Modelling the effects of integrating diabetic retinopathy services in the Malawi health system

Currently, 24 million adults have diabetes in Africa, projected to rise to 55 million by 2045. Diabetic retinopathy (DR) is the most common complication of diabetes, and one of the commonest causes of blindness in working age people. In Malawi 500,000 people with diabetes require regular eye screening to identify those needing treatment to prevent sight loss.

Blindness causes high productivity losses, reduces mobility, affects mental wellbeing, increases dementia risk, increases falls and road traffic crashes, increases care needs, and higher mortality rates.

Cost-effective interventions for DR exist but screening and treatment programmes are not routinely implemented in the African region, leaving people with DM at risk of blindness. There is a need to move from considering the cost-effectiveness of individual interventions to new models incorporating the inter-connections and constrains in the health system that affect the capacity to deliver DR services.

We aim to help reduce sight loss from DM in Malawi by developing mathematical models of integration of screening and treatment for DR within the health system. The project will explore the model that delivers the highest health gains to the population, and will be used to inform health policy makers and planners when prioritizing interventions to include in the national health benefit package.

Our objectives are:

1) Identify models for delivery of DR services, analyse cost-effectiveness and appraise applicability to the Malawi health system 2) Estimate the magnitude and factors that predispose people to developing DR 3) Evaluate coherence of national policies for DM and DR service delivery 4) Assess current delivery of DR services in Malawi’s health system

5) Model inclusion of DR services within DM services and the wider health system in Malawi

We are building upon an existing health system model for Malawi (www.tlomodel.org), already modelled for diabetes. The research will be divided into six linked work packages.

We will use multidisciplinary methods: evidence synthesis to explore models of DR delivery; cross-sectional studies to examine magnitude / risk factors for DR and assess health-seeking behaviour; policy coherence analysis through document review and interviews; mathematical modelling utilizing this information to identify best value approaches to deliver DR services in Malawi. Organizations of persons with diabetes will be co-producing key components of the research and participating as core stakeholders throughout.

The research will take place over 3-years in Malawi, and includes a capacity strengthening programme for a co-applicant/PhD, the project manager and the model programming team.

The project builds on strong existing partnerships. Firstly, the International Centre for Eye Health (ICEH) at London School of Hygiene and Tropical Medicine, Malawi Ministry of Health and Kamuzu University of Health Sciences (KUHeS) to strengthen DR services, through a National DR Steering Committee. KUHeS is a member of the DR-Network coordinated by ICEH.

Secondly, the KUHeS Health Economics and Policy Unit and Imperial College London who have developed the TLO Model for Malawi, which this project is building upon.

Finally, we will use existing DR-Network (DR-NET) and engagement with key stakeholders and community to disseminate the findings and work with policy makers for translation into practice. We will also publish results in academic journals and present at conferences.