Download WG1 - Programme Documentation

Innovation Fund Project Proposal
SIF104
1. Background information
1.1. Organisation Name
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences (AIIMS)
1.2. Organisation Address
All India Institute of Medical Sciences, Ansari Nagar,
New Delhi, INDIA-110029
1.3. Type of Organisation
Which of the following best
describes your organisation?
(Select a maximum of two
categories)
1.4. Main contact person
1.5. Country(ies)/ area(s) &
districts of planned project
Non-Governmental Organisation (NGO)
Blind Peoples’ Organisation (BPO)
Disabled Peoples’ Organisation (DPO)
Organisation working with Disabled People
Academic Institution
Ethnic Minority Group or Organisation
Name: Dr. Praveen Vashist, MD, MSc (CEH), LSHTM
Additional Professor and Head
Department of Community Ophthalmology
Email: [email protected]
[email protected]
Phone: 011-26593140
India, North India, New Delhi
Developing a cost-effective model for communitybased screening of Diabetic Retinopathy in urban
slums of Delhi.
1.6. Project name
1.7. Authors of Proposal
Dr.Praveen Vashist, Prof. Rajvardhan Azad, Dr. Sumit
Malhotra, Dr. Suraj Singh Senjam, Dr. Noopur Gupta,
Dr. Aparna Gupta, Dr. Rajesh Khadgawat
2. Core Innovation Project Information
Eye Health Challenges
Challenge No. 1
Challenge No. 2
Challenge No. 3
Challenge No. 4
2.1.
Implementatio
n Challenge
the project
addresses
(Please tick the
relevant box)
Inclusive Education Challenges
Challenge No. 1
Challenge No. 2
Challenge No. 3
Challenge No. 4
Social Inclusion Challenges
Challenge No. 1
Challenge No. 2
Challenge No. 3
Challenge No. 4
Innovation Fund Project Proposal
2. Core Innovation Project Information
2.3.Backgroun
d information
and project
rationale
Type 2 Diabetes Mellitus is an emerging new-age epidemic in modern world and
Diabetic Retinopathy is the most common complication. It is becoming an
important cause of visual impairment and
blindness in India. One fifth of the world’s
blindness
is
contributed
by
India
(approximately 7.8 million). With increase in
diabetics in India, occurrence of DR in India
and its contribution to blindness is likely to
face inflation. However due to lack of a
definite nationwide screening program, the
currently available figures represent only the
tip of the iceberg. Further, since Diabetic
Retinopathy management requires tertiary
eye care services, which are not accessible
to majority of the population, most cases go undetected and present to hospitals
well past the stages of treatable blindness.
There is a vast disparity in the prevalence of Diabetes Mellitus in urban versus
rural India (Ahuja et al,1991 ). The urban Indians are more predisposed to
developing the disease due to sedentary lifestyle, increased body fat and more
stressful life (Deepa et al, 2006). Hence, we propose to undertake this study in
urban areas of Delhi.
As per 2011 census, the population of Delhi is 16.9 million and 3.2 million (19%)
lived in notified slum areas. Delhi’s slums embody some of the worst instances
of urban poverty and inequality. The vast majority of the slum-dwellers comprise
of daily-wage workers, factory workers, unskilled and semi-skilled workers, and
rag-pickers. Poverty, overpopulation, ignorance, poor environmental hygiene
and lack of healthcare facilities lead to a high degree of morbidity in these areas,
including eye diseases.
There is an urgent need to provide accessible diabetes management services,
including identification of complications early, to these urban slums, where
health awareness and the access to healthcare is poor. The incidence of
Diabetes Mellitus in previous studies conducted in slums of Delhi has been
found to be around 10% (Verma et al,2000; Misra et al, 2001). The prevalence
of known Diabetics in urban population of India is estimated to be around 5% by
earlier studies (Mohan et al, 2003). The prevalence of Diabetic Retinopathy
among known diabetics in urban population is reported to be around 20-26%
(Mohan et al, 2003; Narendran et al, 2002). We plan to reduce the burden of
blindness in this underserved segment of urban population., Currently, the
population-based models of Diabetic Retinopathy screening involve fully
equipped mobile vans with or without telemedicine setup which are very
expensive to create and sustain. Our model proposes a cost-effective and
sustainable approach to population screening of Diabetic Retinopathy, its
identification and management by involving community level and health care
providers trained volunteers, local general practitioners, pharmacists,
laboratories, optometrists and a tertiary care public hospital for imparting
services to the needy population.
