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Community Eye Health
JOUR N A L

VOLUME 26 | ISSUE 83 | 2013
B alancing the books
ACHolel-aedlntirh eF,c oLtosonrt:ed Iornnte Srncahtoioonl oafl CHeyngiteren efo ar nEdy e Pfiantainecnitasl csounsttraiibnuatbei ltioty t ohfe o Philippin
Tropical Medicine, London, UK. eye services. eik
H
Two critical questions face managers of
eye care institutions:
• How can I reduce costs?
• How can I generate income?
Costs/expenditure
The costs of any eye care service can be
divided into:
• Development costs – these are
one-time (or infrequent) costs
• Service provision (running) costs –
these are ongoing (weekly, monthly, or
annual) costs.
Development costs
For the purpose of this article we will How to reduce costs One can reduce the cost of consumables by:
assume that development costs (equipment,
One can reduce salary costs by only • Only purchasing essential consumables
instruments, vehicles, and training staff)
employing essential staff. Each employee • Purchasing in bulk
will be financed by one-time investments
should have a clear job description for • Using generic drugs and other
from the government, non-governmental
which they are well trained. Annual perfor- consumables, thereby avoiding
organisations (NGOs), local philanthro-
mance reviews and objective setting, with expensive ‘brands’ or designer-labelled
pists or hospital savings. These
non-monetary incentives for good perfor- consumables
development investments are very
mance, can create a positive work • Ensuring that the eye care team has a
important; however, they are occasional
culture. culture of cost containment (keeping
and once made they are no longer critical
Increasing productivity does not costs to a minimum, without reducing
to the ongoing financial sustainability of
reduce the salary bill. But, where patients quality).
the eye care service.
pay for services, seeing more outpatients,
How to generate income
Service provision (running) costs dispensing more spectacles and
These ongoing costs include salaries, performing more eye operations (in the It is important that the actual cost of the
consumables, utilities (water and same time and with the same staff) can service (e.g. cataract surgery, outpatient
electricity), rent, maintenance, and improve the fi nancial situation and the consultation or reading spectacles) is
depreciation costs. sustainability of the service. Continues overleaf ➤
ABOUT THIS ISSUE
Thulasiraj Ravilla Many of us have also learnt the hard services and organisations not only have
Executive Director: Lions Aravind way that external fi nancial dependence to sustain themselves in the years to
Institute of Community Ophthalmology, can undermine the growth of an organi- come, but also to expand signifi cantly to
Aravind Eye Care System, Madurai,
sation, and even threaten its very meet growing needs. To address this
India. [email protected]
existence – particularly when it is urgent topic, this issue shares case
Financial sustainability is probably the dependent on funding for day-to-day studies and suggests ways to reduce
most important aspect of organisational functioning. costs (including by enhancing productivity),
sustainability, mainly because of its In the face of ageing populations and generate income, and efficiently manage
immediate impact: when funds are not existing inadequacies of care (including supply chains to ensure uninterrupted
available, activities can come to a a shortage of health promotion and services; all while keeping the focus
grinding halt quite quickly. disease prevention services), eye care firmly on quality.
© The author/s and Community Eye Health Journal 2013. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.
EDITORIAL Continued
In this issue
41 Balancing the books calculated. Include all the ongoing costs If the patient cannot pay then a subsidy
in this calculation: salaries, consum- from another source is required.
44 Patient fl ow and cost
ables, water, electricity, rent,
45 On our own feet: preparing for maintenance and depreciation costs. Other eye patients. Some hospitals
the donor to leave Once the full cost of the service is charge according to their patients’ income
known, then you can determine how or ability to pay. Charging some patients
47 Help! No IOLs for cataract
much income is needed in order to more than the actual cost of the service
surgery
continue to provide the service. allows the hospital to offer the same
48 Practical accounting for eye 'Full cost recovery’ is an often-heard service at a below-cost price to patients
programmes: an introduction fi nancial term; it involves a costing who would otherwise be unable to afford
exercise that allows you to work out what it. This is known as a ‘tiered’ service: the
50 POSTER Eye injury/trauma
your services cost, in full.1 same service is given to different people
52 Procurement support for eye care Income can be generated from a at a different price. With this model,
variety of sources: because some are charged less and
53 Sustainable eye care at Kitale
some are charged more, it may appear
Eye Unit 1 Within the hospital.
that income will not increase. However, by
2 Within the community.
54 How fi xed fees and patient making treatment more affordable, the
3 At the national level.
choice can support eye care for hospital will attract more patients and
4 Internationally.
the poorest therefore the overall income is likely to
The closer the source of income is to you increase, due to economies of scale.
