Preventing diabetes blindness: Cost effectiveness of a screening programme using digital non-mydriatic fundus photography for diabetic retinopathy in a primary health care setting in South Africa
Abstract
Background South Africa like many other developing countries is experiencing an epidemiologic transition with a marked increase in the non-communicable disease (NCD) burden. Diabetic retinopathy is the most common cause of incidental blindness in adults. A screening programme using a mobile fundal camera in a primary care setting has been shown to be effective in the country. Information on affordability and cost is essential for policymakers to consider its adoption. Methods Economic evaluation is the comparative analysis of competing alternative interventions in terms of costs and consequences. A cost effectiveness analysis was done using actual costs from the primary care screening programme. Results A total of 14,541 patients were screened in three primary healthcare facilities in the Western Cape. Photographs were taken by a trained technician with supervision by an ophthalmic nurse. The photographs were then read by a medical officer with ophthalmic experience. A cost effective ratio of $1206 per blindness case averted was obtained. This included costs for screening and treating an individual. The cost just to screen a patient for retinopathy was $22. The costs of screening and treating all incident cases of blindness due to diabetes in South Africa would be 168,000,000 ZAR ($19,310,344) per annum. Conclusion Non mydriatic digital fundoscopy is a cost effective measure in the screening and diagnosis of diabetic retinopathy in a primary care setting in South Africa. The major savings in the long term are a result of avoiding government disability grant for people who suffer loss of vision.
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Image acquisition was often performed by trained non-physician staff, while final grading was typically carried out by ophthalmologists or retinal specialists in 22 out of 30 studies.
“Image acquisition was often performed by trained non-physician staff (technicians, optometrists, nurses, paramedics), while final grading was typically carried out by ophthalmologists or retinal specialists (22/30 studies) [8–13, 15, 16, 18, 21, 22, 24, 26, 27, 30–37]”
From Diabetic retinopathy screening model in low and middle-income countries: a scoping review (2025) · cites this paper as [12]
Mydriasis was employed in 17 out of 30 studies, while the remainder used non-mydriatic techniques when clinically appropriate.
“Mydriasis was employed in 17/30 studies, while the remainder used non-mydriatic techniques when clinically appropriate [9, 12, 18, 22, 24, 27, 33, 35, 36].”
From Diabetic retinopathy screening model in low and middle-income countries: a scoping review (2025) · cites this paper as [12]
The International Clinical Diabetic Retinopathy severity scale was the most commonly utilized severity scale, used in 15 out of 30 studies.
“Various severity scales are used to classify diabetic retinopathy (DR), with the International Clinical Diabetic Retinopathy (ICDR) severity scale being the most commonly utilized in 15 out of 30 studies [9, 11–13, 15, 18, 21–23, 32, 34–36].”
From Diabetic retinopathy screening model in low and middle-income countries: a scoping review (2025) · cites this paper as [12]
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Chen, K.-Y., Chan, H.-C., & Chan, C. (2026) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2026.113610
- Authors
- Khan, T., Bertram, M. Y., Jina, R., Mash, B., Levitt, N., & Hofman, K.
- Affiliations
- University of the Witwatersrand (ZA)
- University of Cape Town (ZA)
- Corresponding author
- Khan, Taskeen
- Bertram, Melanie Y.
- Jina, Ruxana
- Levitt, Naomi
- Hofman, Karen
- Venue
- Diabetes Research and Clinical Practice
- Publisher
- Elsevier BV
- Published
- 2013-08
- Volume
- 101
- Issue
- 2
- Pages
- 170-176
- ISSN
- 0168-8227 (ISSN-L)
- OpenAlex
- W2091014566
- Cited by
- 74
- References
- 26
- Citations by year
- 2026: 3 · 2025: 3 · 2024: 4 · 2023: 4 · 2022: 6 · 2021: 5 · 2020: 13 · 2019: 4 · 2018: 3 · 2017: 7 · 2016: 6 · 2015: 9 · 2014: 6 · 2013: 1
- FWCI
- 5.22
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Diabetes Research and Clinical Practice (publishedVersion)
- PubMed (publishedVersion)
- SUNScholar (Stellenbosch University) (submittedVersion)
- Topics
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Retinal Imaging and Analysis
- Health Sciences › Medicine › Ophthalmology › Retinal Diseases and Treatments
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Keywords
- diabetic retinopathy, non-mydriatic fundus photography, retinopathy screening, cost-effectiveness, primary care, non-communicable diseases, disability grants, Western Cape
- MeSH terms
- Cost-Benefit Analysis, Diabetic Retinopathy, Diagnostic Techniques, Ophthalmological, Fundus Oculi, Humans, Photography, South Africa
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