Field survey for relevance and feasibility of team work for the management of DR in low resource countries

NOTE: This survey is from five hospitals. I have attached all in this document
Objective 4. Field survey for relevance and feasibility of team work for the management of DR in low resource countries
Researchers: Mr Mufarriq Shah, Professor Jill Keeffe, Dr C Alex Harper,
Centre for Eye Research Australia, Department of ophthalmology, University of Melbourne, The Royal Victorian Eye and Ear Hospital

December, 2013
Dear Participant,
The Centre for Eye Research Australia (CERA) conducting a doctoral project to investigate the roles of the eye care workforce (ophthalmologists, optometrists, orthoptists, refractionists, ophthalmic nurses and ophthalmic technicians) in screening/ detection and management of diabetic retinopathy (DR) in low resource countries.
Globally, between 2010 and 2030, the prevalence of diabetes is expected to increase approximately 70% in undeveloped countries and 20% in developed countries. In many developing countries, services of optometrists, orthoptists, refractionists, ophthalmic nurses and ophthalmic technicians are underutilized. Moreover, at present, co-managed care and a team work approach amongst ophthalmologists, optometrists and other health professionals is relatively uncommon in developing countries.
The proposed study aims to investigate barriers to optimal diabetic retinopathy management by investigating the role of the eye care workforce in screening/ detection and co-management strategy in the management of DR in low resource countries. This will involve strategy of TASK SHARING to utilize the services of eye care workers in screening/ detection and management of diabetic retinopathy by adapting the highest level of evidence based practice within the World Health Organization ‘Six pillar’ framework for health system design.
Task sharing: For the purpose of this project Task Sharing has been defined as the rational distribution of tasks among health workforce teams, with specific tasks moved from highly qualified health workers to health workers with shorter training and fewer but adequate qualifications for the task assigned(under supervision), to share tasks and make their collaboration and communication more efficient to achieve a task by co-managing on common ground in order to make efficient use of the available human resources.

The present survey is a part of the above mentioned project and aims to:
Conduct surveys to assess the relevance and feasibility of team work for the management of DR in low resource countries
Your responses will be confidential, and will not be disclosed. The results of this survey will be stored in a secure electronic database at CERA. Through involvement with stakeholders in each of the selected study countries, it will be intended that the co-management strategy model will be presented for possible integration into their eye health strategy and national prevention of blindness plans. Findings from the analysis will be disseminated and will be provided to IAPB Regional Chairs and to stakeholders and individual participants as requested.
Separate formal consent is not sent to you for the emailed survey as consent is assumed if the survey form is completed and returned by you.
Your assistance is much appreciated

Yours sincerely,
Mufarriq Shah
PhD candidate,
Centre for Eye Research Australia, The University of Melbourne, The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
muf@student.unimelb.edu.au

Survey 1
Details of person completing the survey
Name: Dr Mustafa Iqbal Name of Hospital: Khyber teaching Hospital Peshawar Province: Khyber Pakhtoon khwa
Country: Pakistan Date: 01/06/2014
Position: Tick all that apply (double click on box and select checked from default value)
0Dean/Administrator 0General Ophthalmologist 1 Retina specialist
Type of organization(s) you are working in: Tick all that are relevant
1Public/Government 0National prevention of blindness (PBL) committee 0Private 0NGO
What categories of eye care workers are serving in your Institute/Department? Tick all that are relevant
1General Ophthalmologist 1 Retina specialist 1Optometrist 1 Orthoptist 1 Refractionist
1Ophthalmic Nurse 1Ophthalmic technician 0Community health worker 0 other (please mention)

Section 1: Service delivery
1.1. Availability of services
1.1.1. Services available for people with diabetes (DM) and diabetic retinopathy (DR)
Services Yes No
Are people with DM routinely referred for an eye examination? 0
1
Do patients with diabetes attend your facility? 1
0
Do you ask patients visiting the retina clinic if they are known to have diabetes? 1
0
Do you have networks with services for diabetic care? 0
1
Is there a screening program for patients with diabetes for the detection of diabetic retinopathy? If yes, complete section 1.1.3 0
1
Is there community based screening program for DR? 0
1
Do you provide health promotion (Education, information and communication) about DM and DR? If yes, which of the following? 1
0
General advice on diabetes control 1
0
Education about DR prevention 1
0
Education about DR treatment 1
0
Do you have referral pathways with services for diabetes care? 1
0
If yes, please circle 1 or 2
1. One way 2. Reciprocal
Is there Non-Government Organization (NGO) involved in the care for people with DM? 0
1
Is there Non-Government Organization (NGO) involved in the care for people with DR? 0
1
Are low vision services available in your facility for people with DR? 1
0
Are rehabilitation services available in your facility for people with DR? 0
1
Briefly describe:
How ongoing care of people with DM is performed?
Referred to Diabetalogist plus dietician for control of DM, Shared care for complications of DM

Where are the main providers of care for people with DM?( e.g. village, primary health care, tertiary or provincial health care)
Tertiary health care

1.1.2. Coverage of services for managing DR or DM
What is the average number of people with DM attending eye care services per year? 500/month
What is the estimated proportion of all people with DR in the region attending your facility? 300/month
What approaches are being taken to improve the coverage of DR management services?
Response: Started a randomized Control Trial for treatment of PDR
Also trying to start screening services
What barriers are there for services for people with DR?
Response: No cooperation from INGOs like Fred Hollows Foundation and politicisation of eye care in KPK

1.1.3. How screening of DR is performed and by whom?
Activity By whom ( e.g. Ophthalmologist, optometrist, technician)
Visual acuity Technician
Dilated eye examination Ophthalmologist
Mydriatic retinal photography Technician
Non-mydriatic retinal photography N/A
Other( please describe)

