United Nations Public Service Awards Case Studies

Mauritius is known to have one of the highest prevalence of diabetes in the World. According to our noncommunicable diseases survey 2009, the prevalence of diabetes and pre-diabetes in the age group 25 – 74 years stands at 23.6% and 24.2% respectively.

One of the major debilitating complications affecting the eye specially in patients with more than 10 years of diabetes, is diabetes retinopathy. The retina is the part of the eye which converts light rays into electric signals and sends them to the brain through the optic nerve. Diabetes retinopathy, if not detected and treated early, leads to blindness.

Before the initiative, the eye was examined using an ophthalmoscope. This instrument is like a torch with a lens. The examiner looks through the lens, and the back of the eye is illuminated by the torch. The examination is often difficult and the doctor is often not confident of his findings. As such many doctors did not routinely carry out the examination.

Thus retinopathy was often missed and was only diagnosed late and consequently many patients presented with advanced retinal disease or loss of vision. The advanced retinal disease could not be treated locally and at one stage about 5 patients were sent weekly to Chennai, India, for advanced eye surgery.

Though health service is free of user cost, patients affected, not only suffered physically and psychologically but also socially and economically. This situation affected the diabetes population of Mauritius and more specifically those of the lower socio-economic background who could not have access to private medical care.

What is the initiative about? (the solution)
The solution was to find a more efficient, reliable and evidence-based method to carry out screening for diabetes retinal disease. Thus digital retinal cameras were used to take pictures of the retina. The digital images could then be read or even discussed with colleagues and specialists. Complications were thus detected early and treated early. Digital retinal cameras were made available in the five health regions and in Rodrigues. The ophthalmologists (eye specialists) who are usually referred the cases for treatment noted an increase in referral as more cases were detected early. Those cases would have otherwise lost their vision or proceeded to have more advanced eye disease. The treatment usually consists of laser therapy. A solution was found to the increasing workload of the ophthalmologists. A new modern, more efficient, laser equipment, the Pascal Laser, was procured. Since the beginning of the project in 2008 and as at April 2011, some 24,141 patients (mostly with diabetes for more than 10 years) have been screened and some 2,366 patients have been referred for treatment. Though it is expected that over the medium to long term, this project will decrease blindness due to diabetes by around 50%, already benefits are evident. The surgeons have observed that they are seeing less complicated cases. Persons between 15 and 60 years who have attended social security for invalidity pension due to blindness has decreased as follows:- Illness Year 2008 Year 2009 Year 2010 Year 2011 Blindness 19 16 15 8 Total Blindness 2 3 0 0 (Data from Ministry of Social Security, National Solidarity and Reform Institutions)

Who proposed the solution, who implemented it and who were the stakeholders?
Dr. K. Pauvaday, the Director Health Services for Noncommunicable Diseases, having worked in Wales, United Kingdom, saw the National Digital Retinal Screening Service in place there and observed its cost-effectiveness. He recommended that this programme be set up locally. Professor David Owens, who implemented the national programme in Wales was therefore approached by the Ministry of Health and Quality of Life to consider setting up the programme nationally. The Ministry of Health and Quality of Life started a phased implementation of the programme in 2008 and the programme has become national in 2011. The stakeholders involved were:- • Staff of the noncommunicable diseases unit of the Ministry. • Public health doctors in the region. • Nurses and Health Care Assistants in the region. • Ophthalmologists. • Patients.

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
As this was a major project, it was decided to implement the initiative in a phased manner. Thus initially, the project was launched at only two main sites in the country. As usually significant retinopathy only appears after around 10 years, it was decided to screen patients with more than 10 years of diabetes by the new method.

b. What were the key development and implementation steps and the chronology? No more than 500 words
• The first step was to sensitise key government officials about the problem, the proposed solution and the benefits - 2008. • The next step was to train a batch of retinal photographers and graders (people who read the images) - 2008. • Partners of the Ministry were sufficiently convinced about the benefits of the project and two retinal cameras were received in donation. • The programme was launched in two Regions in 2008. • By 2011, the programme has been extended to all 5 Regions in Mauritius and to Rodrigues.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
The main obstacle encountered was that as more effective and efficient retinopathy screening was carried out, the number of cases requiring treatment went up. This was dealt with by the procurement of a more efficient Laser therapy equipment, the Pascal Laser. In the time it takes to treat one patient by the standard laser equipment, 5 – 10 patients may be treated by the Pascal Laser equipment.

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
No new staff was employed specifically for the project. Duties were reallocated and more efficient use was made of staff. The main costs were associated with the procurement of retinal cameras, IT equipment and the Pascal Laser equipment. This amounted approximately to some thirty million rupees (1 million US dollars) approximately. The key benefits, which would be more evident in the medium to long term, would be:- • Decrease in blindness. • Decrease in advanced retinopathy requiring surgery abroad. • Decrease in human suffering and socio-economic costs at family and individual level. • Decrease in disability allocations. • Healthier workface at national level.

Is the initiative sustainable and transferable?
The initiative is easily sustainable. With the government being conscious of the key benefits of the project, there is all the necessary support for it to be sustainable. The project is transferable. The project has thus been implemented on the island of Rodrigues. It is also transferable at international level. In fact, it has been transferred from Wales to Mauritius!

What are the impact of your initiative and the lessons learned?
The key elements which made the initiative a success were:- • During the training period, patients were randomly selected for retinal photography. Advanced, asymptomatic lesions were found in many patients. These were successfully treated thus avoiding blindness. The staff rapidly rallied to the cause. • The ophthalmologists who have, over the years, been seeing a gradual increase of complicated diabetes retinal disease are very supportive of the project as they, at last see, light at the end of the tunnel i.e. early detection with more effective treatment leading to less complicated retinal disease and untreatable blindness. The main lesson learned is that modern technology should be increasingly used even in resource poor settings to decrease human suffering and advance human development.


Institution Name:		Ministry of Health and Quality of Life
Institution Type:		Government Agency
Contact Person:		Keyvoobalan Pauvaday
Title:		DR.
Telephone/ Fax:		2571210/2011819
Institution's / Project's Website:		http://www.gov.mu
E-mail:		kpauvaday@mail.gov.mu
Address:		5th Floor, E. Anquetil Building, Port Louis
Postal Code:
City:		Port Louis
State/Province:
Country:		Mauritius

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information