2
Innovation Fund Project Proposal
2. Core Innovation Project Information
2.4 Project
Duration
(please note this
18 months
can be for a
maximum of 18
months)
2.5.
Organisations
targeted for
replication,
and strategy to
achieve scale
Multidisciplinary public/private hospitals/clinics with a retina unit.
This seems to be a cost-effective approach to screening and management of
Diabetic Retinopathy in the population. We propose a four pronged strategy:
1. Creating awareness of DM and DR in target population
2. Identification and referral of Known Diabetics in the population
3. Community based screening using low cost device.
4. Timely management by referral to tertiary care retina unit
The process is adopted from reach-in program approach recommended by
Government of India, which includes screening at primary level and
management at the base hospital. The success of this model could prompt
initiation of diabetic retinopathy screening at primary-eye care level, and a
reach-in approach to bring all those in need of intervention to the tertiary care
centre for management (similar to our reach-in program for cataract
associated blindness)
2.6. Other
organisations
working on
related issues
in the project
area
The project will be implemented with the support of local Community Based
Organisations (CBOs) and religious organisations working in urban slums of
Delhi, who are involved in screening of Diabetes, awareness generation and
organisation of DR screening camps, in collaboration with the public hospitals
and private practitioners. We have successfully run community-based eye care
programs with the support of Sightsavers International, where some of these
local non-government organisations were involved like ASHA, Deepalaya,
Mamta, Casplan, HOST foundation, Kalyanam, Arpana Charitable Trust,
Agarwal Sabha, Jain sabha, Nirankari foundation for more than ten years.
2.7. What is the
total cost of
the project?
GBP 112,178
(In GBP
sterling)
2.8. Total
funding to be
requested from
Sightsavers for
GBP 74,987
this project
(In GBP sterling
- Maximum:
£50,000)
3
Innovation Fund Project Proposal
2.9 Summary of proposed Goal, Purpose, Expected Outcomes, Outputs and activities
It is important to give the reviewers a clear idea of what the project’s Goal and Purpose (what it aims to achieve) might be, and the desired
outcomes (which will later be translated into specific objectives), outputs, and some illustrative examples of activities that will be implemented in
the first year. It is not necessary to develop a full logical framework at this stage. What is important is for you to demonstrate and articulate a
clear overview of your “theory of change” i.e. ‘HOW’ the project will effect the change it seeks to achieve and respond to the problems identified.
Goal
(What is the overall, higher-level objective to
which the project/programme will contribute?)
To eliminate avoidable blindness due to Diabetic Retinopathy in developing nations.
Purpose (Overall Objective)
Expected outcomes (5 max)
Expected outputs
Main activities
(What is the positive developmental change
that the project will produce if successful?)
(What are the expected short and medium
term effects of the interventions outputs?)
(What are the deliverables achieved as a
result of implementing project activities?)
(Examples of top line activities)
1. Increased awareness
regarding Diabetes Mellitus
(DM) and Diabetic
Retinopathy(DR) and its
management in the target
population
To develop a feasible and
sustainable model for screening
and management of Diabetic
Retinopathy in the Indian
population
1. Awareness generation for
Diabetes and Diabetic Eye
Disease in urban slum population
2. Increase in number of DM
patients picked up from the
community and increased
referral for DR screening
1.Assesing current situation
of awareness regarding DM
and DR in urban slums
2. Developing publicity
material for awareness
regarding DM and DR
including management and
follow up.