Laser 1
0
Ophthalmologist
Vitrectomy 1
0
Ophthalmologist
FFA 1
0
Technician
OCT 1
0
Technician
Other (Please describe)Endo laser 0
0
1.2. Utilization of services
1.2.1. Who benefit from the service(s)?
What is the total population of the area that is serviced by your facility? Difficult to estimate
What is the number of patients with DM that have retinal examination per year? 500
What percentage of patients with DR is treated with retinal laser? 200
Is there any waiting list for laser (time period between the identification for need for laser and performing the laser)? No
1.3. Quality of services
1.3.1. How does the department/eye care facility maintain standards of quality?
Activity Yes No
Does your institute have monitoring and evaluation systems? 1
0
Does your facility follow standard protocols/ guidelines to assess people with DR? 1
0
If Yes, what are the protocols/guidelines followed?
American Academy and NICE protocol
Who has been involved in developing a monitoring and evaluation system?
Response: Head , Himself( Dr Mustafa Iqbal)
1.3. Priorities, policies and programs
Activity Yes No Not sure
Is DM listed as a national health priority? 0
0
1
Is DR listed as a priority in the national prevention of blindness plan? 0
1
0
Does your country has National Diabetes Plan ( NDP)? 0
1
0
Is there national diabetes prevention program? 0
1
0
Is there national diabetes association? 1
0
0
Section 2: Health workforce
2.1. Cadre and Roles
Describe cadres /eye care workforce involved in screening, detection and management of DR at your facility, and the additional activities that could be performed in a task sharing model
Cadre Number Current activities performed relating to screening, detection, and management of DR Activities could be performed in Task Sharing – (Co-management Model)

Ophthalmologists 1 Screening, Treatment SAME
Optometrists 1 Assessment of visual acuity, Refraction Screening
Orthoptist 1 Nil Screening
Refractionist 1 Refraction Screening
Ophthalmic Nurse No role Screening
Nurse assistants No role
Administrative staff No role
Ophthalmic/vision technician No role
Other( Please describe) Diabetalogist
2.2. Qualifications
Educational structure for eye care work force
Cadre name Basic entrance
requirement Duration of Basic pre-service education Clinical Internship duration Name of Degree/diploma What aspects regarding DM and DR are included in course curriculum?
Doctor F.Sc 5 years 1 year MBBS DM diagnosis and management
Ophthalmologist MBBS 4 years 4 year FCPS Diagnosis and management of DR
Optometrist F.Sc 4 years 1 year B.Sc optometry Screening and diagnosis of DR
Orthoptist F.Sc 4 years 1 year B.Sc Orthoptist
Refractionist F.Sc 6 months 1 year Refractionist
Ophthalmic Nurse FA 4 years 1 year Graduate Opht Nurse
Ophthalmic Technician FA 1years 6 Months Diploma
Other( please describe)
2.3. Training of workforce
What training programs are available for eye care workforce?
Activity Yes No
Is there continuing medical education/ refresher programs for staff specifically for management of DR in your facility? 0
1
If yes, how often is the training providing? Describe:

Is there capacity for training of the workforce specifically for management of DR? 1
0
How do you evaluate the effectiveness of training programs? Describe: Clinical Audit

i. Hand-written notes 0
0
ii. Computerized 1
0
iii. Other (Please describe) 0
0
Is there a recall system for patients with DM to have their vision periodically assessed? 0
0
Do you have a record of referrals made to other services? 0
1
Do you provide feedback to the facility that has referred a patient with DM to your facility? 1
0
Do you have data regarding the prevalence of DM in the area served by your facility? 0
1
Who is responsible for entering the health information? Computer operator
How are patients with DR given re-call notices for follow-up examinations? All
What the % age is of people with DM referred from other services? Not sure
What the %age is of people with DM referred to other services? Nil
What strategies are adapted by your department in the community to create awareness of vision impairment due to DR and regular eye examinations? Media 1
Posters in major locations 1
Others __________

What are the barriers to the utilization of linkages and referral pathways for people with DM?
Response: Unawareness, Accessibility, Affordability, No support from Government and INGO like FHF

Section 4: Availability of Technology
4.1. Available resources for managing DR
Equipments available and functional at your facility for the assessment and management of diabetic retinopathy.
Items Available Not Available User (e.g Ophthalmologist, Technician, other)
Distance vision charts 1
0
Technician
Near vision charts 1
0
Optometrist
Trial lens set 1
0
Optometrist
Trial frames 1
0
Optometrist
Auto refractor 1
0
Technician
Tonometer 1
0
Optometrist
Colour vision chart 1
0
Optometrist
Glucometer 1
0
Technician
Slit lamp with accessories 1
0
Optometrist
Streak retinoscope 1
0
Optometrist
Direct ophthalmoscope 1
0
Ophthalmologist
Binocular indirect ophthalmoscope 1
0
Ophthalmologist
Non-mydriatic retinal camera 1
0
Technician
Mydriatic retinal camera 1
0
Optometrist
Argon Laser 1
0
Ophthalmologist
Yag Laser 1
0
Ophthalmologist
Fundus fluorescein angiography 1
0
Technician
Ultrasonography (A scan) 1
0
Technician
Ultrasonography (B Scan) 1
0
Technician
Optical coherence tomography (OCT) 1
0
Technician
Telemedicine equipment 0
1

Vitreoretinal surgical equipment 0
1
VR surgeon is available but no Vitreoretinal surgical equipment
Surgical standard clean running water 0
1

Autoclave (steam steriliser) 1
0
Technician
Steriliser (other) 1
0
Technician
Low vision assessment kit 0
1

Patient medical Record books 1
0
Technician
Computer for health information system records 1
0
Technician
Anti-VEGF 1
0
Ophthalmologist
Others(Please describe) 0

5.2. Support for facility
What are main sources of funding Government
Does the Ministry of Health (government) support you Yes
Does local political groups provide funding No
Does any National/ INGO support you? If yes mention which Their role is obstructionist
Others, please describe
Section 6: Leadership/Governance
Questions Response Tick Describe the roles of each
Who are the key stakeholders overseeing the operation of your facility? Ministry of Health 0

Provincial Government 0

District Government 0

Hospital Administrators 1

Hospital staff 1

Universities/ Teaching institutions 1

Patient advocacy groups 0

Community Leaders 0

NGO 0

Others (Please describe) 0
Self-Regulated
Which personnel are involved in the leadership team of your facility?
Please list and describe their role Self

Are there National/ international guidelines for management of DM? If yes, please describe Nil
Are there National/ international guidelines for management of DR? If yes describe Nil

Survey 2
Details of person completing the survey
Name: Dr Yasir Name of Hospital: COAVS, Mayo Hospital Lahore Province: Punjab
Country: Pakistan Date: 13/05/2014
Position: Tick all that apply (double click on box and select checked from default value)
1Dean/Administrator 0General Ophthalmologist 0 Retina specialist
Type of organization(s) you are working in: Tick all that are relevant
1Public/Government 0National prevention of blindness (PBL) committee 0Private 0NGO
What categories of eye care workers are serving in your Institute/Department? Tick all that are relevant
1General Ophthalmologist 1 Retina specialist 1Optometrist 0 Orthoptist 0 Refractionist
1Ophthalmic Nurse 1Ophthalmic technician 0Community health worker 1 other (please mention) Ophthamic technologists

