrinologist. If an ocular condition is suspected, the person is referred to an ophthalmologist. But at district hospitals, ophthalmologists don’t often have access to retinal cameras, so patients may be referred to a third hospital for a definitive diagnosis before then being sent back to a district hospital for laser treatment.

In this system, patients only reach the point of diagnosis if something obvious is wrong. But early diabetic retinopathy—when the disease is most treatable—shows no symptoms. This system means less than 20% of people with diabetes were seen by an ophthalmologist.

Helen Keller International saw a need for change.

“As many as one in three people with diabetes may develop diabetic retinopathy, which would lead to a public health emergency in Indonesia,” says Country Director Prateek Gupta. “We saw an opportunity to work with the government and the hospitals to update systems to reduce preventable blindness.”

In 2009, a hospital-based screening programme was established in Jakarta. People with diabetes visiting the endocrinology clinic would have retinal photographs taken, and the images would then be transferred to the ophthalmology department. Any patients with diabetic retinopathy would be referred to an eye clinic for care. The process was then replicated in Bandung and Yogyakarta, two cities believed to have many people with diabetes.

In an effort to reach more patients and raise awareness, a new model was tested in Jakarta that revealed valuable information. In some primary health centres, fundus cameras were used for screening. Retinal photographs were taken that helped identify the presence of diabetic retinopathy or other undetected conditions; the images that were unclear or raised concerns earned patients referrals to a district hospital. In other primary health centres, education was provided.

Surveys revealed a lack of awareness about the need for eye care among the patients following both efforts. The first method proved more effective, as the fundus cameras enabled greater patient screening at the earliest point of contact. HKI also learned that patients simply told to visit a hospital were unlikely to follow through, but written referrals enabled reimbursement.

Since HKI began working with the government to address diabetic retinopathy, 10,000 patients have been screened and almost 2,000 treated. Perhaps more importantly, by building the capacity of the healthcare system and the professionals working in it, these efforts have set the stage for more effective care to come.

“We look forward to working with our partners in the Indonesian government and at the health facilities to identify new models for screening and treatment and expanding access to vision-saving care,” says Gupta.

Don’t miss the pavilion session by HKI, on their other work in Indonesia, Lessons learned from a school-based refractive error screening program in Jakarta, Indonesia, on 28th October.