Community EyeHealth Community

16 Pages·2001·0.95 MB·English

by  Blue Box G3

CCoommmmuunniittyy
EEyyee HHeeaalltthh
AN INTERNATIONAL JOURNAL TO PROMOTE EYE HEALTH WORLDWIDE
SUPPORTING VISION 2020: THE RIGHT TO SIGHT
IMPORTANCE OF AFFORDABLE EYE CARE
Martin Kyndt
MBA DipCIM BSc
Deputy Director of Overseas Programmes
Sight Savers International
Grosvenor Hall
Bolnore Road
Haywards Heath
West Sussex RH16 1EL, UK
Introduction
The Global Initiative for the Elimination
of Avoidable Blindness (Vision 2020: The
Right to Sight) sets a major challenge
requiring a significant increase in the provi-
sion and uptake of eye care services. If the
increasing trend in blindness is to be
reversed, then access to eye care services
needs to be made more widely available.
One of the most significant barriers to Waiting for eye care in Uganda
accessing these services is affordability. Photo: Murray McGavin
The shrinking economies of many of the many governments to reform the structure tional and manufacturing efficiencies can
world(cid:213)s poorest countries is placing increas- of their health delivery systems. Many are reduce costs to an affordable level. But to
ing pressure on health care budgets that are choosing to introduce cost recovery mecha- place affordability within the reach of ordi-
already severely over stretched. Competing nisms, as a means of controlling the overall nary people, their families and the commu-
demands from life threatening diseases such rising costs of providing health care nities in which they live, we also need to
as AIDS, malaria, and TB are pushing eye services. understand the demand issues which place
health services further down the agenda list Articles in this issue focus primarily on additional cost burdens that do not allow
of public health priorities. Simultaneously, the supply issues of service delivery, look- access to eye care.
the increasing cost of health care is forcing ing particularly at how increasing opera- The costs are many and complex and the
intention of this article is to explore what
these might be (direct and indirect), and to
J Comm Eye Health2000; 14: 1—16 offer some suggestions as to what might be
done in order to make eye care more afford-
Editorial: Affordable Eye Care Martin Kyndt 1
able to those who can least afford it.
Cost Containment in Eye Care R D Thulasiraj
& A K Sivakumar 4 Direct Costs
Financial Sustainability in Eye Care B R Shamanna, R Dandona,
In an effort to provide sustainable services,
L Dandona & G N Rao 7
many public and NGO health care providers
Vision 2020: Funding & Infrastructure Mike Lynskey 9 throughout the world are increasingly mov-
ing towards the introduction of user fees.
Food Acceptance and Selection among G Kothari, L Bhattacharjee
However, in reaching out to poor and mar-
Young Children in Urban Slums & M Marathe 11
ginalised communities, the effects of these
Developing a Course Curriculum Detlef Prozesky 13 strategies are widely believed to have nega-
tive outcomes on both utilisation and equal-
1
Ed i t o r i a l
Communi ty ity in service uptake. A number of barrier many days an average worker at each per-
studies (conducted primarily in India) have centile point, would need to work in order
found that direct costs, such as those for to afford a simple eye examination and an
EEyyee HHeeaalltthh
transport,treatment,surgery,drugs,glasses average pair of prescription glasses. The
and optical devices like IOLs etc. act as study showed that those on average income
Volume 14 Issue No. 37 2001 major deterrents for those who can least at the 60th percentile would need to work
afford them. When these are removed, for over 52 days in order to afford the neces-
example in offering free surgery, transport sary fees. This contrasted dramatically
and food, not surprisingly there has been with 3.4 days in the USA for the same per-
an increased uptake of services.1However, centile level.3
these same studies have also shown that Whilst the removal of treatment fees or
the removal of these costs alone is still not the introduction of subsidies may improve
enough to encourage full service utilisa- the problem, the issues of affordability are
International Centre tion. In fact, one study in particular in India far more complex. To increase the uptake
for Eye Health demonstrated that the provision of highly of services, we also need to examine and
Institute of Ophthalmology
subsidised fees had little impact on understand the nature and social context of
University College London
improved uptake of services.2 indirect cost barriers.
11— 43 Bath Street
Calculating the cost impact of direct fees
London EClV 9EL
inrealtermsforthe individuals concerned Indirect Costs
Tel: [phone] is not an easy task. An affordability study
Fax: [phone] carried out in Jamaica provides an enlight- The nature of indirect costs will very
E-mail: See box ening approach to calculating what these much depend on circumstances, but they
costs might possibly be. Using national will relate to the cost of time, effort and
Associated with
income data, the average daily income was disturbance of daily activity for both the
Moorfields Eye Hospital
calculated at the 30th, 60th and 90th per- individual concerned and, importantly,
World Health Organization centile. The study then calculated how their families. In a Participatory Rural
Collaborating Centre for
Prevention of Blindness
Editor
Dr Murray McGavin
EEyyee HHeeaalltthh
Nurse Consultant
Ms Susan Stevens
The Journal of Community Eye Health is published four times a year.
Administrative Director
Ms Ann Naughton FREE TO DEVELOPING COUNTRY APPLICANTS
Editorial Secretary 2001/2002 Subscription Rates for Applicants Elsewhere
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Tel: [phone]. Fax: [phone].