Section 1: Service delivery
1.1. Availability of services
1.1.1. Services available for people with diabetes (DM) and diabetic retinopathy (DR)
Services Yes No
Are people with DM routinely referred for an eye examination? 1
0
Do patients with diabetes attend your facility? 1
0
Do you ask patients visiting the retina clinic if they are known to have diabetes? 1
0
Do you have networks with services for diabetic care? 0
1
Is there a screening program for patients with diabetes for the detection of diabetic retinopathy? If yes, complete section 1.1.3 1
0
Is there community based screening program for DR? 0
1
Do you provide health promotion (Education, information and communication) about DM and DR? If yes, which of the following? 1
0
General advice on diabetes control 1
0
Education about DR prevention 1
0
Education about DR treatment 1
0
Do you have referral pathways with services for diabetes care? 1
0
If yes, please circle 1 or 2
2. One way 2. Reciprocal
Is there Non-Government Organization (NGO) involved in the care for people with DM? 0
1
Is there Non-Government Organization (NGO) involved in the care for people with DR? 1
0
Are low vision services available in your facility for people with DR? 1
0
Are rehabilitation services available in your facility for people with DR? 1
0
Briefly describe:
How ongoing care of people with DM is performed?
Referral to diabetes clinic in OPD in the same institution

Where are the main providers of care for people with DM?( e.g. village, primary health care, tertiary or provincial health care)
Tertiary health care

1.1.2. Coverage of services for managing DR or DM
What is the average number of people with DM attending eye care services per year? App 15000
What is the estimated proportion of all people with DR in the region attending your facility? Not sure
What approaches are being taken to improve the coverage of DR management services? Not sure
Screening project in community are in pipeline with collaboration of NGOs

What barriers are there for services for people with DR?
Response: Lack of awareness, Services are costly, Remote areas away from facilities

1.1.3. How screening of DR is performed and by whom?
Activity By whom ( e.g. Ophthalmologist, optometrist, technician)
Visual acuity Technologist
Dilated eye examination Ophthalmologist
Mydriatic retinal photography Technologist
Non-mydriatic retinal photography Technologist
Other( please describe)

1.1.4. What components of eye examination and by who are they performed for patients with DM, attending your facility?
Activity Yes No By whom ( e.g. Ophthalmologist, optometrist, technician)
Assessment of visual acuity 1
0
Technician/ Ophthalmic Nurse
Refraction 1
0
Optometrist
Dilated fundoscopy 1
0
Ophthalmologist
Mydriatic retinal photography 1
0
Ophthalmologist
Non mydriatic retinal photography 1
0
Ophthalmologist
Laser 1
0
Ophthalmologist
Vitrectomy 1
0
Ophthalmologist
FFA 1
0
Technologist
OCT 1
0
Technologist
Other (Please describe)Endo laser 1
0
1.2. Utilization of services
1.2.1. Who benefit from the service(s)?
What is the total population of the area that is serviced by your facility? 1 million
What is the number of patients with DM that have retinal examination per year? App. 7500
What percentage of patients with DR is treated with retinal laser? 30%
Is there any waiting list for laser (time period between the identification for need for laser and performing the laser)? Yes one week
1.3. Quality of services
1.3.1. How does the department/eye care facility maintain standards of quality?
Activity Yes No
Does your institute have monitoring and evaluation systems? 1
0
Does your facility follow standard protocols/ guidelines to assess people with DR? 1
0
If Yes, what are the protocols/guidelines followed? ETDRS

Who has been involved in developing a monitoring and evaluation system? AVECENA
Response:
1.3. Priorities, policies and programs
Activity Yes No Not sure
Is DM listed as a national health priority? 1
0
0
Is DR listed as a priority in the national prevention of blindness plan? 1
0
0
Does your country has National Diabetes Plan ( NDP)? 0
0
1
Is there national diabetes prevention program? 0
0
1
Is there national diabetes association? 1
0
0
Section 2: Health workforce
2.1. Cadre and Roles
Describe cadres /eye care workforce involved in screening, detection and management of DR at your facility, and the additional activities that could be performed in a task sharing model
Cadre Number Current activities performed relating to screening, detection, and management of DR Activities could be performed in Task Sharing – (Co-management Model)

Ophthalmologists 40 Detection and Treatment Detection and Treatment
Optometrists 10 Detection Detection
Orthoptist 03 Not involved Not involved
Refractionist 03 Not involved Detection
Ophthalmic Nurse 04 Visual Acuity Visual Acuity
Nurse assistants 04 Not involved Not involved
Administrative staff 06 Not involved Not involved
Ophthalmic/vision technician 06 Visual acuity/ screening Visual acuity/ screening
Other( Please describe) Not involved Not involved
Ophthalmologist technologist 4 Screening Screening

2.2. Qualifications
Educational structure for eye care work force
Cadre name Basic entrance
requirement Duration of Basic pre-service education Clinical Internship duration Name of Degree/diploma What aspects regarding DM and DR are included in course curriculum?
Doctor F.Sc 5 years 1 year MBBS DM diagnosis and management
Ophthalmologist MBBS 2.5 years 2.5 year FCPS Diagnosis and management of DR
Optometrist F.Sc 4 years 1 year B.Sc optometry Screening and diagnosis of DR
Orthoptist F.Sc 4 years 1 year B.Sc Orthoptist
Refractionist F.Sc 2 years 1 year Refractionist screening
Ophthalmic Nurse FA 1 years 1/2 year Graduate Opht Nurse Introduction to DM and DR
Ophthalmic Technician FA 2years 1 year Diploma Introduction to DM and DR
Other( please describe) Introduction to DM and DR
2.3. Training of workforce
What training programs are available for eye care workforce?
Activity Yes No
Is there continuing medical education/ refresher programs for staff specifically for management of DR in your facility? 1
0
If yes, how often is the training providing? Describe:
2 weeks training on DR
Is there capacity for training of the workforce specifically for management of DR? 1
0
How do you evaluate the effectiveness of training programs? Describe:
Post training performance
Section 3: Health Information Management Systems
Activities Yes No
Is there a health information management system for patients’ records in your facility? 0
1
If yes, what of the following information relevant to the assessment of patients with DM is recorded in the medical records? 0
viii. Demographic details 0
1
ix. Type of diabetes 0
1
x. Measurement of risk factor (HbA1c, Fasting blood glucose, Random blood glucose, Lipid levels) 0
1
xi. Presence and stages/ level of severity of DR 0
1
xii. Treatment of diabetes (insulin, oral medications) 0
1
xiii. Treatment of DR (laser, vitreoretinal surgery 0
1
xiv. Other (Please describe) 0
1
How is the health information management system recorded?
iv. Hand-written notes 1
0
v. Computerized 0
1
vi. Other (Please describe) 0
1
Is there a recall system for patients with DM to have their vision periodically assessed? 0
1
Do you have a record of referrals made to other services? 0
1
Do you provide feedback to the facility that has referred a patient with DM to your facility? 1
0
Do you have data regarding the prevalence of DM in the area served by your facility? 1
0
Who is responsible for entering the health information? Computer operator Data entry operator
How are patients with DR given re-call notices for follow-up examinations? N/A
What the % age is of people with DM referred from other services? 10%
What the %age is of people with DM referred to other services? 5%
What strategies are adapted by your department in the community to create awareness of vision impairment due to DR and regular eye examinations? Media 1
Posters in major locations 1
Others __________