56 Tips for fundraising
as the service provider, the more self- Another approach is for additional
56 PRACTICAL ADVICE reliance and self-determination you will non-clinical services to be offered at an
How to check and record a have. If the income source is further away additional cost. For example, a person
patent’s body temperature (p 56) (for example, if you are being funded with plenty of money may be given the
nationally or internationally), you can option to pay an additional fee to have a
Fungus: how to prevent growth increase your self-reliance and self-deter- private consultation at a time to suit
and remove it from optical mination by developing additional sources them, and be hospitalised in a private
components (p 57) of income, closer to ‘home’, i.e. within single room with air conditioning, an
58 TRACHOMA UPDATE Mali: the hospital or the community. Some en suite bathroom and internet access.
achieving success along the ideas are discussed below. The price paid for these non-clinical
path to trachoma elimination services can be used to subsidise consul-
1 Within the hospital tations, treatments and operations for
59 CPD QUIZ
The patient receiving the service. The patients who cannot pay. The model is
60 NEWS AND NOTICES patient may pay the full cost of the service, similar to air travel – one may travel fi rst
be it a consultation, treatment or operation. class, business class or economy class,
Community Eye Health Editor Editorial assistant Anita Shah Address for subscriptions
JOURNAL Elmien Wolvaardt Ellison Design Lance Bellers Anita Shah, International Centre for Eye

VOLUME 26 | ISSUE 83 | 2013 [email protected] Proofreading Jane Tricker Health, London School of Hygiene and
B alancing the books
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Volume 26 | Issue 83 Consulting editor for Issue 83 Low- and middle-income countries © International Centre for Eye Health, London. Articles
Readers in low- and middle-income may be photocopied, reproduced or translated provided
Allen Foster
Supporting countries get the journal free of charge. these are not used for commercial or personal profi t.
VISION 2020: Regional consultants Send your name, occupation, and Acknowledgements should be made to the author(s)
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42 COMMUNITY EYE HEALTH JOURNAL | VOLUME 26 ISSUE 83 | 2013
n to help directly by providing volunteers. and national sources. Long-term reliance
pi
p
hili This can have its own challenges, but one on INGOs for running costs does not
P
o should try and use volunteers as best as promote financial sustainability and
Heik possible, while ensuring that the quality independence.
of services remain high. Volunteers can
help translate or help illiterate patients How to keep quality high
to fill out forms. They can also run a While taking the above steps to reduce
refreshment stall, with the profit going costs and increase income, it is essential
to the eye clinic. that the quality of service and patient
satisfaction are maintained at the highest
Donations. Some pharmaceutical
levels. Ongoing monitoring of treatment
companies, or other businesses involved
outcomes and patient satisfaction makes
in eye care, may provide appropriate
it possible to deal with any problems as
donations of essential medicines or
they arise and to ensure that quality
equipment. These can be used to lower
remains high. Previous issues of the
the cost of the service to low-income
Community Eye Health Journal contain
patients. Previous issues of the
Sale of spectacles can support income useful advice for monitoring clinical
Community Eye Health Journal have
generation. outcomes and patient satisfaction.4,5
contained useful advice for making the
depending on the available funds! most of such donations.2,3 Top tips to achieve
However, it is important that the clinical financial sustainability
service is of the same high quality for 3 At the national level
• Use what you have well, before looking
everyone; in air travel the pilot is the
Government. Ministries of health may for more resources.
same, regardless of the class of travel.
provide all the running costs, or they may • Aim to contain costs by ensuring only
Sales of spectacles or eye medicines. only provide the salaries of some staff, essential, generic consumables are
Ready-made spectacles can be purchased or a ‘bed or service’ grant. Governments bought – in bulk.
or made on site and sold at a profit. Similarly, are responsible for health service • Employ only essential staff who are well
eye medicines can be bought in bulk and provision to the population and wherever trained and have a clear job description.
dispensed to patients, also at a profit. possible they should be requested and • Promote a positive work culture
encouraged to provide the funds for eye through objective setting, regular
care services. feedback on performance and
Every little bit helps
non-monetary incentives.
