Diabetic eye diseases have been a growing concern for Bangladesh requiring greater attention from the policymakers and service providers. According to IDF Diabetes Atlas 10th Edition 2021, it is 12.5% among 20-79 aged population are suffering from diabetes which results in different eye diseases such as diabetic retinopathy (DR). Bangladesh yet to make diabetic eye care services available and accessible to a large portion of its population, particularly those who are poor and those who live in rural areas. Against such a backdrop, Orbis International, Bangladesh organised a policy dialogue titled ‘Integrated DM and DR Services – Reaching the Unreached’ at the West Inn Dhaka on June 26, 2022 in collaboration with partner organisations. Prof. Dr. AHM Enayet Hussain, Director General, Directorate General of Medical Education (DGME) was present as the chief guest while Prof Dr. Md Robed Amin, Line Director of NCDC at DGHS, and Dr. Masud Reza Kabir, Line Director of CBHC at DGHS, attended as special guests. National Prof. AK Azad Khan, President of Bangladesh Diabetic Somity (BADAS), chaired the policy dialogue while Dr. Munir Ahmed, Country Director, Orbis International, Bangladesh, moderated the program.
Prof Dr AHM Enayet Hussain
I always recognize Orbis International for two achievements. Firstly, during Flying Eye Hospital visit in 1985, Orbis provided Bangladesh around 2,000 intraocular lenses andophthalmologists at that time started cataract surgery in Bangladesh using those lenses. And secondly, Orbis established the foundation of paediatric ophthalmology in Bangladesh. And I feel privileged to have joined their fellowship programme abroad.
The government has good programmes to reach health care services to the people. We are very optimistic about that, and improvement is happening on different indicators, but still, we could not reach everyone, particularly the people, women, poor, person with disabilities and marginalized groups. We don’t have any programme specially designed for them. We must focus on that area. There are some challenges, including cultural and educational barriers, in reaching services to the people who are still unreached. We need to design health programmes keeping in mind the challenges so that they could be effective and yield desired results.
We need to offer diabetic eye care services in a coordinated way because the coordination between government and non-government sectors and inter-sectoral coordination is necessary for making any programme successful. If we want to achieve our SDG target, we have to take collaborative efforts to reach the unreached. Such cooperation has been very successful in the immunisation programmes of the country.
Prof AK Azad Khan
Bangladesh has tremendous health infrastructure and now the cooperation among different players is happening. We can set an example of real health care in the world if we can give proper attention to prevention. The doctors’ community or the community involved with health care services always complain that people don’t receive services. But I have found out that is not true. Truth is that we (the doctor community) don’t know what language will motivate them to receive services. That needs to be worked out. The government has established a tremendous healthcare infrastructure. Such infrastructure is available only in developed countries, not in any other developing country. No developing country has yet been able to announce that all Type-1 diabetic patients will be given free insulin. I have been fighting for this issue for the last 10 years that insulin is a human right for Type-1 diabetic patients. I would like to announce that BADAS will be an enthusiastic partner to work with the government’s health department, Orbis International and other organisations in providing diabetic eye care services.
Prof Md Robed Amin
The government in health sector has introduced an NCD management model which has been developed with the provision of NCD corner at theUpazilaHealth Complex(UHC/sub-district level hospital). This is a unique system that offers NCD services to the people living in remote rural areas and emphasizedpoor households.The NGOs are also running camps for NCD services which is complementing and needs to be an active system so that people are mobilized and seek services from the NCD corners.We need to ensure that people from all walks of life can take services irrespective of their socio-economic status.Therefore, we need to ensure a system tovisit households and motivate patients to first access to the government community clinics which is at their doorsteps and have their DM screening done and referred diabetic patients to the NCD corner of UHC. This system worked very effectively during the pilot phase. So, we should scale up the system which has worked well. The digital NCD management system is now functioning in 80 Upazilas. We have a plan to raise the number of NCD corners up to 200 in 2022 and introduce the same system by involving 2,000 community clinics at the grassroot level.
