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ObjectivesGlaucoma is a major cause of irreversible blindness in India; however, if detected early, its progression can be either prevented or stabilised through appropriate medical or surgical treatment. We aim to evaluate the cost–utility of various models for population-based glaucoma screening at primary health centres in India. We also assess the potential impact of the implementation of a population-based screening programme on overall costs of care for glaucoma.DesignCost–utility analysis using a mathematical model comprising a decision tree and Markov model was conducted to simulate relevant costs and health outcomes over a lifetime horizon.SettingScreening services were assumed to be delivered at primary health centres in India.ParticipantsA hypothetical cohort of different target population groups in terms of age groups and risk of glaucoma (age group 40–75 years, 50–75 years, 40–75 years age group at high risk of glaucoma, 50–75 years age group at high risk of glaucoma) were included in comparative screening strategies.InterventionsThe exclusive intervention scenarios were 12 screening strategies based on different target population groups (age group 40–75 years, 50–75 years, 40–75 years age group at high risk of glaucoma, 50–75 years age group at high risk of glaucoma), screening methods (face-to-face screening and artificial intelligence-supported face-to-face screening) and screening frequencies for 40–75 years aged population (annual vs once every 5 years screening), in comparison to usual care scenario. The usual care scenario (current practice) implied opportunistic diagnosis by the ophthalmologists at higher levels of care.Primary and secondary outcomesThe primary outcome was the incremental cost–utility ratio for each of the screening strategies in comparison to usual care. The secondary outcomes were per person lifetime costs, lifetime out-of-pocket expenditures, life years and quality-adjusted life-years (QALYs) in all screening scenarios and usual care.FindingsDepending on the type of screening strategy, the gain in QALY per person ranged from 0.006 to 0.046 relative to usual care. However, the screening strategies, whether adjusted for specific age groups, patient risk profiles, screening methods or frequency, were not found to be cost-effective. Nonetheless, annual face-to-face screening strategies for individuals aged 40–75 years could become cost-effective in a scenario of strengthened public financing and provisioning, such that at least 67% of those seeking care for confirmatory diagnosis and treatment use government-funded facilities, in conjunction with 60% availability of medications at government hospitals.ConclusionsEnhancing continuity of care following screening through either strengthening of public provisioning or strategic purchasing of care could make glaucoma screening interventions not only cost-effective, but also potentially cost-saving.

This paper is based on qualitative research carried out in a diabetic retinopathy (DR) programme in three districts of Pakistan. It analyses the organisation and delivery of DR services and the extent to which the interventions resulted in a fully functioning integrated approach to DR care and treatment. Between January and April 2019, we conducted 14 focus group discussions and 37 in-depth interviews with 144 purposively selected participants: patients, lady health workers (LHWs) and health professionals. Findings suggest that integration of services was helpful in the prevention and management of DR. Through the efforts of LHWs and general practitioners, diabetic patients in the community became aware of the eye health issues related to uncontrolled diabetes. However, a number of systemic pressure points in the continuum of care seem to have limited the impact of the integration. Some components of the intervention, such as a patient tracking system and reinforced interdepartmental links, show great promise and need to be sustained. The results of this study point to the need for action to ensure inclusion of DR on the list of local health departments’ priority conditions, greater provision of closer-to-community services, such as mobile clinics. Future interventions will need to consider the complexity of adding diabetic retinopathy to an already heavy workload for the LHWs.