National NGOs, foundations or corpo-
If one dispenses 40 pairs of spectacles rations. There may be a national NGO • Develop sources of income closer to
a day for 250 working days per year at you, the direct service provider – this will
with a mandate to improve eye care which
a profit of £2 per pair, the income increase the degree of self-determination
can fund some of the services.
generated is £20,000, which will available to your programme.
Alternatively, a foundation or corporation
subsidise 400 cataract operations at • Generate income by charging for clinical
may be willing to sponsor the service,
£50 per operation. and non-clinical services, to the extent
although this is more likely to be possible
that you are free to do so.
for development costs, rather than
• Look to the local community and
Creating small business to generate service provision (running) costs.
insurance schemes (if available) for
income. The hospital may generate
Insurance schemes. Some countries additional sources of income.
income from small businesses (e.g. a tea
have insurance schemes for all or part of • Use external support to pay for project
or coffee shop, a restaurant, or by
the population, which can be used to start-up costs or to meet development
providing accommodation for the relatives
subsidise or pay for the cost of the service. costs such as staff training or the purchasing
of patients).
of equipment and instruments.
It is essential that any activities that 4 Internationally
The suggestions in this article may be
support income generation are well Bilateral or multilateral development easier to apply in the non-government
managed in order to ensure that the quality aid. Government-to-government aid may sector than in the government sector;
of services remain high. fund eye services. Examples are oncho- however, the principles of cost containment
cerciasis and trachoma control activities and income generation are true for all
2 Within the community funded through the World Bank and the sectors. How one applies them requires
Local philanthropy. Individuals or local UK Department for International adaptation and perhaps a little innovation!
service groups within the community may Development (DfID). This is usually
agree to subsidise outreach clinics, eye administered by the ministry of health. References
1 For an explanation of full cost recovery, visit: www.
surgery for poor patients, or even the
International NGOs. There are many fit4funding.org.uk/support-pages/making-applica-
purchase of equipment or buildings. tions/full-cost-recovery/ There is also a full cost
international NGOs (INGOs) which provide
recovery case study – follow the link to the left of the
Corporate sponsorship. Similarly, local support for eye care services. As far as web page.
2 Cordero I, Murray N, Nkumbe HE. Donations: how to
businesses may agree to sponsor the eye possible it is best to use this support for
ensure you really benefit. Community Eye Health J
services as part of their commitment to development costs such as staff training, 2010;23(73):32–33.
corporate social responsibility, particularly or one-off equipment costs. It may also 3 Cordero I. Donations of consumables and surgical
instruments: how to ensure you really benefit.
if the service can promote their name or be useful for initial start-up costs, until a
Community Eye Health J 2011;24(76):41.
logo (their 'brand'). programme is able to cover its monthly or 4 Comm Eye Health J 2011. 20 years to VISION2020:
Sometimes, local service organisa- annual expenditure by generating its own Why information matters.
5 Comm Eye Health J 2012. Putting patients at the
tions, businesses or individuals may want income from patients, the community centre of eye care.
© The author/s and Community Eye Health Journal 2013. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.
PRODUCTIVITY
Patient flow and cost
Thulasiraj Ravilla mmedical record (assuming
e
oELifxo eCncosum Atirmvaevu Dinniidrtey I cn tsotri:t ute Care Systtrhepaet aotnineg is s momaien toafi ntheed ),
Ophthalmology, Eye investigations or asking
Aravind Eye Care nd the patient to provide the
System, Madurai, India. avisame information again.
Ar
[email protected] The surgeon performed
The design of eye care most of the routine
services influences the clinical and administrative
ongoing operational tasks, such as measure-
expenses and the ments for determining IOL
resources (including the power and ensuring its
costs of investing in these availability. This involves
resources) required to a lot of duplication in
deliver them. This is just as services as the highly paid
true at a hospital as it is, doctor performs tasks
for example, in a district which can be done just as
eye programme. well by a trained technician
or manager. All of this
District eye
Task-shifting: fundus imaging is done by a technician. translates into signifi-
programmes cantly higher costs.
