Title: Evaluation of an innovative model for the early detection and referral of diabetes and diabetic retinopathy in Pakistan
Authors: 	Dr Farah Riaz1, Dr Fabrizio D’Esposito2
		1The Fred Hollows Foundation, Pakistan
		2The Fred Hollows Foundation, Australia
Background
More than seven million people have been diagnosed with Diabetes Mellitus (DM) in Pakistan (6.9% of the population), and a further three million remain undiagnosed. Diabetic Retinopathy (DR) – a complication of DM that affects the blood vessels of the retina in the eye – is the leading cause of avoidable blindness in the working age population worldwide. 
Eye care services for people at risk of DR in Pakistan are very limited. Existing services have poor accessibility and are not integrated into routine care in primary health care settings. Accessibility and uptake of services is also inequitable; it is often particularly difficult for women to use health services unless these are culturally acceptable and accessible in practice. 
A health system strengthening program for DM and DR was piloted in collaboration with local government in Pakistan between 2013 and 2016. The key objective of the program was to increase the proportion of the population at risk of DM/DR accessing services in a timely manner, with a particular focus on increased service uptake among women. The program strived to achieve this by building the capacity of the primary health care level to detect and manage DM/DR patients and refer cases to secondary level for management, as appropriate.  
Training of Lady Health Workers (LHWs), an existing cadre of primary health workers, was a major focus of this program. LHWs were trained to conduct risk assessments for unknown cases of DM at the community level and to improve suitability and access to services for women with DM. 
Following completion, the program was evaluated.
Aims 
The evaluation aimed to assess the extent to which the program’s objectives were achieved.
Methodology
Secondary analysis of program monitoring data from three districts in Pakistan was performed to determine the prevalence of DM among individuals screened in three districts of Pakistan, to assess the impact of the program on number of people assessed for DM/DR and referred on for further care, and to assess whether this differed for men and women.
Results
A total of 73,289 individuals were assessed for risk of DM. Of these, almost half (45%) were found to be at high risk of developing the disease, and 9.1% were found to have impaired glucose metabolism. More than half (59.3%) of those with impaired glucose metabolism were referred for further treatment for diabetic eye disease. However, only less than half (42.6%) of those referred to tertiary hospitals for DR presented to receive treatment. 
Compared to the first year of the project, the number of people assessed for DM risk more than doubled (227% increase) in year two, before plateauing and then decreasing in years three and four. This trend was also observed for all sources of assessment (e.g. LHWs, Medical Officers, etc.), with the exception of individuals who self-reported for assessment. The latter increased steadily across the duration of the project. Notably, the number of individuals assessed by LHW increased the most in year two compared to all other modes of assessment.
Almost two thirds (63.9%) of individuals assessed for risk of DM were women. LHWs were also significantly more likely to refer women for risk assessment and DM screening than men (p<0.001). No difference was observed in the proportion of men and women who were referred to tertiary hospital for DR and later presented for treatment (p=0.450). 
Conclusions
Findings from the evaluation of this innovative model for the early detection and referral of DM and DR in Pakistan suggest that the model of care implemented is effective in increasing access to services, particularly among women. For the first time LHW and the primary health care level were successfully engaged in screening for DM and DR in Pakistan. 
This suggests that tasks can be shifted across service delivery levels to bring DM and DR services to the primary health care settings, thus promoting more timely identification of cases and individuals at risk, and reducing stress on the otherwise overburdened secondary and tertiary health settings.
Focussing on training LHWs was also a successful strategy to increase suitability and equitable access to service for women. 
Future project should focus on strengthening referral pathways to promote improved presentation rates for treatment at the tertiary care level.