The government alone cannot deal with everything. So, public-private partnerships (PPP) approach works well where NGOs can supplement and complement where there is gaps and issues related to access to NCD services. There is no alternative to PPP approach for expanding NCD especially DM services and referral. NGOs are working as the extended government infrastructure in the health systems. Without them, it will be hard to reach services to the people who remained unreached. So, NGOs should consider them anessential part of the health service delivery system. We all should work under a system that is effective and works for all.
In some Upazilas, there are NCD corners and community vision centres both, but there is no coordination between them. Again, we are offering DM screening and care services at NCD corners but for DR screening the patients are being sent to general hospitals at district headquarters. It’s a burdenand this could easily be addressed if the community vision centres are utilized properly. We need to address these missing points for reaching the unreached population in DM and DR services in Bangladesh.
Dr Munir Ahmed
The objectives of the dialogue are to reinforce Diabetic Mellitus (DM) and Diabetic Retinopathy (DR) services in the purview of NCDs and eye health; share issues, challenges and lessons learned while implementing the DM and DR integrated services in selected areas of Bangladesh; and to get additional knowledge and recommendations from the learned participants to design a scalable model in near future as an integrated approach for DM and DR services; to address the missing links, scopes and opportunities as a way forward to achieve universal eye health coverage by the year 2030. Our experience suggests that there is no alternative to collective efforts for attaining what we want, and we need to engage with private sector to speed up our efforts.
Orbis’s vision is to transform the lives of people through the prevention and treatment of eye diseases. We work with partners. We are contributing to the national eye care plan. Our global programme has four focus areas – paediatric eye care; community-based primary eye care; capacity building and system strengthening through training and innovative learning; and emphasising women, young girls, persons with disabilities, displaced populations, and most vulnerable people.
Dr Masud Reza Kabir
Diabetes is the mother of all diseases. But unfortunately, most of doctors do not understand diabetes well and cannot manage diabetic patients. If a doctor cannot do that what will be the case for others. Awareness about diabetes must be created among the physicians first. They will have to be imparted training on diabetes. Courses about diabetes are inadequate at the graduate level. So, more importance should be given to the disease in the graduate-level course curricula.
According to IDF 2021, around 12.5 per cent people (20 - 79 years of age) are suffering from diabetes in Bangladesh. Over 50 per cent of the patients do not know they are diabetic. They don’t have any awareness about diabetes – what is diabetes and how to control it and importance of lifestyle changes. The incidence of diabetes is on the rise among the rural population. For fighting diabetes, the government has set up 14,158 community clinics which has included diabetic screening and have a plan to raise the number such clinics up to 14,890 by 2023. We are giving them glucometers and strips. If we cannot provide diabetes health care at the community clinics, we cannot control diabetes.
Dr Sadhana Bhagwat
The number of diabetic patients in Bangladesh is huge. We all know about the double burden of diseases -- communicable, maternal, and non-communicable diseases – in our countries and in this region. But if we look at our non-communicable diseases, we have a double burden here. Because we deal with patients who don’t even know about their illness. And these people have already so many complications when they are diagnosed with diabetes. In such cases, the cost of treatment goes quite high. Diabetic retinopathy links very closely with what NCD corners are offering. We have well-equipped NCD corners, but it is not possible for the NCD staff to give attention to every patient. There is a need for strong referral services to offer better services. We are happy to see that all are thinking of reaching the unreached.
Dr Shamim Talukder
We need to determine where we should go in terms of policy for NCD. NCDC needsa multi-sectoral action plan for our country and NCDC division of the DG Health can take the lead to engage multi-sectors for eye care, diabetes care and hypertension care. Eye care should be integrated with diabetes care and hypertension care. Around 40 percent of children face some sorts of eye ailment that affect their education. So, the ministry of education should be engaged in the eye care system. There must be some scope for the patients so that they can raise their issues as they are the biggest stakeholders. A separate mechanism needs to be developed through the partnership of government and non-government organisations for covering more people in the urban areas.
