Table 2. Development of retinopathy of prematurity and diabetic retinopathy pilot projects using WHO’s health systems framework, India, 2014–2018.

Aspect of health systems framework	Retinopathy of prematurity pilot project		Diabetic retinopathy pilot project
	Activities envisaged	Outcomes achieved by March 2018	Activities envisaged	Outcomes achieved by March 2018
Building block
Leadership and governance	(i) establish a national task force and state coordination committees to steer the project; (ii) establish technical expert groups for individual project components; and (iii) identify strategies for implementation	(i) national task force met 4 times; (ii) 9 state coordination committee meetings held; (iii) 22 technical expert group meetings held; and (iv) 4 meetings held between project management team and national health secretary	(i) establish a national task force and state and district coordination committees to steer the project; (ii) establish technical expert groups for individual project components; and (iii) identify strategies for implementation	(i) national task force met 5 times; (ii) 7 state coordination committee and 5 district coordination committee meetings held; (iii) 19 technical expert group meetings held; and (iv) 4 meetings held between project management team and national health secretary
Health workforce	(i) improve the capabilities of paediatricians, nurses, ophthalmologists and support personnel	(i) 21 ophthalmologists trained to screen for retinopathy of prematurity; (ii) 5 ophthalmologists trained in laser treatment; (iii) 21 paediatricians and 48 nurses trained in improving neonatal care and preventing retinopathy of prematurity; (iv) 19 nurse educators trained in improving the quality of neonatal care; and (v) staff in 16 district early intervention centres trained in improving neonatal care and reducing the risk retinopathy of prematurity	(i) improve the capabilities of physicians, ophthalmologists, ophthalmic assistants and primary health-care personnel	(i) 127 personnel trained in diabetic retinopathy screening; (ii) 27 ophthalmologists trained in laser treatment; (iii) 3 153 health support staff educated about diabetic retinopathy; (iv) 326 physicians educated about risk factors and early screening for diabetic retinopathy; and (v) e-learning modules developed for physicians
Service delivery	(i) identify 4 states each with 6 medical schools and 12 district hospital SNCUs suitable for participation; and (ii) establish infrastructure for the screening and treatment of retinopathy of prematurity	(i) 5 971 preterm infants screened; and (ii) 185 infants treated for retinopathy of prematurity	(i) identify 10 districts suitable for participation; (ii) establish infrastructure for screening and managing diabetes and its risk factors for complications at noncommunicable disease clinics; and (iii) augment facilities for managing diabetic retinopathy at the district level	(i) 34 550 people with diabetes screened for diabetic retinopathy; (ii) 1 601 people with diabetes treated for diabetic retinopathy; and (iii) 15 diabetes support groups established
Medical products and technologies	(i) provide all pilot district hospitals with an indirect ophthalmoscope for screening; (ii) provide 7 medical schools with laser treatment systems; and (iii) establish simulation laboratories for quality improvement training at mentoring institutions and state medical schools	(i) 14 indirect ophthalmoscopes, 6 Retcams, 8 laser treatment units, 22 Volk 20D diagnostic lenses, 8 Volk 30D diagnostic lenses, 1 pulse oximeter and 1 Heine Omega 500 digital video camera provided; and (ii) dedicated open access web site set up for online training: it included 126 short webinars and videos for training to improve the quality of neonatal care and focused on preterm care for doctors, nurses and support staff	(i) install fundus cameras for screening at noncommunicable disease clinics in community health centres; (ii) install laser treatment systems at district hospitals; (iii) provide optical coherence tomography equipment at tertiary care centres in the district; and (iv) establish systems for on-the-spot and remote reporting of fundus images	(i) 50 fundus cameras provided at noncommunicable disease clinics; (ii) 10 laser treatment systems installed at district hospitals; (iii) optical coherence tomography equipment installed at 6 tertiary care facilities; (iv) dedicated web site developed to support people with diabetes and their caregivers; and (v) telephone counselling helpline established for people with diabetes
Information systems and research	Develop software for retinopathy of prematurity project management that: (i) is integrated with the SNCU online database; (ii) can record details of all infants eligible for retinopathy of prematurity screening, including when they were screened and their treatment and follow-up; (iii) facilitates referral for treatment; and (iv) serves as a repository for advocacy and communication documentation developed by, and shared with, stakeholders	(i) software has been developed that can track all infants eligible for retinopathy of prematurity screening and their treatment and follow-up and that can be used for clinical monitoring; and (ii) 4 tablet computers provided	(i) develop software for project management; (ii) register details of people with diabetes on tablet computers located at primary and secondary health-care centres; and (iii) carry out operational research	(i) 40 tablet computers with dedicated patient-tracking software installed at community health centres in 10 pilot districts; and (ii) 10 operational research projects commissioned
Health-care financing	(i) provide free retinopathy of prematurity screening and treatment at public health facilities in project areas	(i) free retinopathy of prematurity screening established in 16 SNCUs; and (ii) treatment facilities provided at 6 medical schools and 1 district hospital	(i) provide free diabetic retinopathy screening and laser treatment at public health facilities in project areas; and (ii) provide free medication for managing diabetes and associated risk factors, such as hypertension	(i) free diabetic retinopathy screening established at 50 health facilities in 10 districts; and (ii) diabetic retinopathy treatment services augmented in 10 district hospitals, at no cost to patients
Performance
Access	(i) improve access to retinopathy of prematurity services in public health facilities in tier-2 cities (i.e. cities with a population of around 1 million and important regional hubs) and rural districts, which cover poor and rural populations	(i) need for poor parents to travel far for screening and to seek treatment in large cities reduced; and (ii) access to timely care provided	(i) register people with diabetes and carry out preliminary diabetic retinopathy screening at health centres in rural areas where such facilities were not previously available (these centres are predominantly used by women and poor people)	(i) 57.3% of people with diabetes screened were women; (ii) the need for people with diabetes to travel far for screening and treatment was reduced
Coverage	(i) screen all preterm infants admitted to SNCUs who are eligible for retinopathy of prematurity screening at the secondary care level in the public health system; and (ii) treat all infants with sight-threatening retinopathy of prematurity	ND	(i) include all registered people with diabetes seen at primary and secondary health-care centres in the public health system in project areas	ND
Quality	(i) monitor outcomes regularly; (ii) upgrade staff skills through personal and online training; and (iii) provide supportive supervision	ND	(i) monitor outcomes regularly; and (ii) upgrade staff skills through training	ND
Safety	(i) ensure the care provided is to an accepted standard	(i) operational safety guidelines were finalized and disseminated following consultations	(i) ensure the care provided is to an accepted standard	(i) national technical guidelines are being drafted

ND: not determined; SNCU: sick newborn care unit; WHO: World Health Organization.