Here, approximately 80% of the needs Clinical protocol (including routine investi- This scenario, which also plays out
for eye care services are relatively simple, gations) regularly when getting spectacles for
such as refractive errors or cataract surgery. refractive errors, for example, illustrates
1 Who does what in the protocol
The remaining 20% is made up of more that there could be enormous cost
2 Internal policy on patient flow and how
complex surgical interventions (including savings if we were able to accomplish
different stages of care are managed.
retinal or vitreous surgery, for example). much of the treatment cycle in a single
When an eye programme is well This is best illustrated by considering two visit by having appropriate policies and
designed and well managed, solutions for different scenarios involving a patient patient flows, as the next scenario illustrates.
simple needs (80%) can be delivered requiring cataract surgery.
Scenario B
close to communities, with minimal
Scenario A • A patient presents with severe loss of
investment and cost both to the patient
• A patient presents with severe loss of vision. The doctor determines that
and the provider.
vision. On determining that cataract cataract surgery is required and orders
Staff at this 'primary' or 'community'
surgery is required, the doctor advises the necessary investigations, as per the
level can be trained both to meet these
the patient to undergo some hospital protocol.
simple needs and to recognise the 20% of
investigations (lab, ECG, etc.). • All the investigations are carried out by
patients that must be referred. The
• The patient is advised to return on a trained technicians, including A-scan
equipment required would be the
later date to get the results and to allow and keratometry, and the results are
minimum needed for an eye examination,
the doctor to determine his or her made available immediately.
and the services provided should include
fitness for surgery. • While the patient waits, the doctor
refractive error correction and first-level
• The patient attends for the appointment reviews the findings. The doctor sees
treatment of ocular infections and injuries.
and the doctor finds the patient fit for the patient again and advises that he
When such services are not available
surgery. or she can be admitted immediately
locally, however, the only option for
• The doctor carries out the pre-operative for surgery.
patients is to go to the secondary (district
investigations, such as keratometry and • The hospital manager is responsible for
or provincial) hospital or to a tertiary care
A-Scan, to determine the power of the ensuring that there is sufficient stock of
facility. Then the cost goes up enormously,
lens to be implanted. a wide range of IOLs and that
for both patients and providers. These
• The doctor or the hospital gives the equipment is maintained regularly and
centres of higher levels of care would then,
patient the date for surgery, which could kept in perfect working condition.
for the most part, be treating conditions for
be several days to several months later. Everything is therefore already in place
which there are over-designed. They would
• The doctor checks whether the required for the cataract operation.
be providing the same services with similar
IOL lenses and other surgical • The patient is admitted and operated on.
outcomes as in primary eye care centres,
consumables are available. If not, he or All of this happens during a single visit.
but at a significantly higher cost.
she orders them.
Where eye care is delivered, and by By having a team of well-trained people
• The patient comes back on the appointed
whom, has a significant impact on who support the ophthalmologist in
day for surgery and has the operation.
resources and associated costs. carrying out routine clinical and adminis-

In this first scenario, the patient ends up trative tasks, costs are saved and the eye
At the hospital
making three or four visits to the hospital. unit performs more efficiently, providing
In a hospital setting the following factors Each visit triggers a series of activities good quality care at an affordable price to
significantly affect cost: such as registration, retrieving the more patients.
© The author/s and Community Eye Health Journal 2013. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.
PLANNING
On our own feet: preparing for the
donor to leave
Bo Wiafe Reducing costs water were turned off at the end of the
Regional Director for Africa: Operation The two key principles we applied were: day. Any leaks and faults were reported
Eyesight Universal, Accra, Ghana.
and fixed immediately.
[email protected] 1 To keep costs as low as possible.