3. Conducting 150 Eye
Health Education events on
DM and DR
1.Training healthcare
workers, volunteers and local
general practitioners in
identification and referral of
Known Diabetics (KD)- 25
training events
4
Innovation Fund Project Proposal
Purpose (Overall Objective)
Expected outcomes (5 max)
Expected outputs
Main activities
(What is the positive developmental change
that the project will produce if successful?)
(What are the expected short and medium
term effects of the interventions outputs?)
(What are the deliverables achieved as a
result of implementing project activities?)
(Examples of top line activities)
2. Development of a rapid,
cost-effective tool for
community-based
screening of DR
3. Increase in referral of
diabetic patients by promoting
awareness and counselling
2.Using opportunistic model
for identification and referral
of DM patients
1. Developing a rapid and
convenient method for DR
screening by using a portable,
user friendly and non mydriatic
fundus camera.
1.Training of Optometrist in
non-mydriatic fundus
photography and DR
identification
2.Using hand-held nonmydriatic fundus camera in
the community
1. Conducting 150 DR
screening camps in slum
clusters in one year
1.Transportation of subjects
requiring intervention to
tertiary care hospital
1.Subsidized evaluation of
referred subjects using OCT
and Fundus Fluorescein
Angiography
2. Expert review on the
preferred line of
management
1. Subsidised treatment cost
for intravitreal injections,
laser, surgery, wherever
needed
2. Increased number of
Diabetics being screened for
DR at primary level
1. Increased number of DR
being taken for treatment
2. Quality eye-care provided to
those in need of intervention
1. Referral and cost-effective
services for Diabetic
Retinopathy in a tertiary
care hospital
3. The treatment will be
provided at a subsidised cost,
utilising infrastructure of public
tertiary care hospital
5
Innovation Fund Project Proposal
Purpose (Overall Objective)
Expected outcomes (5 max)
Expected outputs
Main activities
(What is the positive developmental change
that the project will produce if successful?)
(What are the expected short and medium
term effects of the interventions outputs?)
(What are the deliverables achieved as a
result of implementing project activities?)
(Examples of top line activities)
1. Coverage of 1 million
population in Delhi slums
4. Reduction in the burden of
blindness due to DR.
5. Model for a nationwide
screening program for Diabetic
Retinopathy
2. Identification of Known
Diabetics(KDs) and their
screening for DR
3. Early detection of slight
threatening DR and quality
management of all cases for
prevention of blindness
1. Successful implementation of
the project with specified
targets.
2. Advocacy of the model to
Government of India& policy
makers for blindness control at
national level
3. Presentation of model in
National and International
conferences and submission to
indexed journal
1. Training of 200 volunteers
for identification of Known
Diabetics
1. Conducting 150 camps for
screening of DR in one year
1. Adequate management of
all referred cases at base
hospital at subsidised cost
1. Periodic monitoring of all
the targets
2. Review meetings
periodically
1. Meeting key officials in
Government and seeking
their opinions
2. Sharing success stories
1. Presentation in at least 2
National and International
conferences and submission
in at least one indexed
journal
6
Innovation Fund Project Proposal
3. Detailed Innovation Project Information
3.1. Why is this project needed at this time in this location?
India is currently home to more than 50 million diabetics and 20% of them develop
Diabetic Retinopathy (DR) at a given time, further the lifetime chances of developing DR
for a diabetic patient is more than 80%. The prevention of blindness due to DR is
considered to be an international priority as it mainly affects the economically productive
age-group, unlike cataract and AMD.
Delhi’s slums embody some of the worst instances of urban poverty and inequality. The
squalor of urban slums paired with overpopulation and a lack of healthcare facilities mean
that diseases and malnutrition contributing to the onset of blindness are rife. These
people seek help for health problems in their immediate vicinity, to prevent loss of wages
and save time that may be used to earn money. It is imperative that community based
integrated comprehensive eye care services be provided to this segment of the
population at their doorstep.
The penetration of healthcare services in slums is poor due to lack of basic infrastructure
and hygiene. Hence health awareness and delivery of health services remain a big
challenge in these underserved areas.