What are the barriers to the utilization of linkages and referral pathways for people with DM?
Response: Lack of staff and financial resources

Section 4: Availability of Technology
4.1. Available resources for managing DR
Equipments available and functional at your facility for the assessment and management of diabetic retinopathy.
Items Available Not Available User (e.g Ophthalmologist, Technician, other)
Distance vision charts 1
0
Technician
Near vision charts 1
0
Technician
Trial lens set 1
0
Optometrist/Refractionist
Trial frames 1
0
Optometrist/Refractionist
Auto refractor 1
0
Optometrist/Refractionist
Tonometer 1
0
Ophthalmologist
Colour vision chart 1
0
Optometrist/Refractionist
Glucometer 1
0
Ophthalmic Nurse
Slit lamp with accessories 1
0
Ophthalmologist
Streak retinoscope 1
0
Ophthalmologist
Direct ophthalmoscope 1
0
Ophthalmologist
Binocular indirect ophthalmoscope 1
0
Ophthalmologist
Non-mydriatic retinal camera 1
0
Ophthalmologist
Mydriatic retinal camera 1
0
Ophthalmologist
Argon Laser 1
0
Ophthalmologist
Yag Laser 1
0
Ophthalmologist
Fundus fluorescein angiography 1
0
Ophthalmologist
Ultrasonography (A scan) 1
0
Ophthalmologist/Ophthalmic Technologist
Ultrasonography (B Scan) 1
0
Ophthalmologist/Ophthalmic Technologist
Optical coherence tomography (OCT) 1
0
Ophthalmologist/Ophthalmic Technologist
Telemedicine equipment 0
1

Vitreoretinal surgical equipment 1
0
Technician/Ophthalmic Technologist
Surgical standard clean running water 1
0
Technician
Autoclave (steam steriliser) 1
0
Technician
Steriliser (other) 1
0
Technician
Low vision assessment kit 1
1
Optometreist
Patient medical Record books 1
0
Data entry operator
Computer for health information system records 1
0
Data entry operator
Anti-VEGF 1
0
Ophthalmologist
Others(Please describe) 0
0

5.2. Support for facility
What are main sources of funding Government
Does the Ministry of Health (government) support you Yes
Does local political groups provide funding Yes
Does any National/ INGO support you? If yes mention which Yes
Others, please describe
Section 6: Leadership/Governance
Questions Response Tick Describe the roles of each
Who are the key stakeholders overseeing the operation of your facility? Ministry of Health 1

Provincial Government 1

District Government 1

Hospital Administrators 1

Hospital staff 1

Universities/ Teaching institutions 1

Patient advocacy groups 1

Community Leaders 1

NGO 1

Others (Please describe) 0

Which personnel are involved in the leadership team of your facility?
Please list and describe their role Principal
Assistant Professor
Teaching staff
Are there National/ international guidelines for management of DM? If yes, please describe Yes, ETDRS
Are there National/ international guidelines for management of DR? If yes describe ETDRS

Survey 3
Details of person completing the survey
Name: Dr Nasir Saeed Name of Hospital: Hayatabad Medical Complex Peshawar Province: Khyber Pakhtoonkhwa
Country: Pakistan Date: 12/06/2014
Position: Tick all that apply (double click on box and select checked from default value)
1Dean/Administrator 1General Ophthalmologist 0 Retina specialist
Type of organization(s) you are working in: Tick all that are relevant
1Public/Government 1National prevention of blindness (PBL) committee 0Private 0NGO
What categories of eye care workers are serving in your Institute/Department? Tick all that are relevant
1General Ophthalmologist 1 Retina specialist 1Optometrist 1 Orthoptist 1 Refractionist
1Ophthalmic Nurse 1Ophthalmic technician 0Community health worker 0 other (please mention)

Section 1: Service delivery
1.1. Availability of services
1.1.1. Services available for people with diabetes (DM) and diabetic retinopathy (DR)
Services Yes No
Are people with DM routinely referred for an eye examination? 0
1
Do patients with diabetes attend your facility? 1
0
Do you ask patients visiting the retina clinic if they are known to have diabetes? 1
0
Do you have networks with services for diabetic care? 0
1
Is there a screening program for patients with diabetes for the detection of diabetic retinopathy? If yes, complete section 1.1.3 0
1
Is there community based screening program for DR? 0
1
Do you provide health promotion (Education, information and communication) about DM and DR? If yes, which of the following? 0
1
General advice on diabetes control (Only to patients in attending OPD) 1
0
Education about DR prevention 1
0
Education about DR treatment 1
0
Do you have referral pathways with services for diabetes care? 0
1
If yes, please circle 1 or 2
3. One way 2. Reciprocal
Is there Non-Government Organization (NGO) involved in the care for people with DM? 0
1
Is there Non-Government Organization (NGO) involved in the care for people with DR? 0
1
Are low vision services available in your facility for people with DR? 1
0
Are rehabilitation services available in your facility for people with DR? 0
1
Briefly describe:
How ongoing care of people with DM is performed?
Opportunistic when they visit ophthalmologists

Where are the main providers of care for people with DM?( e.g. village, primary health care, tertiary or provincial health care)
Just treatment in tertiary hospital when they visit by themselves