Dr Bishwajit Bhowmik
Only half of the people with diabetes in Bangladesh have access to diabetes care. BADAS, Bangabandhu Sheikh Mujib Medical University (BSMMU), a few medical college hospitals in the public sector, and several private corporate and non-profit hospitals now have the facility for diabetes treatment and most of the facilities concentrating on the capital and major cities. Only 10.4 percent of the people with diabetes are aware of their diagnosis but not about treatment while only 13.6 percent had their blood glucose under control. People with diabetes in Bangladesh spend nine percent of their annual household income on managing the disease while the total annual per capita expenditure on medical care is six times higher for people with diabetes (US$635 vs. US$104, respectively). US$297 could be saved annually by preventing only one case of diabetes. BADAS is currently looking after 50 percent of all people with diabetes in Bangladesh and is working to cover 75 percent by 2025. The association owns more than 114 institutions, 100 large, medium, and small-sized hospitals with more than 4000 beds, providing primary, secondary, and tertiary care in all disciplines.
Md Shafiqul Haque Chhutu
At BADAS Dinajpur, we have screened around 20,000 children for diabetic eye disease under an Orbis programme titled “Model for Children with Diabetic Eye Disease in Bangladesh” and we found 800 positive cases. Diabetes has assumed almost an epidemic form on one hand and the cost of treatment of the disease has increased to the level that many cannot afford it, on the other. Many people are suffering from the disease but cannot receive treatment for financial constraints; even many cannot afford travel costs for coming to health facilities. We provided free insulin for children of poor families but the travel cost of some of them, particularly those living far away from the hospital, surpasses the insulin price. Health care facilities for diabetic eye diseases have expanded to a great extent in the country but still, there is a long way to go.
Mohammad Awlad Hossain
Orbis’sBangladesh DR project funded by World Diabetic Foundation (WDF) has attained many achievements. Through the project, we were able to integrate DR screening into diabetes care services, especially in rural and semi-urban settings. We were also able to screen over 110,000 diabetic patients for DR at district diabetic hospitals. Besides, more than 130,000 community people were screened at community clinics for DM. Under the project, 400 community clinics were equipped as vision points where community people can have their primary eye check; referral networks were created between community clinics, district diabetes hospitals and eye hospitals.
Besides, with the support of its partner organisations, Orbis reached the unreached people through community DM and DR screening programmes. The organisation trained a team of photographers and graders, especially non-medical graders which is an example of task-shifting.
We, Dr K Zaman BNSB Eye Hospital, have partnership with Orbis International for around 20 years. Under the agreement, we have established an eye unit at Sherpur BADAS hospital. We found the collaboration very fruitful. The unit is working very effectively. We would like to request for greater collaboration between BADAS and eye hospitals in other parts of the country. If support can be taken from eye hospitals, it will be effective in providing eye care services. At every diabetic hospital, there is a system for maintaining the patients’ records. If we can have the lists of the patients and determine how many people underwent eye screening, our job will be easier. We have referred around 13,000 patients from different outreach programmes at Jamalpur, Kishoreganj and Tangail and only 696 patients came to our hospital. We asked why they did not come. Their answers were that they did not have money and company to travel to the hospital. We need a coordinated effort to address these issues.
There is a lack of awareness about eye diseases among stakeholders, including service receivers and service providers. Because of the lack of awareness, many people, particularly those living in rural areas, do not go to doctors in case they are affected by such diseases; rather they prefer going to quacks that can only lead the situation from bad to worse. To many people in rural areas believe that crossed eyes are still no problem; they are the blessings of God. For the lack of awareness among the service providers, many highly expensive eye treatment machines donated by international NGOs are left inoperative.
Dr Arifur Rahman
There are two issues – first is the identification of diabetic cases and then treatment. The treatment of diabetic retinopathy is very expensive. If diabetes can be kept under control, there is little chance of diabetic retinopathy, neuropathy or myopathy and other prolonged complications. Laser, surgery and injection for DR care are very expensive. Free injections are given only at the National Institute of Ophthalmology and Hospital in Bangladesh. But it is not possible to give it to all patients. The number of ophthalmologists is low. The delivery of eye care services at the district and Upazila levels needs to be strengthened.