Language and Communication
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Consultant
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2 Community Eye Health Vol 14 No. 37 2001
Ed i t o r i a l
Appraisal study carried out in India, 40% system that is sensitive and responsive to early by advertising the cost of blindness
of respondents quoted such indirect costs, these cost barriers in order to make eye compared to the cost of treatment
as the major reason for non-attendance. care more affordable. ¥ Promote ECCE with IOL surgery — the
Here, the cost of lost income to attend use of this surgery dramatically reduces
treatment for both the individual and their Making Eye Care More Affordable patient recovery time compared to ICCE
accompanying minder, as well as concerns with aphakic correction
Making eye care more affordable to those
about the length of recovery time, were ¥ Identify and train community eye health
who can least afford it, requires specific
given as the main reasons for not accessing carers — working closely with the com-
strategies that target the root causes of both
services.4 This is particularly interesting munity, identify motivated (cid:212)carers(cid:213) to
direct and indirect cost barriers. Such
because the recovery time for cataract assist by accompanying patients coming
strategies might include the following;
surgery (which if performed early, is only a forward for surgery/treatment
matter of a few days with ECCE and an ¥ Introduce demand management strate-
Reducing the burden of direct costs
IOL implant) is more likely to be affected gies — structure service management to
by associated complications arising from meet the variations of seasonal peaks in
¥ Promote community based screening and
late presentation. As the onset of cataract is demand, to reduce patient waiting time.
treatment — extend the reach of services
painless and is characterised by a slow
into the community and reduce the bur-
decline in vision, the pressure of afford- There is little doubt that affordability sig-
den of travel costs for patients
abilitydelaysthedecision to come forward nificantly limits the reach of many eye care
¥ Provide financial support for transport
early, thus increasing therisksofcomplica- programmes. If Vision 2020 (The Right to
and food — encourage those who are par-
tions and, consequently, lengthening the Sight) is to achieve its very worthwhile
ticularly poor to come forward for sur-
time of recovery and cost to the individual goals, greater efforts are needed to reduce
gery, by offering incentives that reduce
and their families. the costs of access, particularly in the
the cost burden
Another study in Uganda recorded rea- design of service provision, so that eye
¥ Introduce a user fee structure that does
sons such as (cid:212)too busy(cid:213) to be a major deter- care can truly become an accessible right
not deny affordable access — implement
rent for accessing services.5Here the issue for all.
a cross subsidy pricing structure (to
is one of (cid:212)opportunity cost(cid:213) where in a
include free service where necessary)
typically rural subsistence community the References
where wealthier patients pay more to
meeting of basic living needs, such as food
subsidise poor patients through the offer- 1 Brilliant GE, Lepkowski JM, Zurita B,
production to feed the family, override all
ing of value added services (e.g., private Thulasiraj RD. Social determinants of cataract
other concerns (like the gradual clouding surgery utilisation in South India. Arch
rooms)
of vision) which are regarded as non- Ophthalmol1991; 9: 584—9.
¥ Reduce unit cost of service provision —
essential. 2 Fletcher A E, Donoghue M, Devavaram J,
increase operational efficiency and vol- Thulasiraj RD, Scott S, Abdulla M,
Once vision deteriorates to a point
ume of output (e.g., number of opera- Shanmugham CAK, Bala Murugan P. Low
where daily functions can no longer be per- uptake of eye services in rural India. Arch
tions)
formed, the sufferer soon becomes com- Ophthalmol1999; 117: 1,393—99.
¥ Reduce the need for repeated visits — 3 Cannon W, Orenstein J, Levine R (1997). A
pletely dependent on other family mem-
create a (cid:212)one stop(cid:213) referral and/or treat- study of the availability, accessibility and afford-
bers for their sustained well-being. Even at ment service, to reduce the burden of ability of refractive error correction in Jamaica.
this point where the problem has become Help the World See consultancy report.
unnecessary travel and time costs for
obvious, barrier studies have shown that 4 Fletcher A E, Donoghue M (1998). Barriers to
patients uptake of cataract services and proposed strate-
people still may not present for such rea-
¥ Mobilise community resources — encour- gies to address these. Background paper pre-
sons as (cid:212)no one to accompany them(cid:213) or pared for WHO informal consultation on analy-
age communities themselves to support
(cid:212)family opposition(cid:213). There is no doubt that sis of blindness outcomes, Geneva.
the treatment of poor patients out of their 5 Whitworth J, Pickering H, Mulwanyi F,
in many very poor communities, the oppor-
own resources. Ruberantwari A, Dolin P, Johnson G. Determi-
tunity cost of a family member accompa-
nants of attendance and patient satisfaction at
nying a blind relative to hospital may be eye clinics in south-western Uganda. Health
Reducing the burden of indirect costs
too great a price to pay, if the lost time is at Policy & Planning1999; 14(1): 77—81.