1.1.2. Coverage of services for managing DR or DM
What is the average number of people with DM attending eye care services per year? No record
What is the estimated proportion of all people with DR in the region attending your facility? No record
What approaches are being taken to improve the coverage of DR management services? No record
Response:

What barriers are there for services for people with DR?
Response: Cost and man-power

1.1.3. How screening of DR is performed and by whom?
Activity By whom ( e.g. Ophthalmologist, optometrist, technician)
Visual acuity Optometrist
Dilated eye examination Ophthalmologist
Mydriatic retinal photography Optometrist
Non-mydriatic retinal photography Optometrist
Other( please describe)

Laser 1
0
Ophthalmologist
Vitrectomy 1
0
Ophthalmologist
FFA 1
0
Optometrist
OCT 1
0
Optometrist
Other (Please describe) 0
0
1.2. Utilization of services
1.2.1. Who benefit from the service(s)?
What is the total population of the area that is serviced by your facility? People may come from anywhere from the whole province even Afghanistan. Not specific population
What is the number of patients with DM that have retinal examination per year? No Record
What percentage of patients with DR is treated with retinal laser? No Record
Is there any waiting list for laser (time period between the identification for need for laser and performing the laser)? Yes
1.3. Quality of services
1.3.1. How does the department/eye care facility maintain standards of quality?
Activity Yes No
Does your institute have monitoring and evaluation systems? 0
1
Does your facility follow standard protocols/ guidelines to assess people with DR? 0
1
If Yes, what are the protocols/guidelines followed?

Who has been involved in developing a monitoring and evaluation system?
Response:
1.3. Priorities, policies and programs
Activity Yes No Not sure
Is DM listed as a national health priority? 0
0
1
Is DR listed as a priority in the national prevention of blindness plan? 1
0
0
Does your country has National Diabetes Plan ( NDP)? 0
0
1
Is there national diabetes prevention program? 0
0
1
Is there national diabetes association? 1
0
0
Section 2: Health workforce
2.1. Cadre and Roles
Describe cadres /eye care workforce involved in screening, detection and management of DR at your facility, and the additional activities that could be performed in a task sharing model
Cadre Number Current activities performed relating to screening, detection, and management of DR Activities could be performed in Task Sharing – (Co-management Model)

Ophthalmologists 17 All levels Management of DR
Optometrists 7 FFA Non-mydriatic FF/OCT
Orthoptist 1 Orthoptics clinic Detection and referral
Refractionist 2 Refraction Detection and referral
Ophthalmic Nurse 3 Not involved Not involved
Nurse assistants 0 Not involved Not involved
Administrative staff 6 Not involved
Ophthalmic/vision technician 5 Visual acuity Not involved
Other( Please describe)
2.2. Qualifications
Educational structure for eye care work force
Cadre name Basic entrance
requirement Duration of Basic pre-service education Clinical Internship duration Name of Degree/diploma What aspects regarding DM and DR are included in course curriculum?
Doctor F.Sc 5 years 1 year MBBS DM diagnosis and management
Ophthalmologist MBBS 4 years 4 year FCPS Diagnosis and management of DR
Optometrist F.Sc 4 years 1 year B.Sc optometry
Orthoptist F.Sc 4 years 1 year B.Sc Orthoptist
Refractionist F.Sc 2 years 1 year Refractionist
Ophthalmic Nurse FA 4 years 1 year Graduate Opht Nurse Screening
Ophthalmic Technician FA 1years 6 Months Diploma
Other( please describe)
2.3. Training of workforce
What training programs are available for eye care workforce?
Activity Yes No
Is there continuing medical education/ refresher programs for staff specifically for management of DR in your facility? 0
1
If yes, how often is the training providing? Describe:

Is there capacity for training of the workforce specifically for management of DR? 0
1
How do you evaluate the effectiveness of training programs? Describe:

vii. Hand-written notes 1
0
viii. Computerized 1
0
ix. Other (Please describe) 0
0
Is there a recall system for patients with DM to have their vision periodically assessed? 0
1
Do you have a record of referrals made to other services? 0
1
Do you provide feedback to the facility that has referred a patient with DM to your facility? 0
1
Do you have data regarding the prevalence of DM in the area served by your facility? 0
1
Who is responsible for entering the health information? Doctors
How are patients with DR given re-call notices for follow-up examinations? Verbally/on OPD chit
What the % age is of people with DM referred from other services? Not sure
What the %age is of people with DM referred to other services? Not sure
What strategies are adapted by your department in the community to create awareness of vision impairment due to DR and regular eye examinations? No Media 0
Posters in major locations 0
Others _____________

What are the barriers to the utilization of linkages and referral pathways for people with DM?
Response: Unawareness, Accessibility, Affordability

Vitreoretinal surgical equipment 1
0
Ophthalmologist
Surgical standard clean running water 0
1

Autoclave (steam steriliser) 1
0
Technician
Steriliser (other) 1
0
Technician
Low vision assessment kit 1
0
Optometrist
Patient medical Record books 1
0
Doctor
Computer for health information system records 1
0
Operator
Anti-VEGF 1
0
Ophthalmologist
Others(Please describe) 0

Section 5: Health Financing
5.1. Expenses for treatment
For specific services provided to the patients with DR, describe and quantify who pays for below procedures
Activity % cost funded by government % cost funded by patient % cost funded by NGO others (Please describe)
Laboratory tests 20% 80%
Retinal examination 100% 0%
Retinal photography 100% 0%
Fluorescein angiography 50% 50%
Laser photocoagulation 60% 40%
Vitreoretinal surgery 50% 50%
Cataract surgery 50% 50%
Intra ocular lens 0% 100%
In hospital medications 20% 80%
5.2. Support for facility
What are main sources of funding Government
Does the Ministry of Health (government) support you Yes
Does local political groups provide funding No
Does any National/ INGO support you? If yes mention which FHF
Others, please describe
Section 6: Leadership/Governance
Questions Response Tick Describe the roles of each
Who are the key stakeholders overseeing the operation of your facility? Ministry of Health 1

Provincial Government 1

District Government 0

Hospital Administrators 1

Hospital staff 1

Universities/ Teaching institutions 1

Patient advocacy groups 0

Community Leaders 0

NGO 1

Others (Please describe) 0

Which personnel are involved in the leadership team of your facility?
Please list and describe their role Dean, Deputy Dean, Chief Executive and management counsel

Are there National/ international guidelines for management of DM? If yes, please describe International Guidelines
Are there National/ international guidelines for management of DR? If yes describe No National Guidelines