2 Where costs could not be reduced Use of offi cial vehicles
Many eye care programmes are further, to make the best use of each Strict control measures were applied,
supported by donors and once this resource. including the use of a log book. The cost
funding stops, they can collapse. In this of running hospital vehicles was reduced
Personnel
article, I will explain how some by half. The log book also helped each
Only essential personnel were recruited. A
programmes and institutions have been hospital to know which department to
typical team would consist of one
able to keep going despite losing their charge for each trip.
ophthalmologist, two optometrists,
donor funding. I have had the opportunity
one administrator, two ophthalmic Bulk buying
to work with government, church-run and
nurses, two ophthalmic technicians, five Hospitals were encouraged to change from
privately owned institu-
nurse assistants, one purchasing on a monthly basis to annual or
tions in Ghana, Zambia, ‘However secure
equipment technician, quarterly bulk purchasing of drugs and
Kenya and Rwanda, and
two housekeepers, and consumables, as well as quarterly
will share with you what the funding might
one driver. The number purchasing of spectacle frames.
we have done to promote
seem, it is helpful of staff can be increased
sustainability in some of Non-eye care services
as the workload
these organisations. Security, grounds maintenance and
to think about how increases.
catering are not part of the core business
We reviewed the
Starting the thinking long funding might of providing eye care, and it may be
effectiveness of all
process cheaper to enter into contracts with
continue and plan members of the team
With any programme, external companies to provide these
every year and deter-
however secure the services (known as outsourcing). We
accordingly’ mined whether there
funding might seem, considered each case carefully to ensure
was a way to reduce the
it is helpful to think about that it made financial sense to outsource,
costs associated with
how long funding might and to ensure that quality would be
their work or to improve their output (e.g.
continue and plan accordingly. maintained at an acceptable level.
the number of patients seen or treated).
In general, as mentioned on pages
Increasing income
41–43, it is best to use external funding Utilities (water, electricity, phones)
for development and start-up costs In a facility, much power and water is We increased the number of appoint-
(training, equipment, infrastructure) wasted because staff are unaware of the ments and operations by attracting more
and then work towards sustainability, impact it can have on expenditure. We patients and working more effectively.
meeting the ongoing or running costs drew their attention to this and We also diversifi ed our sources of funding
from other sources that are reliable in encouraged them to make sure lights and Continues overleaf ➤
the long term.
n
The programmes and institutions with ppi
which we worked had mostly been Phili
o
provided with infrastructure, equipment, eik
H
staff training and, in some instances,
some consumables, to start their work.
Money was needed for the following
ongoing costs:
• salaries (40–70% of total ongoing
costs)
• consumables
• communication (internet, telephone,
publicity and awareness creation)
• office and other costs (including water,
electricity, maintenance, etc.).
As a next step, we acknowledged that
tensions existed between sustainability
on the one hand, and creating quality
services that everyone could access
at an affordable price on the other.1
In particular, we acknowledged that
income might be too low to meet
operating costs, while staying true to
the principles of quality, equal access
and affordability. It is cheaper to buy drugs and consumables in bulk.
COMMUNITY EYE HEALTH JOURNAL | VOLUME 26 ISSUE 83 | 2013 45
PLANNING Continued
by linking up with health insurance • eye surgery Standardisation. Standardising
schemes, for example by ensuring that • eye tests procedures/protocols and equipment
each eye clinic or department was linked • spectacle dispensing. improves efficiency and enhances the
with (or accredited by) at least one local quality of the outcomes.
In addition, we visited companies and
insurance scheme. 3 Monitoring. Put systems in place for
factories to provide screening services
Accreditation can be a lengthy process monitoring patient outcomes and
for workers who are too busy to come to
but ultimately it is worthwhile. It generally patient satisfaction, and take steps to
the clinics.
involves: make any changes needed.
Keeping quality high
• ensuring that the facility is certified by
Challenges
the appropriate authority (e.g. the The quality of services can be kept high by
It has not been easy to get to where we
ministry of health or the district health applying a number of strategies:
are without challenges. In the case of the
authority)
1 Human resources. Select staff government institutions, one of the main
• applying to the relevant insurance
carefully and treat them well so they challenges is to encourage administrators
scheme(s)
always want to give their best. This to think of creative solutions. Other
• completion of the accreditation forms
includes providing staff with the challenges are listed below.
