Nayantara : An integrated mobile service for treatment of diabetic retinopathy in semi urban and rural India Dr. Mohita Sharma Chief Ophthalmologist Tirupati Eye Centre Noida, India

India : home of largest number of diabetics in the world WHO estimation of diabetes 135 million in 1995 to 300 million in 2025 Indian estimation 18 million in 1995 to 54 million in 2025 (195 %) INDIA- largest diabetic population million (followed by China 43.2 million)

Indian Challenge 70% people live in rural areas 70 % ophthalmologists live in urban areas Majority of diabetics are undiagnosed UNDIAGNOSED CASES 2/3 in urban ¾ in rural areas

Uttar Pradesh No population based surveys on diabetic retinopathy Most populous state 190 million population 16.4 % of whole population

Barriers for treatment of DR FFALASER Unable to perform/interpret45 %60 % Equipment costly71.25 % Patients cannot afford35 % Number of patients doesnt justify investment 70 % Instruments is/are unnecessary 12.5 %

Solutions Share equipment A mobile van Sound economic model aimed at Sustainable Charity Economic incentive for local doctor Offer free service for the poor

Project: Tirupati Eye Centre DR Mobile Unit Diagnosis and treatment of DR and complications 5 districts of Western UP Mobile unit Pre decided route map Local ophthal, GPs access to equipments

Mobile unit details Heat- AC- temp regulation Dust- air ionizer- dust free Electric power supply- generator, UPS Voltage fluctuation- stabilizers

Team in the mobile unit Trained retina consultant Optometrist Paramedical worker Driver

Work at mobile unit

Free of cost treatment to poor patients and minimal charges to those who can pay Refuse treatment to none for want of money

Sound economic model Minimal charges for those who can pay Earnings are shared between the local Doctor (ophthalmologist/ physician) and the Project Physician/Ophthalmologist – Timely eye treatment EARN WHILE THEY LEARN/TREAT Project income– SELF SUSTAINABLE

Target population 231,402 diabetics Diabetic retinopathy 67,106 in this population Treatment would prevent 1735 people from becoming blind.

Training Ophthalmologist trained in retina on board Each participating ophthalmologist individually trained on the stopovers Lot of enthusiasm to learn

CMEs/ training sessions with lectures

Model eye laser session Doctors use the laser machine to obtain burns in the model eye Concept of spot size, power, duration, interval and its effect in model eye are understood

Doctors Training

AMC CME Date: 09 th Oct Physicians

Training session : Local health workers

Training sessions- Booklets Hindi and English For Doctors as well as lay public

Community participation- religious organizations and clubs Noida Diabetes Forum Lions Club Sai Temple

Diabetes Camp at Haldwani

What we have achieved Achieved Trained ophthalmologists98 Trained GPs142 Trained healthcare workers102 DR screening14565 FFAs3830 Lasers4689 Perimetries3607

Lessons learnt Training most important aspect- retained interest of ophthalmologists, GPs also need a continuous reinforcement by training in steps: 1. CMEs 2.Practical training- screening for DR changes on retina Regular training sessions-1 time training not sufficient, assessment of the adequacy of training and capacity building

Training of already trained ophthalmologists

Lessons learnt Semi urban areas- patients- paying capacity not very low. Project has reached self sustainability in 50% of its expenses Semi urban areas- ophthalmologists- low cost lasers and FFAs

Challenges ahead Manage the running costs by income generated on the van Replace van and equipment periodically Add on new districts to the area of coverage Replicate the design in other parts of India and the world

Conclusion Empowering local community/professionals to access quality care, skills and knowledge Taking superspeciality care for treatment of diabetic retinopathy to the unreached

If you want to feed a man for one day, serve him fish. If you want to feed him for life, teach him fishing

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