ObjectiveThe aim of this study was to assess the prevalence of diabetic retinopathy (DR) and retina screening coverage among people with diabetes in the catchment area of a high-volume eye care organisation in north India.DesignA population-based cross-sectional study using Rapid Assessment of Avoidable Blindness survey, including the DR module.SettingA customised rural district in the catchment of Dr Shroff’s Charity Eye Hospital in Uttar Pradesh in north India.Participants4095 people of age 50 years and above were enrolled using a two-staged cluster sampling, 3867 (94.4%) participated; 2167 (52.9%) were women. 3803 of 4095 (92.9%) participants were assessed for diabetes. People with already diagnosed diabetes and anyone with a random blood glucose ≥200 mg/dL were offered dilated fundus examination.Primary and secondary outcomesPrimary and secondary outcomes were the prevalence of DR and screening coverage for DR, respectively.ResultsThe prevalence of diabetes was 7.0% (95% CI 5.9% to 8.0%). 50.2% of all people with diabetes were newly detected. The prevalence of any DR among people with diabetes who consented to dilated pupillary examination was 22.8% (51 of 224), (95% CI 18.2% to 27.3%). 5.8% (13/224) of people with diabetes were found to have sight-threatening DR and only 15.4% (2/13) had received treatment. 84.8% of people with previously diagnosed diabetes had never had their eyes tested for DR; this was significantly higher in women (90.2% vs 76.0%, respectively, p<0.001). 76% of people with previously diagnosed diabetes had poorly controlled diabetes; this was significantly higher for those on non-allopathic treatment (p<0.01). The odds of DR were higher with duration of diabetes >10 years and poor glycaemic control (OR of 1.8 and 1.6, respectively), but this was not found to be statistically significant.ConclusionThe prevalence of DR in this predominantly rural setting was found to be higher than the national average. Coverage of retinal screening and treatment was found to be very low. Working with general health providers to increase detection of people with diabetes and leveraging vision centres to improve DR screening coverage is needed in this region.

Background In 1994, the Lady Health Workers (LHWs) Programme was established in Pakistan to increase access to essential primary care services and support health systems at the household and community levels. In Khyber Pakhtunkhwa (KPK) province in northern Pakistan, eye care is among the many unmet needs that LHWs were trained to address, including screening and referral of people with eye conditions to health facilities. However, despite an increase in referrals by LHWs, compliance with referrals in KPK has been very low. We explored the role of LHWs in patient referral and the barriers to patient compliance with referrals. Methods Qualitative methodology was adopted. Between April and June 2019, we conducted eight focus group discussions and nine in-depth interviews with 73 participants including patients, LHWs and their supervisors, district managers and other stakeholders. Data were analysed thematically using NVivo software version 12. Results LHWs have a broad understanding of basic health care and are responsible for a wide range of activities at the community level. LHWs felt that the training in primary eye care had equipped them with the skills to identify and refer eye patients. However, they reported that access to care was hampered when referred patients reached hospitals, where disorganised services and poor quality of care discouraged uptake of referrals. LHWs felt that this had a negative impact on their credibility and on the trust and respect they received from the community, which, coupled with low eye health awareness, influenced patients’ decisions about whether to comply with a referral. There was a lack of trust in the health care services provided by public sector hospitals. Poverty, deep-rooted gender inequities and transportation were the other reported main drivers of non-adherence to referrals. Conclusions Results from this study have shown that the training of LHWs in eye care was well received. However, training alone is not enough and does not result in improved access for patients to specialist services if other parts of the health system are not strengthened. Pathways for referrals should be agreed and explicitly communicated to both the health care providers and the patients.

The Sunderbans are a group of delta islands that straddle the border between India and Bangladesh. For people living on the Indian side, health services are scarce and the terrain makes access to what is available difficult. In 2018, the international non-governmental organisation Sightsavers and their partners conducted a population-based survey of visual impairment and coverage of cataract and spectacle services, supplemented with tools to measure equity in eye health by wealth, disability, and geographical location. Two-stage cluster sampling was undertaken to randomly select 3868 individuals aged 40+ years, of whom 3410 were examined. Results were calculated using standard statistical processes and geospatial approaches were used to visualise the data. The age–sex adjusted prevalence of blindness was 0.8%, with higher prevalence among women (1.1%). Cataract Surgical Coverage for eyes at visual acuity (VA) 3/60 was 86.3%. The study did not find any association between visual impairment and wealth, however there were significant differences by additional (non-visual) disabilities at all levels of visual impairment. Geospatial mapping highlighted blocks where higher prevalence of visual impairment was identified. Integrating additional tools in population-based surveys is critical for measuring eye health inequalities and identifying population groups and locations that are at risk of being left behind.