• inspection by the insurance scheme
equipment they need to do their work,
• receiving certification. • Putting funds into a single account, also
offering training programmes to build
known as commingling of funds (i.e. not
Government insurance schemes (or capacity, and providing a safe working
separating them into different
national health insurance schemes) have environment.
accounts). This makes tracking progress
helped to increase the numbers of 2 Equipment. Use initial or start-up
and reporting to sponsors difficult; for
patients who use the facilities. This is funding to equip facilities with the
example, funds budgeted for one
because patients who would otherwise equipment needed to make accurate
activity may end up in expenditures for
delay coming to the hospital came more diagnoses. Employ a part-time
another (see article on page 48 for a
readily because they did not have to pay equipment maintenance officer, or
suggested way to handle this problem).
cash for services; these costs were assign equipment maintenance
• Delays in the payments by the National
covered by the insurance scheme. responsibilities to another staff
Health Insurance Scheme to the hospitals.
member (while ensuring they are
• Difficulties in retaining staff, especially
Attracting more patients properly trained and resourced). This
in government institutions.
We decided to attract all kinds of patients will ensure that equipment is properly
to the clinics by creating a one-stop maintained, which means it will remain Reference
1 Shamanna BR, Dandona L, Dandona R, Rao GN.
facility, like a supermarket, with a compre- in good working condition for as long as
Financial sustainability. Community Eye Health J
hensive list of eye services, including: possible. 2001;14(37): 7–8.
National health insurance schemes in Ghana
National health insurance came afe
into being in Ghana with the passing Wi
g
n
of the National Health Insurance Act e
at
in 2003. Bo
Its three main sources of funding are:
• the National Health Insurance Levy, a
2.5% value-added tax on goods and
services (70%)
• social security taxes, paid by people in
formal employment (23%)
• individual premiums, paid by insurance
scheme members (5%).
The implementation of national health
insurance has increased access to
public health care services and raised
public expectations: there is evidence
that enrolled individuals are more likely Eye care providers have to be accredited by the National Health Insurance Authority
to seek care for illness or injury.1,2 This before they can display the sign of the relevant scheme at their institution.
translates to greater patient numbers,
which improves sustainability. can access services at accredited insti- Eye care benefits include cataract
Once a health care facility has been tutions without having to pay at the point and eyelid surgery, biometry, assessment
accredited (registered and approved) by of service; the scheme then reimburses of visual fields, refraction, and basic
the National Health Insurance Authority, the health care facility according to a set ophthalmic preparations, but not
it is permitted to display the sign of the tariff. Everyone has to pay a registration spectacles and other optical devices.
relevant insurance scheme(s). (There fee to obtain an insurance card, but
References
are three different types of insurance some people are exempt from paying 1 Witter S, Garshong B. Something old or something
schemes permitted by the act, and 145 the premiums, including people over 70, new? Social health insurance in Ghana. BMC Int
are currently registered.) pregnant women, children (if both their Health Hum Rights 2009;9:20
2 Blanchett NJ, Fink G, Osei-Akoto I. Ghana Med J.
Members of the insurance scheme parents enroll) and the very poor. 2012;46(2):76–84.
© The author/s and Community Eye Health Journal 2013. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.
FORUM
Help! No IOLs for cataract surgery
Elmien Wolvaardt Ellison be discussed in advance and should not of such a business plan, the ophthalmol-
Editor: Community Eye Health Journal, happen abruptly. On the other hand, eye ogist might find a new partner which could
International Centre for Eye Health,
departments should try to reduce their even be the hospital itself.
London School of Hygiene and Tropical
need for overseas aid over time by
Medicine, London, UK.
[email protected] reducing costs and increasing local Hannah Faal Nigeria
income, e.g. from consultation fees, When we talk about purchasing IOLs,
During a recent visit to Africa, an ophthal- health insurance, or local donors. administrators might be thinking some or
mologist told me that his eye department, I would suggest that my colleague all of the following.
in a rural part of his country, had recently develops a business plan for cataract
• What is it? You have never explained or
lost its non-governmental organisation surgery which demonstrates to the
shown it to me, or shown me how it works.