the expense of providing the family with ¥ Raise awareness about the cost of blind- I I I
basic needs such as food. Elderly people ness — motivate people to come forward
suffering from cataract blindness frequent-
ly have little say over how the family
resources are utilised and, in this respect,
COMMUNITY EYE HEALTH COURSES 2001/2002
(cid:212)family opposition(cid:213) may well be an expres-
sion of discrimination, where the family F MScinCommunityEyeHealth—1year(Sept.2001—Sept.2002)
concludes that investment of minimal
F DiplomainCommunityEyeHealth—6months(Sept.2001—Mar.2002)
resources on an ageing relative is of little
F Certificate inCommunityEyeHealth—3months(Sept.—Dec.2001)
value when weighed against other compet-
ing demands. F Certificate in Planning for Eye Care — 3 months (Jan. — Mar. 2002)
As we have seen, the issues of afford-
F Short Courses — 1—4 weeks (on-going)
ability are many and complex and whilst
barrier studies show a remarkable similari- F Planning for Vision 2020 — one week (25—29 June 2001)
ty of results, it is also true that there will be Enquiries: Courses Promotions Officer, International Centre for Eye Health,
variation in cost deterrents, depending 11—43 Bath Street, London, EC1V 9EL, United Kingdom
upon the circumstances of specific situa- Fax: [phone]; E-mail: [email protected]
tions. The challenge is to design a delivery
Community Eye Health Vol 14 No. 37 2001 3
Review Article
Cost Containment in Eye Care
R D Thulasiraj MBA Fixed Costs2
A K Sivakumar MHM
In health care organisations, the fixed cost
Lions Aravind Institute
could account for as much as 70% of the
of Community Ophthalmology
total recurring expenditure and hence
1 Anna Nagar
deserves the most attention. Investment in
Madurai 625 020
infrastructure, size of the facility and
India
staffing are the major determinants of fixed
Voluntary eye hospitals committed to costs. While leasing out a part of the build-
serving the community must under- ing, reducing staff or better negotiations of
stand the reality of increasing costs due to maintenance or salary contracts could be
inflation, advancements in medical tech- some of the options to reduce fixed costs, Bilateral cataract in a young woman
nology and changing expectations of staff the focus in cost containment must be more Photo: Murray McGavin
and patients. However, these costs are on reducing the (cid:212)fixed cost component
often not matched by the patients(cid:213) paying within the overall unit cost(cid:213) of service sustained cost containment. Seasonal vari-
capacity.Whileincreasingincome,through through optimum utilisation of the infra- ations in patient load affect capacity utili-
increased user fees or donations are finan- structure. This focus will lead to continu- sation and thereby affect the costs. Salaries
cial options which will be considered, this ous efficiency improvements resulting in constitute the major proportion of fixed
article will focus on cost containment.
Factors Contributing to Cost Containment1
Conditions for Effective Cost Control
Parameters Factors Affecting Cost Containment
1. Leadership and Attitude ¥ Concerned about cost
Though cost containment is influenced by
¥ Instituting a culture of cost consciousness
the health care systems that exist, certain
¥ Being available for timely decisions
organisational conditions have to be in ¥ Viewing the patient as a partner in the healing process
place for them to be effective. The leader-
2. Increasing the uptake of eye ¥ Forecasting and planning for expected workload
ship has a strong role in this. The organisa- care services ¥ Utilisation of community resources
tional leadership must be within the eye
3. Human Resources ¥ Job description
care system and be available to the organi- ¥ Workload variations versus manpower planning
sation whenever required (as opposed to ¥ Recruitment and selection
hospitals run by Government or Religious ¥ Employee retention
Organisations wherein the leadership is 4. Building and Infrastructure ¥ Appropriate size and design
often outside the hospital system and not ¥ Appropriate building technology and material
readily available). Delayed or inappropri- ¥ Flexible and functional building design
ate decisions tend to increase costs and ¥ Durability and ease of maintenance
inefficiency. It is also important that the 5. Supplies, Instruments ¥ Group purchasing
leadership promotes a culture of cost con- & Equipment ¥ Inventory management
sciousness. ¥ Models easy to repair and service
Standard clinical and administrative pro- ¥ Appropriate technology
tocols are necessary to institute and review ¥ Preventive maintenance
cost containment measures without affect- 6. Systems & Procedures ¥ Standardisation
ing quality, productivity or patient satis- ¥ Periodic review to eliminate unnecessary systems
faction. The first table lists the various
Definitions Relating to Cost
factors that influence costs.
Capital Cost: Cost of land, building, major equipment, etc.
Variable Costs Fixed Cost: Costs that have to be incurred regardless of the level of activity. e.g., salaries,
interest, depreciation, annual maintenance contracts, etc.
Variable costs are mostly made up of clini-
Variable Cost: Costs that vary directly with the level of activity. e.g., cost of sutures, IOLs,
cal consumables, stationary, etc. Cost sav-
medicines, etc.
ings in this area require good inventory
Recurring Cost: Sum of Fixed and Variable costs
management and group purchasing for bet-
Unit Cost: Fixed cost + Variable cost per Unit of service
ter prices. Good materials management, to
Marginal Cost: Additional cost in an ongoing production/service set up to produce one more
reduce wastage through storage and pilfer-
Unit of service or commodity.
age, will again reduce the variable costs.
However,reviewingtheclinicalprotocols Note: Several cost items tend to have, within them, elements of fixed and variable costs.
and eliminating investigations, procedures e.g., electricity, housekeeping.
and medications that do not contribute to
quality, productivity, good outcome or Unit Cost of Cataract Surgery
patient comfort can result in greater reduc-
Fixed cost apportioned to cataract surgery
tions in variable costs. Setting up a good
+ Consumables cost per surgery
clinical information system is necessary for
No. of cataract surgeries
makingsuchevidencebaseddecisions.