Dr Md Abdul Mazid Osmani
Diabetes is the mother of all diseases. It invites so many diseases, particularly eye, heart, and kidney diseases. Services could not be reached to around 50 per cent of diabetic patients. How they can be reached is a challenge. We have progressed a lot in the journey. We have established NCD corners in many Upazilas though they all are not strong enough to serve the people in the remote areas. If we can provide dedicated doctors, nurses, and other necessary people there, a massive improvement in diabetic eye health care will take place.
The diabetic situation in Bangladesh is moving towards a dangerous level. Fred Hollows Foundation has been working with diabetes since 2017. We, the NGOs working in the field, are observing some barriers. We think referral services need to be strengthened. We have partnerships with several health facilities, having even laser treatment facilities, but we’re not getting an adequate number of patients. If the chain of referral services is strengthened, we will be able to overcome the situation.
Khondoker Shamima Akter
We found that many diabetic patients living in villages are totally unaware that they are suffering from the disease. I encountered one patient who came to me to seek a medicine that can ‘cure’ her weakness. I suspected she is diabetic, but she was not allowing me to do a diabetes test. Finally, I convinced her to undergo the test and I found that her sugar level reached as high as 23. Then I referred her to Netrakona BADAS hospital as I do in other suspected diabetes cases. As community healthcare providers, we have to do so many things and do not get enough time to give special attention to diabetic patients. If we get such a scope, we can visit the patients at their houses. It will yield better results.
Individuals with diabetes are generally prone to infections of any kind and at any site predisposing them to acute infection, which is normally of bacterial origin in the orbit and eyelids. About 25-30 percent of the diabetic population have Diabetic Retinopathy, an emerging cause of visual impairment and blindness. Orbis is implementing a three-year program titled ‘Creation of Diabetic Retinopathy Referral Network in Bangladesh’ in Gopalganj, Bogura, Mymensingh, Sherpur and Netrakona for screening and referral of DM at the community clinics and inclusion of DR screening and standard grading system within the BADAS diabetic health care services. Through the project, an effective referral system has been established between community clinics and district diabetic hospitals and selected eye hospitals in the project area. Government frontline health workers including service providers of community clinics can effectively raise awareness about diabetes and eye health problems.
Md Mamun Hassan
We have been working with Orbis International for over a decade. During this period, we have been able to offer eye care services to numerous people. We are also working with referral services. One of the objectives of the project is to create awareness about diabetic retinopathy among diabetic patients, screen the retina of the patients, and work with community clinics at the grassroots level. Under the project, DR screening was conducted on over 35,000 diabetic patients. Of them, 4,522 people were found DR positive. A total of 1,158 of them received advanced-level treatment, including laser treatment at our hospital.
For raising awareness about DR, we need to give counselling to the diabetic patients coming to the hospital, bring old and new diabetic patients under screening, strengthen ties with community clinics, conduct eye camps in rural areas, and strengthen the referral system.
• Prof Dr AHM Enayet Hussain, Director General, DGME
• National Prof AK Azad Khan, President, BADAS
• Prof Dr Md Robed Amin, Line Director, NCDC, DGHS
• Dr Masud Reza Kabir, Line Director, CBHC, DGHS
• Dr Munir Ahmed, Country Director, Orbis International Bangladesh
• Dr Bishwajit Bhowmik, Project Director BADAS Global Health Research Program
• Md Mamun Hassan, Assistant Director, BADAS Bogura
• Md Shafiqul Haque Chhutu, General Secretary, BADAS Dinajpur
• Sharifuzzaman Parag, Coordinator, Dr K Zaman BNSB Eye Hospital
• Shafiqul Islam, Program Manager, Diabetic Retinopathy Project, Orbis
• Dr Arifur Rahman, Program Manager, Helen Keller International
• Musabbir Alam, Sr. Finance & Operation Manager, Fred Hollows Foundation
• Shiabur Rahman, Executive Editor, The Bangladesh Post
• Dr Sadhana Bhagwat, WHO, Team Leader, NCD
• Khondoker Shamima Akter, CHCP, RaidumRuhi CC, Netrakona Sadar
• Mohammad Awlad Hossain, ME&QA Specialist, Orbis International
• Dr Shamim Talukder, Member Secretary, Bangladesh NCD Forum
• Dr Md Abdul Mazid Osmani, Assistant Director, (Admin- 1), DGME