3.2. What specific change is this initiative intended to achieve?
We intend to achieve elimination of avoidable blindness due to DR in urban slums of
Delhi, health-awareness generation, increase in health-seeking behavior and better
quality of life.
The project is planned to cover 1 million population directly.
Following are the Project assumptions:
1. Around 20% population is in the age-group of 40+ years in targeted slum clusters
2. Estimated prevalence of Known Diabetics is around 5% in 40+ population.
3. Prevalence of Diabetic Retinopathy among known diabetics is around 20-25%.
4. Around 10% of Diabetic Retinopathy cases need intervention in form of laser/
intravitreal injection/ surgery.
3.3. What is the methodology and approach to be used by the project to achieve the
changes described?
Describe briefly the main activities of the project?
1.Training healthcare workers, volunteers and local general practitioners in identification
and referral of Known Diabetics (KD)- 200 volunteers in 25 training events.
2. Using opportunistic model for identification and referral of DM patients Creating
awareness in the target area with the help of community healthcare
workers and
volunteers.
3. Training of Optometrist in using hand-held non-mydriatic fundus camera in the
community for DR identification.
4. Conducting 150 DR screening camps in slum clusters in one year.
5. Subsidized evaluation of referred subjects using OCT and Fundus Fluorescein
Angiography and subsidised treatment for intravitreal injections, laser, surgery, wherever
needed.
6. Periodic monitoring of all targets.
7. Meeting key officials in GOI and seeking their opinion for making the program
sustainable.
7
Innovation Fund Project Proposal
3. Detailed Innovation Project Information
3.4 Who will be carrying out the project activities?
The project will be implemented by Department of Community Ophthalmology, Dr.
Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi
All India Institute of Medical Sciences (AIIMS) is an apex health care institute for
research, training and health-care delivery in India catering to nearly 2 million patients per
year. The Health minister of Government of India is ex-officio president of the Institute.
The eye hospital of AIIMS, Dr. Rajendra Prasad Centre for Ophthalmic Sciences is
recognized as the apex body of all ophthalmic institutions in the country by Government
of India under National Programme for Control of Blindness (NPCB). Our centre is the
first WHO collaborative centre for prevention of blindness and primary eye care activities
in SEAR region. The Chief of Dr. R.P. Centre is advisor to Government of India for eyehealth related policies. Hence, the organization is in unique position and capability to
chalk out a roadmap for future policy of Government of India on a “National Screening
Program for Diabetic Retinopathy”.
The hospital is equipped with world class infrastructure and state of art equipment, to
manage all eye diseases. There is a distinguished faculty of experts in all ophthalmic subspecialties including retina which will ensure best service delivery to our target population.
It caters to 0.4 million patients per year. The treatment cost is heavily subsidized to suit
the poor population of India. It is the only public hospital with a dedicated community
ophthalmology department. We have 3 permanent faculty members and the department
is involved in community eye health related research, training and service delivery. The
department in the last 10 years has handled 25 research projects, national level surveys
and training programs in collaboration with agencies like Sightsavers International,
ORBIS, OEU, Wellcome trust, WHO, ICMR and NPCB and Government of India.
We have implemented 3 projects with SSI in urban slums and are sustaining them in 12
slum clusters.
Public health specialists from Community ophthalmology department and
ophthalmologists from retina unit were involved in designing the project.
We propose to implement the project in partnership with Sightsavers International,
Community Based Organisations (CBOs), local religious organisations, NGOs and
Government of India with which we have already worked in the past.
RPC has been working with Sightsavers since the last 10 years demonstrating
approaches to addressing eye health needs of urban poor in slums. Over the years the
key learning has been that meeting the unmet eye care needs of poor can be more
effectively undertaken by Government in collaboration with NGOs working in these
difficult situations. The community based NGOs have a strong presence, sustained and
harmonized relationship with community members which will be utilised while
implementing this project. This will also contribute to the sustainability of this model.