4 Community Eye Health Vol 14 No. 37 2001
Cost Containment
costs. Thus, the staff utilisation pattern, important that salary packages are Delegating routine, repetitive and mea-
especially that of the ophthalmologists, has designed keeping this in view. Incentives surement related clinical tasks to well
a direct impact on costs. The factor that linked to surgeries adversely affect the trained ophthalmic technicians can
has the most impact on (cid:212)unit fixed cost(cid:213) is cost reductions that come from increased significantly increase the productivity of
productivity. The simplified exercise,3 productivity. the ophthalmologists.
shown in the box below, illustrates that as ¥ Work Culture: Developing a positive ¥ Community Participation in Outreach:
productivity increases to match capacity, work culture reduces bureaucracy, pro- One resource that is hardly used is the
the unit fixed cost reduces to a fourth and motes teamwork and a commitment to community. In many programmes, the
the total cost comes down to almost a third. patient care. All of these have a very hospital staff does the publicity, arranges
direct impact on costs. a campsite, necessary furniture, etc. All
Cost Containment Strategies these activities can be better carried out
¥ Local Production of Consumables:4
by the community, often at no cost to the
¥ Daily Planning: In addition to long Many housekeeping supplies, bandages,
hospital. When the community comes in
range or annual planning it is essential to cotton pads, swabs, etc. can be produced
as an equal partner, the camp attendance
plan for the next day and ensure that all locally (if less expensive than buying
also goes up.
resources/supplies are organised and all them). This also gives an opportunity to
concerned staff are informed. The involve the clinical staff when there is no ¥ Other Strategies: These include devel-
patient load, availability of staff and patient care. oping in-house competence for instru-
requirement of supplies can be deter- ¥ Managing Seasonal Variations:5 Pro- ments/equipment maintenance, institut-
mined with a high level of reliability the ductivity is governed by the patient load, ing appropriate recycling systems for
previous day. Emergency procurements which tends to have seasonal and also waste products, regular review of cost
and delays in service delivery increase daily fluctuations. It is necessary to find data and administrative systems, such as
the cost. ways of accommodating the demand daily review of revenues and expendi-
tures, control over expenses through for-
¥ Clinical Process: A patient protocol and, when this is not possible, activities
mal procedures for approval, and inde-
based on an integrated path for diagno- like staff training, painting or vacation
pendent audit of all internal records.
sis, investigations, admission, surgery time for staff can be scheduled accord-
and follow-up would substantially ingly.
Role of Hospital Administrator
reduce delays and associated costs.
¥ Appropriate Use of Human Resources:
¥ Personnel Costs: Hospital is a labour Since salaries are a major element of The above principles and strategies need to
intensive organisation. Staff salaries fixed costs, these require special atten- be translated into action and systems
constitute a major percentage of the total tion. The ophthalmologist(cid:213)stime is both appropriate to local settings and day-to-day
operating expenditure. Hence, it is expensive and in limited supply. practice. These systems require periodic
Consider an Eye Hospital with the following Resources, Performance and Expenditures:
A. Resources:
Facilities:: Staff:
Beds : 50 Ophthalmologists : 2
Equipped Operating Theatre : 1 Paramedics : 9
IOL surgery sets : 2 Housekeeping staff : 6
Office & Security staff : 6
Capacity of the Above Resource :
¥ From bed capacity perspective : 4,000 surgeries assuming 80 surgeries per bed (average stay of 3 days)
¥ From the staff perspective : 2,000 surgeries, assuming 1,000 surgeries per surgeon
B. Annual Performance:
Out-patient visits : 20,000 Cataract/IOL Surgery : 500
Admissions : 600 Other Surgeries : 50
C. Annual Expenditure (All figures in US$):
Fixed Costs: Variable Costs (for cataract surgery only):
Salaries : 35,200 Sutures, Drugs, etc. : 2,660
Electricity : 1,330 IOLs (450 @ $6.44) : 2,700
Maintenance : 1,250 Instruments replacement : 750
Other fixed costs : 2,220 Stationery : 230
Other variable costs : 660
Total Fixed Costs : 40,000 Total Variable Costs : 7,000
D. Unit Cost per Cataract Surgery (All figures in US$):
Assuming that 80% of fixed costs are incurred in providing cataract surgery, cost per surgery for the current output, for 1,000 surgeries and at
capacity of 2,000 surgeries will workout as follows:
Number of Cataract Surgeries Total Fixed Cost(US$) Unit Fixed Cost (US$) Unit Variable Cost (US$) Total Cost (US$)
500 32,000 64 14 78
1000 32,000 32 14 46
2000 32,000 16 14 30
Community Eye Health Vol 14 No. 37 2001 5
Cost Containment Scholarship
review and changes, arising out of new
developments, changes in the infrastruc-
ture, staffing or patient complaints or sug-
gestions. It requires a person who can pay
constant attention and be responsible — one
of the roles of the hospital administrator or
manager. For this role to be effective, it is
London School of Hygiene & Tropical Medicine
necessary that this person is trained in hos-
pital management and, ideally, does not Lt Col Henry Kirkpatrick Scholarship
have a dual clinical role. However, the per-
Applications are invited for the above Scholarship to be awarded for October 2001 for
son needs to work closely with clinical
studies in tropical ophthalmology and is available for study towards either Masters or
staff to reduce the length of stay, eliminate
Research studies. The scholarship will provide tuition fees and a contribution towards living
unnecessary investigations, drugs and ther-
expenses. In order to be considered, candidates will need to hold an offer of admission from
apies, and bring about economies in the use
the School for postgraduate study and will not already be in attendance on a research course
of supplies, facilities and human resources.
of study.