Survey 4
Details of person completing the survey
Name: Dr Sheharyar Altaf Name of Hospital: Pakistan Atomic Energy Commission Hospital Rawalpindi Province: Punjab
Country: Pakistan Date: 06/05/2014
Position: Tick all that apply (double click on box and select checked from default value)
0Dean/Administrator 1General Ophthalmologist 0 Retina specialist
Type of organization(s) you are working in: Tick all that are relevant
1Public/Government 0National prevention of blindness (PBL) committee 0Private 0NGO
What categories of eye care workers are serving in your Institute/Department? Tick all that are relevant
1General Ophthalmologist 0 Retina specialist 1Optometrist 0 Orthoptist 0 Refractionist
1Ophthalmic Nurse 1Ophthalmic technician 0Community health worker 0 other (please mention)

Section 1: Service delivery
1.1. Availability of services
1.1.1. Services available for people with diabetes (DM) and diabetic retinopathy (DR)
Services Yes No
Are people with DM routinely referred for an eye examination? 1
0
Do patients with diabetes attend your facility? 1
0
Do you ask patients visiting the retina clinic if they are known to have diabetes? 1
0
Do you have networks with services for diabetic care? 1
0
Is there a screening program for patients with diabetes for the detection of diabetic retinopathy? If yes, complete section 1.1.3 0
1
Is there community based screening program for DR? 0
1
Do you provide health promotion (Education, information and communication) about DM and DR? If yes, which of the following? 1
0
General advice on diabetes control 1
0
Education about DR prevention 1
0
Education about DR treatment 1
0
Do you have referral pathways with services for diabetes care? 1
0
If yes, please circle 1 or 2
4. One way 2. Reciprocal
Is there Non-Government Organization (NGO) involved in the care for people with DM? 0
1
Is there Non-Government Organization (NGO) involved in the care for people with DR? 0
1
Are low vision services available in your facility for people with DR? 0
1
Are rehabilitation services available in your facility for people with DR? 0
1
Briefly describe:
How ongoing care of people with DM is performed?
Known cases are treated and kept on stick follow-up regarding DM and DR. Screening for cases of DR in new cases of DM is also carried out.

Where are the main providers of care for people with DM?( e.g. village, primary health care, tertiary or provincial health care)
Tertiary health care

1.1.2. Coverage of services for managing DR or DM
What is the average number of people with DM attending eye care services per year? More than 500
What is the estimated proportion of all people with DR in the region attending your facility? Not sure
What approaches are being taken to improve the coverage of DR management services? Not sure
Screening of patients attending medicines department. We also pick up cases of early DR and take follow up schedule.

What barriers are there for services for people with DR?
Response: Poor patients follow-up

1.1.3. How screening of DR is performed and by whom?
Activity By whom ( e.g. Ophthalmologist, optometrist, technician)
Visual acuity Optometrist
Dilated eye examination Ophthalmologist
Mydriatic retinal photography Ophthalmologist
Non-mydriatic retinal photography Optometrist
Other( please describe)

Laser 0
1

Vitrectomy 0
1

FFA 0
1

OCT 0
1

Other (Please describe)Endo laser 0
0
1.2. Utilization of services
1.2.1. Who benefit from the service(s)?
What is the total population of the area that is serviced by your facility? 800
What is the number of patients with DM that have retinal examination per year? 500
What percentage of patients with DR is treated with retinal laser? 20-25%
Is there any waiting list for laser (time period between the identification for need for laser and performing the laser)? Laser is not available
1.3. Quality of services
1.3.1. How does the department/eye care facility maintain standards of quality?
Activity Yes No
Does your institute have monitoring and evaluation systems? 1
0
Does your facility follow standard protocols/ guidelines to assess people with DR? 1
0
If Yes, what are the protocols/guidelines followed? ETDRS

Who has been involved in developing a monitoring and evaluation system? Hospital management
Response:
1.3. Priorities, policies and programs
Activity Yes No Not sure
Is DM listed as a national health priority? 0
1
0
Is DR listed as a priority in the national prevention of blindness plan? 1
0
0
Does your country has National Diabetes Plan ( NDP)? 0
0
1
Is there national diabetes prevention program? 0
0
1
Is there national diabetes association? 1
0
0
Section 2: Health workforce
2.1. Cadre and Roles
Describe cadres /eye care workforce involved in screening, detection and management of DR at your facility, and the additional activities that could be performed in a task sharing model
Cadre Number Current activities performed relating to screening, detection, and management of DR Activities could be performed in Task Sharing – (Co-management Model)

Ophthalmologists 2 Screening and Management Screening and follow up by Optometrists
Optometrists 1 Not involved Detection and Follow-up
Orthoptist Not involved
Refractionist Not involved Detection
Ophthalmic Nurse 1 Not involved Follow-up
Nurse assistants Not involved Not involved
Administrative staff Not involved Not involved
Ophthalmic/vision technician 1 Visual acuity VA and assist in intravitral
Other( Please describe)
2.2. Qualifications
Educational structure for eye care work force
Cadre name Basic entrance
requirement Duration of Basic pre-service education Clinical Internship duration Name of Degree/diploma What aspects regarding DM and DR are included in course curriculum?
Doctor F.Sc 5 years 1 year MBBS DM diagnosis and management
Ophthalmologist MBBS 4 years 4 year FCPS Diagnosis and management of DR
Optometrist F.Sc 4 years 1 year B.Sc optometry Screening and diagnosis of DR
Orthoptist F.Sc 4 years 1 year B.Sc Orthoptist
Refractionist F.Sc 6 months 1 year Refractionist screening
Ophthalmic Nurse FA 4 years 1 year Graduate Opht Nurse screening
Ophthalmic Technician FA 1years 6 Months Diploma screening
Other( please describe)
2.3. Training of workforce
What training programs are available for eye care workforce?
Activity Yes No
Is there continuing medical education/ refresher programs for staff specifically for management of DR in your facility? 0
1
If yes, how often is the training providing? Describe:

Is there capacity for training of the workforce specifically for management of DR? 0
1
How do you evaluate the effectiveness of training programs? Describe:

Section 3: Health Information Management Systems
Activities Yes No
Is there a health information management system for patients’ records in your facility? 1
0
If yes, what of the following information relevant to the assessment of patients with DM is recorded in the medical records? 0
xxii. Demographic details 0
1
xxiii. Type of diabetes 1
0
xxiv. Measurement of risk factor (HbA1c, Fasting blood glucose, Random blood glucose, Lipid levels) 0
1
xxv. Presence and stages/ level of severity of DR 1
0
xxvi. Treatment of diabetes (insulin, oral medications) 1
0
xxvii. Treatment of DR (laser, vitreoretinal surgery 0
1
xxviii. Other (Please describe) 1
0
How is the health information management system recorded?
x. Hand-written notes 0
0
xi. Computerized 1
0
xii. Other (Please describe) 0
1
Is there a recall system for patients with DM to have their vision periodically assessed? 1
0
Do you have a record of referrals made to other services? 1
0
Do you provide feedback to the facility that has referred a patient with DM to your facility? 0
1
Do you have data regarding the prevalence of DM in the area served by your facility? 0
1
Who is responsible for entering the health information? Doctors/Optometrist
How are patients with DR given re-call notices for follow-up examinations? By phone call/ FU appointment
What the % age is of people with DM referred from other services? 5-10%
What the %age is of people with DM referred to other services? 5-10%
What strategies are adapted by your department in the community to create awareness of vision impairment due to DR and regular eye examinations? Media 0
Posters in major locations 0
Others _ _________

What are the barriers to the utilization of linkages and referral pathways for people with DM?
Response: Poor compliance, Affordability

Mydriatic retinal camera 0
1

Argon Laser 0
1

Yag Laser 1
0
Ophthalmologist
Fundus fluorescein angiography 0
1

Ultrasonography (A scan) 1
0
Technician
Ultrasonography (B Scan) 1
0
Technician
Optical coherence tomography (OCT) 0
1

Telemedicine equipment 0
1

Vitreoretinal surgical equipment 0
1

Surgical standard clean running water 1
1

Autoclave (steam steriliser) 1
0
Technician
Steriliser (other) 0
1

Low vision assessment kit 0
1

Patient medical Record books 0
1

Computer for health information system records 1
0
Technician
Anti-VEGF 1
0
Ophthalmologist
Others(Please describe) 0
0

5.2. Support for facility
What are main sources of funding Government
Does the Ministry of Health (government) support you Yes
Does local political groups provide funding No
Does any National/ INGO support you? If yes mention which No
Others, please describe
Section 6: Leadership/Governance
Questions Response Tick Describe the roles of each
Who are the key stakeholders overseeing the operation of your facility? Ministry of Health 0

Provincial Government 0

District Government 0

Hospital Administrators 1

Hospital staff 0

Universities/ Teaching institutions 0

Patient advocacy groups 0

Community Leaders 0

NGO 0

Others (Please describe) 0

Which personnel are involved in the leadership team of your facility?
Please list and describe their role Departmental hospital management

Are there National/ international guidelines for management of DM? If yes, please describe Not sure
Are there National/ international guidelines for management of DR? If yes describe ETDRS

Survey 5
Details of person completing the survey
Name: Dr Wajid Ali Khan Name of Hospital: Al-Shifa Trust eye Hospital Rawalpindi Province: Punjab
Country: Pakistan Date: 02/06/2014
Position: Tick all that apply (double click on box and select checked from default value)
1Dean/Administrator 1General Ophthalmologist 0 Retina specialist
Type of organization(s) you are working in: Tick all that are relevant
0Public/Government 1National prevention of blindness (PBL) committee 0Private 1NGO
What categories of eye care workers are serving in your Institute/Department? Tick all that are relevant
1General Ophthalmologist 1 Retina specialist 1Optometrist 1 Orthoptist 1 Refractionist
1Ophthalmic Nurse 1Ophthalmic technician 1Community health worker 0 other (please mention)

Section 1: Service delivery
1.1. Availability of services
1.1.1. Services available for people with diabetes (DM) and diabetic retinopathy (DR)
Services Yes No
Are people with DM routinely referred for an eye examination? 1
0
Do patients with diabetes attend your facility? 1
0
Do you ask patients visiting the retina clinic if they are known to have diabetes? 1
0
Do you have networks with services for diabetic care? 0
1
Is there a screening program for patients with diabetes for the detection of diabetic retinopathy? If yes, complete section 1.1.3 1
0
Is there community based screening program for DR? 0
1
Do you provide health promotion (Education, information and communication) about DM and DR? If yes, which of the following? 1
0
General advice on diabetes control 1
0
Education about DR prevention 1
0
Education about DR treatment 1
0
Do you have referral pathways with services for diabetes care? 0
1
If yes, please circle 1 or 2
5. One way 2. Reciprocal
Is there Non-Government Organization (NGO) involved in the care for people with DM? 0
1
Is there Non-Government Organization (NGO) involved in the care for people with DR? 1
0
Are low vision services available in your facility for people with DR? 1
0
Are rehabilitation services available in your facility for people with DR? 1
0
Briefly describe:
How ongoing care of people with DM is performed?
Opportunistic when they visit ophthalmologists

Where are the main providers of care for people with DM?( e.g. village, primary health care, tertiary or provincial health care)
village, tertiary and provincial health care

1.1.2. Coverage of services for managing DR or DM
What is the average number of people with DM attending eye care services per year? 24000
What is the estimated proportion of all people with DR in the region attending your facility? 50%
What approaches are being taken to improve the coverage of DR management services? Not Sure
Response: Camps, HRD, Conferences, Pamphlets, Radio

What barriers are there for services for people with DR?
Response: Cost and man-power, Socio-economic status, No networking, infrastructure

Laser 1
0
Ophthalmologist
Vitrectomy 1
0
Ophthalmologist
FFA 1
0
Technician
OCT 1
0
Technician
Other (Please describe)Endo laser 1
0
Ophthalmologist

1.2. Utilization of services
1.2.1. Who benefit from the service(s)?
What is the total population of the area that is serviced by your facility? 5 million
What is the number of patients with DM that have retinal examination per year? 24000
What percentage of patients with DR is treated with retinal laser? 25%
Is there any waiting list for laser (time period between the identification for need for laser and performing the laser)? Yes
1.3. Quality of services
1.3.1. How does the department/eye care facility maintain standards of quality?
Activity Yes No
Does your institute have monitoring and evaluation systems? 1
0
Does your facility follow standard protocols/ guidelines to assess people with DR? 1
0
If Yes, what are the protocols/guidelines followed?
ETDRS
Who has been involved in developing a monitoring and evaluation system?
Response: Hospital Management
1.3. Priorities, policies and programs
Activity Yes No Not sure
Is DM listed as a national health priority? 0
0
1
Is DR listed as a priority in the national prevention of blindness plan? 1
0
0
Does your country has National Diabetes Plan ( NDP)? 0
1
0
Is there national diabetes prevention program? 0
1
0
Is there national diabetes association? 1
0
0
Section 2: Health workforce
2.1. Cadre and Roles
Describe cadres /eye care workforce involved in screening, detection and management of DR at your facility, and the additional activities that could be performed in a task sharing model
Cadre Number Current activities performed relating to screening, detection, and management of DR Activities could be performed in Task Sharing – (Co-management Model)