8
Innovation Fund Project Proposal
3. Detailed Innovation Project Information
3.5. Innovation: Why is this approach considered to be innovative? .
The current approach used by many institutions for screening of Diabetic Retinopathy
involves
1. Inviting ophthalmologists to diabetic eye check-up camps once in a while, which is
not sustainable since it requires taking out time from a busy practice and there is
no assured treatment or follow-up. Mostly self-reported diabetics turn up, which are
just the tip of the iceberg.
2. Another approach being used is that of a fully-equipped mobile van with a fundus
camera with or without a laser machine, which requires large amount of funds to
install and maintain. This is not sustainable for public hospitals with limited
resources.
3. There is lack of community awareness programs, community involvement and
participation in the screening programmes, without which the program may not be
sustainable.
We are using a novel approach of
1. Identification of Known Diabetics at the community level by trained volunteers and
opportunistic screening in urban slums, where penetration of healthcare
information and facilities is difficult and poor.
2. Population screening of a potentially sight-threatening eye disease by optometrists
at primary level, using a cost-effective user-friendly, non-mydriatic fundus camera.
Who (urban slum population) or what is the inspiration behind this project?
There is an obvious need for reaching out effectively with low-cost screening models for
identifying Diabetic retinopathy patients at the community level in the underserved urban
areas. Till now, few models that have been initiated at the community level for screening
are costly and have not been scaled up for wider use. Owing to increasing burden of DR
in India, newer cost-effective, scalable models are required to be tested.
The following are the challenges expected:
1. We expect to face challenges in training of volunteers and optometrists in the
screening methods.
2. We may face some challenge in conducting health awareness and education
program in slums since they are busy struggling for the basic necessities of life
and do not assign priority to healthcare. The department has successfully
conducted heath education and awareness camps in urban slums and we hope to
benefit from that experience.
3. The patients will not be able to pay even for the subsidised treatment, we expect
Sightsavers International to fund the cost of treatment.
4. The patients may not give priority to come to base hospital for treatment- our
experience from cataract surgery camps suggests that the response is enthusiastic
if the quality care is assured. We plan to ensure delivery of quality services to the
subjects and keep a record of non-compliant subjects for further compliance and
motivation.
5. The project area could be hit by natural or man-made disasters during the
operational period. We expect Sightsavers to keep that into consideration.
The model being community-based and cost-effective has potential to be adopted and
replicated countrywide in public hospitals with tertiary eye-care services..
9
Innovation Fund Project Proposal
3. Detailed Innovation Project Information
3.6. Planning for sustainability
Cost-effectiveness
If it is successful, it is likely that the program will be adopted by the other national level
institutes with support of Government of India. Government of India has included
elimination of avoidable blindness as priority under National Program for Control of
Blindness. Therefore we hope that project will be adopted as a nation-wide program.
Since there will be training of volunteers and awareness generation programs in the
community, this will increase the health-seeking behaviour among poor diabetics in
slum-dwellers contributing to the sustainability of this model. Also, the project involves
sensitization of general practitioners in the community about DM and DR, we believe
that the community level detection of DM and timely referral for identification of DR will
be done by them, benefiting the entire community at large in a sustained fashion.
4. Project Management & Required Resources
4.1. Financial
requirements
4.2. Partner resources
available
4.3. Management of
the project
Please give estimated financial requirements for each stage
of the project (in GBP)
Please provide a project budget in the separate Excel
worksheet provided.
Attached
Provide information of any potential resources available
from project partners, either financial or in-kind.
Existing Human Resources and Infrastructure of Dr. R.P.
Centre, which is an apex institute for eye care and has state
of the art facilities for management of Diabetic Retinopathy
including expert human resources.
Detail the arrangements, structures and processes for
managing the project and the roles and responsibilities of the
various parties. Include an organogram if appropriate.
Attached
4.4. Implementation
plan
Please provide an implementation plan in the separate
worksheet provided. Based on the timing/ sequencing of
activities as laid out in the Implementation plan can you
foresee any challenges to its delivery, and if so, how do you
plan to deal with them?
Attached
4.5. M&E plan
Attached
10