He or she has to devote enough time and
We are looking for graduates who have or will have a first or upper second class honours
attention in reviewing and improving sys-
degree, or equivalent. For research studies, applicants will also need to have an MSc, or
tems and procedures, such as planning for
equivalent.
services and facilities, and scheduling of
FormoreinformationcontactTheRegistry,LondonSchoolHygiene&Tropical
staff and patients for optimum utilisation
Medicine, 50 Bedford Square, London WC1B 3DP. Telephone: [phone],
of resources to enable cost containment.
Fax: [phone], E-mail: [email protected] reference kirk.ceh.
Or visit our web site at www.lshtm.ac.uk/prospectusfor further details.
Conclusion
Application should be made by no later than 30 April 2001.
Cost containment is a continuous organisa-
tional process. A narrow and too simple Abstract
approach will not necessarily be of benefit.
It is a complex interaction of technical,
organisational and human factors, which Rates of Hospital
needs committed leadership, good attitudes
of staff and a system approach. Higher
Admissions for Primary
expenses per surgery do not necessarily
mean higher quality. Hospitals that provide
Angle Closure Glaucoma
quality service, and in large volume rela-
tive to their size, tend to have lower unit
costs through better systems. On the among Chinese, Malays and
whole, cost containment should be viewed
as one of the strategies to enhance efficien- Indians in Singapore
cy in eye care delivery.
References Tien Yin Wong mean annual rate of PACG admissions
Paul J Foster was 11.1 per 100 000 (95% confidence
1 R D Thulasiraj, R Priya, S Saravanan. High
interval (CI), 10.4, 11.8) among people
Volume, High Quality Cataract Surgery. Indian Steve K L Seah
Journal of Community Ophthalmology 1997; aged 30 years and over. The annual rate
Paul T K Chew
3(2): 24—32. was highest for Chinese (age and sex
2 R D Thulasiraj, S Saravanan. Productivity: adjusted rate: 12.2 per 100 000), which
Getting Cataract Patients Through and Out. Aim:
was twice that of Malays (6.0 per 100
J CommEye Health, 2000; 13: 22—23.
3 R D Thulasiraj. Social Marketing for Effective To estimate the rates of hospital 000) and Indians (6.3 per 100 000).
Eye Care Delivery. NPCB Course Material for admissions for primary angle closure Females had two times higher rates than
Training in District Programme Managers, 1995, glaucoma (PACG) in Chinese, Malays males in all three races (age adjusted
pp 79—86.
4 Raymond J Cisneros. Practical Pointers Most and Indians in Singapore. relative risk: 2.0, 95% CI: 1.7, 2.3).
Institutions Have a Wealth of Potential Cost
Saving Areas. HFM, Oct 1979, pp 47—51. Methods: Conclusion:
5 V K Sahney. Managing Variability in Demand,
A Strategy for Productivity Improvement in A population-wide hospital discharge Malay and Indian people had identical
Health Care Services. Health Care Management database in Singapore was used to rates of hospital admissions for PACG,
Review 1982; 37—41. identify all hospital admissions with a which were only half the rates compared
primary discharge diagnosis of PACG with Chinese.
I I I (International Classification of Disease-
CM code: 365.2). The Singapore census Published courtesy of :
was used for denominator data. Br J Ophthalmol2000; 84: 990—92.
Results:
I I I
Between 1993 and 1997 there were 894
hospital admissions for PACG. The
6 Community Eye Health Vol 14 No. 37 2001
Review Article
Financial Sustainability
B R Shamanna MD MSc staff, with the emphasis on
Consultant hands-on training. On com-
Rakhi Dandona BOpt pletion of training, they
were recruited as employees
Consultant
of the rural eye care Centre
Lalit Dandona MD MPH
with performance-related
Director
increases in salary and pro-
Gullapalli N Rao MD
motion.
Director
All patients are counselled and assessed
International Centre Service Provision
Photo: B R Shamanna
for Advancement of Rural Eye Care
At this Centre, standard secondary level system wherein the type and quality of the
L V Prasad Eye Institute
eye care services are provided utilising rea- surgical services provided are the same and
Hyderabad 500 030
sonable facilities and equipment, and the difference is only in the facility of
India
adhering to the highest quality standards. accommodation. Non-paying patients who
Background The services provided include refraction, are advised surgery are offered the same
detailed eye examination, medical treat- surgery at no cost to them. In addition to
In developing countries it is most impor- ment, and operations such as cataract the medical and surgical services, optical
tant that eye care programmes provide surgery with an intraocular lens, glaucoma and pharmacy shops are an integral part of
quality eye care services to communities in surgery, lid surgery, and lacrimal duct this Centre. A cafeteria is also available
the long term. However, they must be surgery. The systems and staffing of the and this caters for the needs of the patients
financially sustainable within a reasonable eye care Centre currently allow for exami- and staff alike.
