A comprehensive strategy of diabetic retinopathy screening in a public health system: Identifying and overcoming obstacles for implementation

This study reports the implementation of a diabetic retinopathy (DR) screening program in Aracaju, Brazil, emphasizing the challenges and premature termination. The program, a collaboration between local health authorities, national DR screening experts, private clinics, trained retinal imaging technicians, a portable retinal camera with artificial intelligence (AI), telemedicine, and AI-assisted image analysis, was established. Screening occurred at primary care centers, with free specialized treatment for high-risk DR cases. After a public tender, two clinics were selected for screening, and four for secondary management. Initially, diabetic patient attendance at primary care clinics varied considerably, posing a challenge. Nonetheless, the screening continued, with 3,561 patients screened within six months. However, due to complaints and disputes between providers and authorities, the program was prematurely terminated, achieving less than a quarter of the initial screening target. The DR screening program faced significant challenges, including low adherence and organizational issues at primary care centers. This experience highlights the need to standardize clinical workflows, enhance organization and integration among primary care units, and address cultural factors to improve adherence rates. These insights are valuable for implementing screening programs, particularly in low- and middle-income countries.