Ophthalmologists Many in all categories All levels SAME
Optometrists Refraction Diagnosis of DR and funduscopy
Orthoptist Orthoptics clinic No
Refractionist Refraction Detection of DR and referral
Ophthalmic Nurse OT No
Nurse assistants Registration, Dates for follow-up screening
Administrative staff Administration/Management Developing linkages
Ophthalmic/vision technician Visual acuity Visual acuity
Other( Please describe)
2.2. Qualifications
Educational structure for eye care work force
Cadre name Basic entrance
requirement Duration of Basic pre-service education Clinical Internship duration Name of Degree/diploma What aspects regarding DM and DR are included in course curriculum?
Doctor F.Sc 5 years 1 year MBBS DM diagnosis and management
Ophthalmologist MBBS 4 years 4 year FCPS Diagnosis and management of DR
Optometrist F.Sc 4 years 1 year B.Sc optometry Screening and diagnosis of DR
Orthoptist F.Sc 4 years 1 year B.Sc Orthoptist
Refractionist F.Sc 6 months 1 year Refractionist
Ophthalmic Nurse FA 4 years 1 year Graduate Opht Nurse
Ophthalmic Technician FA 1years 6 Months Diploma
Other( please describe)
2.3. Training of workforce
What training programs are available for eye care workforce?
Activity Yes No
Is there continuing medical education/ refresher programs for staff specifically for management of DR in your facility? 1
0
If yes, how often is the training providing? Describe:
Included in training
Is there capacity for training of the workforce specifically for management of DR? 1
0
How do you evaluate the effectiveness of training programs? Describe:
Assessment of students and trainee
Section 3: Health Information Management Systems
Activities Yes No
Is there a health information management system for patients’ records in your facility? 1
0
If yes, what of the following information relevant to the assessment of patients with DM is recorded in the medical records? 0
xxix. Demographic details 1
0
xxx. Type of diabetes 0
0
xxxi. Measurement of risk factor (HbA1c, Fasting blood glucose, Random blood glucose, Lipid levels) 0
0
xxxii. Presence and stages/ level of severity of DR 1
0
xxxiii. Treatment of diabetes (insulin, oral medications) 1
0
xxxiv. Treatment of DR (laser, vitreoretinal surgery 1
0
xxxv. Other (Please describe) 1
0
How is the health information management system recorded? 1

xiii. Hand-written notes 1
0
xiv. Computerized 1
0
xv. Other (Please describe) 0
0
Is there a recall system for patients with DM to have their vision periodically assessed? 0
0
Do you have a record of referrals made to other services? 0
1
Do you provide feedback to the facility that has referred a patient with DM to your facility? 1
0
Do you have data regarding the prevalence of DM in the area served by your facility? 0
1
Who is responsible for entering the health information? Computer operator
How are patients with DR given re-call notices for follow-up examinations? 10%
What the % age is of people with DM referred from other services? Not sure
What the %age is of people with DM referred to other services? 15%
What strategies are adapted by your department in the community to create awareness of vision impairment due to DR and regular eye examinations? Media 1
Posters in major locations 0
Others _Pamphlets__________

What are the barriers to the utilization of linkages and referral pathways for people with DM?
Response: Unawareness, Accessibility, Affordability

Section 4: Availability of Technology
4.1. Available resources for managing DR
Equipments available and functional at your facility for the assessment and management of diabetic retinopathy.
Items Available Not Available User (e.g Ophthalmologist, Technician, other)
Distance vision charts 1
0
Technician
Near vision charts 1
0
Optometrist
Trial lens set 1
0
Optometrist
Trial frames 1
0
Optometrist
Auto refractor 1
0
Technician
Tonometer 1
0
Optometrist
Colour vision chart 1
0
Optometrist
Glucometer 1
0
Technician
Slit lamp with accessories 1
0
Optometrist
Streak retinoscope 1
0
Optometrist
Direct ophthalmoscope 1
0
Ophthalmologist
Binocular indirect ophthalmoscope 1
0
Ophthalmologist
Non-mydriatic retinal camera 0
1
Technician
Mydriatic retinal camera 1
0
Optometrist
Argon Laser 1
0
Ophthalmologist
Yag Laser 1
0
Ophthalmologist
Fundus fluorescein angiography 1
0
Technician
Ultrasonography (A scan) 1
0
Technician
Ultrasonography (B Scan) 1
0
Technician
Optical coherence tomography (OCT) 1
0
Technician
Telemedicine equipment 0
1
Ophthalmologist
Vitreoretinal surgical equipment 1
0
Ophthalmologist
Surgical standard clean running water 0
1
Technician
Autoclave (steam steriliser) 1
0
Technician
Steriliser (other) 1
0
Technician
Low vision assessment kit 1
0
Optometrist
Patient medical Record books 1
0
Technician
Computer for health information system records 1
0
Technician
Anti-VEGF 1
0
Ophthalmologist
Others(Please describe) 0

5.2. Support for facility
What are main sources of funding Donations, Hospital Income, Government, INGOs, NGOs
Does the Ministry of Health (government) support you Yes
Does local political groups provide funding No
Does any National/ INGO support you? If yes mention which Yes
Others, please describe
Section 6: Leadership/Governance
Questions Response Tick Describe the roles of each
Who are the key stakeholders overseeing the operation of your facility? Ministry of Health 0

Provincial Government 0

District Government 0

Hospital Administrators 1

Hospital staff 1

Universities/ Teaching institutions 1

Patient advocacy groups 0

Community Leaders 0

NGO 0

Others (Please describe) 0

Which personnel are involved in the leadership team of your facility?
Please list and describe their role President of Trust, Trustee board, Executive directors, Dean, Academic Counsel

Are there National/ international guidelines for management of DM? If yes, please describe Not sure
Are there National/ international guidelines for management of DR? If yes describe Yes. ETDRS

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Field survey for relevance and feasibility of team work for the management of DR in low resource countries

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