period of time.1Methods of sustainability nation of 12,000—18,000 out-patients and
have to be introduced from the very begin- 1,200—1,800 operations in a year. The Capital Investment
ning of any eye care programme for these overall infrastructural design, with the nec-
to benefit the community in the long term. essary additional staffing of BGRPEC, has Local and international non-governmental
The L V Prasad Eye Institute (LVPEI), a the capacity to cater for a maximum of organisations and local philanthropists
not-for-profit, tertiary eye care hospital in 40,000 out-patients and 5,000 operations in helped LVPEI set up this rural eye care
Hyderabad, India, has been involved in set- a year. Centre to meet the needs of a population of
ting-up a permanent infrastructure for eye The charter of this Centre calls for the 500,000, spread over 3 districts in the two
care in underserved rural areas.2—5 Details provision of 50% of all services free of cost states of Andhra Pradesh and Maharashtra.
of this infrastructure,which include rural to the economically underprivileged in the The capital investment towards the setting
eye care centres and community program- society, with the remaining 50% realised up this Centre was approximately Rs. 81.3
mes, have been described elsewhere.4From on payment of charges by those who can lakhs (US$ 189,000), details of which are
the beginning, barriers to eye care, accessi- shown in Table 1.
afford to pay. Patients are triaged in to
bility, availability and affordability, were
paying and non-paying categories for
taken into consideration. This resulted in Financial Self-sustainability
eye care service delivery based on their
the setting up of the first rural satellite eye
socio-economic status. Assessment is by The service delivery figures for BGRPEC
care centre, the Bhosle Gopal Rao Patel
experienced eye care personnel, called since the Centre was established have
Eye Centre at Mudhol village, in the poor
counsellors. For patients who are advised shown an increase in the number of out-
district of Adilabad in the southern Indian
to undergo surgery, the counsellor consid- patients seen and operations performed.
state of Andhra Pradesh. Successful and
ers the paying capacity of these patients by While the ratio of paying to non-paying
self-sustainable functioning of this Centre
assessing the total family income. This out-patients was 50:50 (Fig. 1), the opera-
prompted LVPEI to develop other rural eye
includes the possession of a ration card tions maintained a ratio of 35:65 respec-
care centres in Andhra Pradesh which are
provided to families with a monthly tively (Fig. 2). Average cost-recovery per
well on their way to become financially
income below a certain level, and posses- month for monthly income and expenditure
self-sustainable. We describe in this article
sion of other assets. Surgical services for was used as a measure to assess financial
the systems that made Bhosle Gopal Rao
paying patients are offered in a tiered sustainability over every 6 months period.
Patel Eye Centre financially self-sustain-
able. Table 1. Initial Investment for Capital Items at BGRPEC, Mudhol
Item Amount in Lakhs of Indian Rupees
Bhosle Gopal Rao Patel Eye Centre (Thousands of US$)*
(BGRPEC)
Land & Development 1.75 (4.0)
Buildings 61.17 (142)
Staff
Generator 2.54 (5.9)
A total of 25 staff, including one ophthal- Air conditioner 0.52 (1.2)
mologist, work at this Centre. The majority Furniture and fixtures 5.04 (11.7)
Equipment 10.11 (23.4)
of the staff were drawn from local commu-
Kitchen equipment 0.17 (0.4)
nities, and were trained for varying periods
of time at LVPEI. During the training peri- Total 81.30 (188.6)
od, area-specific jobs were assigned to *1 US$ = Rs. 43.20
Community Eye Health Vol 14 No. 37 2001 7
Financial Sustainability
Cost-recovery was calculated as a ratio of pharmacy shops were major sources of proper patient-care systems with equal
income divided by expenditure and was income. Expenditure related to salaries of emphases on medical and management
expressed as a percentage. Standard for- personnel, purchase of medical consum- systems, well-trained clinical and non-
clinical staff working as a team, and the
Fig. 1: Out-patients seen at BGRPEC, Mudhol, 1997 to 1999
support of the local community.
The standard and quality of clinical care
at BGRPEC is a major factor in reaching
financial self-sustainability. The quality of
service does not differ for those who pay
and those who do not pay for the service.
BGRPEC is also able to address the barri-
ers to eye care services in relation to acces-
sibility, availability and affordability of the
services.
Optimum utilisation of staff, intelligent
purchasinganduseofconsumablesthrough
bulk central purchase, and minimum wast-
age are other factors that have contributed
to financial sustainability. BGRPEC has
Fig. 2: Operations performed at BGRPEC, Mudhol, 1997 to 1999
also demonstrated that having stronglinks
with social development organisations for
community relations and mobilisation, and
political will, are as important in achieving
financial sustainability, as are systems
within the Centre itself.
The experience with BGRPEC has
demonstrated the importance of good train-
ing for clinical and non-clinical staff, a
team approach to eye care, provision of
good quality eye care services, and com-
munity support, all of which can lead to
financial self-sustainability. Sustainable
and optimally functional eye care systems
is an important element of any approach
Fig. 3: Cost-recovery for BGRPEC, Mudhol
that hopes to substantially reduce blindness
Financial Years 1997—98 and 1998—99
in the long-term.6
Acknowledgement
ThecontributionofV.Rajashekar(Admin-
istrator, ICARE) is gratefully acknowl-
edged in connection with various activities
related to setting-up of this rural eye
Centre and collection of the data presented.
References
1 Sommer A. Towards affordable, sustainable
eye-care. Int Ophthalmol1995; 18: 287—92.
2 Dandona L, Dandona R, Shamanna BR,
Naduvilath TJ, Rao GN. Developing a model to
reduce blindness in India: the International
Centre for Advancement of Rural Eye Care.
ables, optical and pharmacy shop require-
mats that are used at BGRPEC for record- Indian J Ophthalmol1998; 46: 263—68.
ments, payment of electricity and other 3 Shamanna BR (1999). A study of cost-recovery
ing income and expenditure on a monthly
bills,cafeteria,and office expenses. mechanisms during the developmental stage of a
basis provided the basis for calculating The average monthly cost-recovery for new rural eye-centre in South India. MSc
cost-recovery. Recurrent grants received Dissertation. Submitted to University College
the operating costs increased from 72.7%
and depreciation (reductions in value) on London.
in the first half of 1997—98 to 104.3% in 4 Dandona L, Dandona R, Shamanna BR, Rao
capital and equipment were not included in
the last half of 1998—99 (Fig. 3). GN (2001). A model for high-quality sustain-
these calculations as they are calculated on able eye-care services in rural India. In:
a yearly basis in our system. Pararajasegaram R, Rao GN, editors. World
Income resulted from the eye care ser- Achieving Financial Blindness and Its Prevention: Volume 6.
Self-sustainability Hyderabad: International Agency for the
vices provided, sales from optical and
Prevention of Blindness.
pharmacy services, from the cafeteria, and Within 3 years BGRPEC became finan- 5 Rao GN. Human Resource Development.
interest on the bank deposit. The surgical JComm Eye Health2000; 13: 42—43.
cially self-sustainable. This achievement
6 Dandona L. Blindness control in India: beyond
services and sales from the optical and
can be attributed to the establishment of anachronism. Lancet 2000; 356: s25. q
8 Community Eye Health Vol 14 No. 37 2001
Vision 2020: The Right to Sight
Extra Funds are Needed for
Vision 2020: The Right to Sight
Mike Lynskey BA has happened. In Vietnam it is
Chief Executive now estimated that 100,000
The Fred Hollows Foundation people per year have their sight
Locked Bag 100 restored through modern eye
Rosebery NSW 1445 surgery which is paid for with
Sydney local money. Countries like India,
Australia Nepal and Pakistan have also
made dramatic progress, and cost
The Vision 2020 campaign was con-
recovery makes this self-sustain-
ceived as a fundraising concept
ing.
because the incidence of avoidable blind-
So if cost recovery is a critical
ness in developing countries was increas-
strategy in blindness prevention,
ing faster than available resources to tackle Hundreds waiting for an eye examination
funds also need to be raised to pay
in Bangladesh
the problem. Without extra resources the
for the development of cost
Photo: Murray McGavin
levels of avoidable blindness will double
recovery work.
over the next twenty years. made available to disadvantaged blind peo-
Avoidable blindness is a major health Fundraising Cannot Marginalise ple in developing countries, 80% of whom
problem in less developed countries Local Input are estimated to be avoidably blind. There
because large numbers of people do not are few other examples of such a powerful
have access to eye health personnel, equip- Many people in developed countries selling point to funders.
ment and consumables. Blindness preven- believe that nothing can be done in a devel- The numbers of avoidably blind people
tion is very attractive to potential donors oping country without help from wealthy are huge — it is estimated around 1,000 mil-
because it is one of the few areas of public developed country donations. The reality is lion of the world(cid:213)s poorest people will be
health where things can be done. In com- that the contribution from foreign donors is targeted to benefit from the Vision 2020
parison to other public health issues, blind- unlikely to work without strong, commit- campaign. Fortunately, we live at a time
ness prevention can be very cost effective. ted and effective local involvement. It is when it is possible for something to be
Hence the Vision 2020:The Right to Sight most important that the Vision 2020 cam- done. The Vision 2020 campaign is based
campaign. paign explains and communicates that upon the idea that we know what to do and
local capacity building is the key to suc- we know how to do it.
Good Planning is Needed cess. This will also help attract the kind of
donor who can work more effectively with How Much Extra Money is Needed?
Fundraising for Vision 2020 cannot be
the Vision 2020 campaign.
done in isolation from the special develop- The Vision 2020 campaign currently con-
ment needs of blindness prevention. Unique Selling Point to Funders — tributes around US$100 million to blind-
Money alone will not solve the problem. 80% of Blindness is Avoidable ness prevention work through NGOs such
Funds raised must be well targeted and as Lions International, Agenzia Inter-
effectively used. It is rare to find positive, life changing and nazionale Per La Prevensione Della Cecita,
Fundraising and resource mobilisation- cost effective examples of development aid Al Noor Foundation, ChristianBlind Mis-
to help train eye health workers, to acquire and health care. The Vision 2020 campaign sion International, Sight Savers Inter-
equipment, to help with the supply of con- needs to develop strategies to exploit its national, Helen Keller Worldwide, Orbis
sumables and to develop management sys- unique fundraising advantage. International, International Centre for Eye-
tems will be the key to the success of Affordable, high quality eye care can be care Education, Operation Eyesight Uni-
Vision 2020.
It will be necessary to explain to funders
COMMUNITY EYE HEALTH WORKSHOPS
that different approaches will be needed in
different places to implement Vision 2020.
The workshops at the following venues are designed for eye health workers
It is not simply a matter of transferring
who are working or plan to work in Community Eye Health.
technology and techniques that might work
Applicants must be resident in the region to which they apply.
in New York or London to a remote
province in China, rural India or in an
African village.
For example, by lowering the cost of Colombia: April 2001 India: July 2001
cataract surgery to around US$25 — US$50 Pakistan: April 2001 Nigeria: September 2001
per eye in some developing countries (sig- Tanzania: June 2001
nificantly lower than the US$1,000 plus it
costs in many developed and developing
Letters of enquiry should be sent to:
countries), it begins to be possible for even
Graham Dyer, ICEH, 11—43 Bath Street, London, EC1V 9EL
the poorest-of-the-poor to benefit from
Fax: [phone] E-mail: [email protected]
modern eye surgery. In many places this
Community Eye Health Vol 14 No. 37 2001 9
Vision 2020: The Right to Sight
versal, Organisation pour la Pr(cid:142)vention de al product. Unfortunately this decline in activities better within their own countries.
la C(cid:142)cit(cid:142), The Carter Center, The Fred official funding is happening at a time The Vision 2020 logo and name is being
Hollows Foundation and some 60 other when companies around the world are dri- registered as a trademark in a wide range of
organisations. ven by shareholders who demand the high- countries so that the good name of Vision
It is estimated that an extra US$100 mil- est returns possible on their investments. 2020 can be professionally managed and
lion per year is needed. The capacity of private companies and protected. Fundraising guidelines and other
industries to donate funds for development organisational matters are also being devel-
How Do We Reach the Funders? work is therefore also under great pressure. oped.
Immensely wealthy individuals such as National Vision 2020 entities will play
A wide range of sources will be targeted. Bill and Melinda Gates, Ted Turner and an important part in helping facilitate
These include: other philanthropists have to some extent fundraising.
¥ wealthy foundations filled the gap created by the reduction in
¥ governmental and inter-governmental government and corporate generosity. But Fundraising Strategy
donors, such as the European Union and the demands upon these people, founda-
the World Bank tions and organisations is extraordinary. So Fundraising is a discipline involving a
¥ the corporate and business communities Vision 2020 must be very well organised, wide range of sophisticated techniques.
¥ individual donors. clever and inventive to get to the front of These techniques include direct mail, tele-
the ever growing queue of thosefundrais- marketing, bequests (legacies), special
Because Vision 2020 has a wonderfully
ing. events, capital campaigns (to raise money
positive unique selling point, the chances
An international Vision 2020 Executive for infrastructure and equipment) and pub-
of success with these funders are high.
Director, who will be located with the lic appeals.
Competition is so great with funders that
World Health Organization in Geneva, is Vision 2020, through its members and
a poorly thought out approach is unlikely
also being recruited. A key responsibility partners around the world, has access to
to bring results. Under pressure from
of this position will be fundraising. highly developed fundraising expertise.
organisations such as the International
Sharing knowledge, contacts, fundraising
Monetary Fund, governments the world
National Vision 2020 Entities skills and expertise amongst the wide
over are shrinking their public sector.
range of groups and individuals involved
Government funds from developed coun- SomecountriessuchasAustralia,Indiaand will be crucial to successful Vision 2020
tries for development aid is therefore the United Kingdom have either decided fundraising. Guidelines on how to handle
falling as a percentage of the donor coun- or are considering establishing national these matters are being developed.
try(cid:213)s own annual income, i.e., gross nation- Vision 2020 organisations to co-ordinate q
ROYAL COLLEGE OF OPHTHALMOLOGISTS
17 Cornwall Terrace, Regent(cid:213)s Park, London NW1 4QW, UK
Diploma Examination in Ophthalmology
DRCOphth
ANNOUNCING A CHANGE
TO THE STRUCTURE
From November 2001, there will be no Practical UK and Overseas Examination Calender 2001
Refraction section in the Diploma examination
Exam Dates of examination Location Closing date
The New Diploma Examination (DRCOphth) is a test
Part 1 23—24 April UK, India 12 March
of ophthalmic knowledge including relevant basic
MRCOphth 8—9 October UK, India, 27 August
sciences and clinical skills for candidates who have
Egypt
worked in ophthalmology for one year (full-time or
equivalent). This work experience need not have been
Part 2 18—22 June UK 7 May
gained in the UK
MRCOphth 10—11 October India 27 August
5—9 November UK 24 September
Information, Exams syllabi, Applications from:
The Head of the Examinations Department at Part 3 12—15 March UK 29 January
the above address MRCOphth 17—21 September UK 6 August
Or tel: [phone] 11—12 October India 27 August
Or fax: [phone]
Or e-mail: [email protected] DRCOphth 25—28 June UK 14 May
Or visit the College website www.rcophth.ac.uk 19—20 November UK 8 October
Overseas locations:
Aravind Eye Hospital, Madurai, Tamil Nadu, India
The British Council, Cairo, Egypt
10 Community Eye Health Vol 14 No. 37 2001