(NGO) support. As a result, he had not hospital management its potential as a
• Your NGOs have been providing them all
performed any cataract operations for feasible procedure. Hospital adminis-
these years, why have they stopped?
several weeks, because the hospital had trators and finance managers think and
Please go back to them.
not ordered the necessary intra-ocular talk in a different language from ophthal-
lenses (IOLs). This seemed a very unfor- mologists, and might have a different • I do not know where to buy them.
tunate state of affairs – but also definition of a feasible procedure. It is • The number you need is too small.
something others could learn from. worth becoming familiar with the most • They are not available locally and
We have therefore invited ophthalmol- important objectives and terms of financial cannot be bought using a local
ogists and regular Community Eye Health purchase order (LPO).
management, e.g. by consulting the free
Journal contributors in Africa to explain • They are too expensive and do not
financial guide at www.mango.org.uk
how this situation could be better handled generate revenue for the hospital.
This business plan could include
– and avoided – in future. What follows is • Patients buy their glasses and dentures;
increasing income by linking with local
an edited collection of their responses. they should buy these too.
health insurance schemes or by attracting
both affluent and poor patients, with Unless ophthalmologists are able
Boateng Wiafe Ghana
different fee structures for additional successfully to bridge this gap, they and
Cataract surgery should be the minimum
services. their patients will lose out.
service offered in any ophthalmic setting,
Computer registration of patients and It is worth remembering that an IOL is
especially when there is a resident
services, a separate cash point with an item, with a seller and a buyer. I would
ophthalmologist. It takes time to build up
invoices and receipts generated from the advise the ophthalmologist to think like
a practice and win the confidence of
same database, stock management and an entrepreneur and start a business
patients. Once this is done one has to make
standardised procurement procedures importing IOLs or similar items. Fix the
sure that the services are regular.
should also be considered. With the help prices at a level which patients can afford
The ultimate solution is to
and think about sourcing, impor-
educate management and pin tation policy, duty waivers, purchase
encourage them to stock these hilip by LPO, advertising, and so on.
items in the pharmacy, just like o P
all the other essential items eik
H John Nkurikiye Rwanda
they stock.
This doctor should use his own
In the short term, network with
initiative. Cataract surgery at a
other eye institutions and barter
referral hospital is not a free
with them. This is what I used to
service. It is up to the doctor to
do many years ago when facing
convince the management of the
similar situations. For example,
hospital to put IOLs on their
one institution may have IOLs in
annual procurement list. For
abundance, but no sutures or
example, in Rwanda, IOLs are on
visco-elastic, and may be willing
the new list of essential drugs and
to make an exchange if you have
consumables and there is no
sutures or visco-elastic to spare.
reason why they cannot be
Keep management informed so
purchased.
they can officially record the
transaction, and ensure that
Susan Lewallen South Africa
everything you exchange or
Stock keeping and procurement
receive can be used before it
are critical management tasks in
reaches the expiry date. You
an eye care service. Unless they
could also ask patients to buy
are taken seriously, such ‘crises’
their own IOLs.
will continue to happen.
Heiko Phillippin Tanzania
Recommended reading
In an ideal world, an NGO will Instruments and consumables. Community Eye
commit to support an eye Polymethylmethacrylate (PMMC) intraocular lenses are Health J 2011;24(76):25.
Equipment for eye care. Community Eye Health
department for a stated time of high quality and can be procured at affordable
J 2010;23(73):21–22.
period. Reducing funding should prices in low- and middle-income countries. Available from www.cehjournal.org
© The author/s and Community Eye Health Journal 2013. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.
ACCOUNTING
Practical accounting for eye
programmes: an introduction
Heiko Philippin n Software solutions
pi
Head of postgraduate training and hilip Initially, systems and standard procedures
glaucoma specialist: Kilimanjaro o P can be developed manually (on paper),
Christian Medical Centre, Moshi, Heik also taking into consideration the
Tanzania. [email protected]
country's legal requirements. Spread-
Richard Hess
sheet software is good for keeping
Management consultant, Singen,
records of income and expenditure. Once
Germany. [email protected]
these standard procedures are established,
they can be translated into a software
No institution can survive without
system for easier and safer data entry,
balanced books
planning and reporting. A general
Financial and administrative management Spreadsheet software can be a helpful
accounting software package is often
are fundamental to any institution. This accounting tool.
good enough, as you can use a special
applies also to eye care projects. Eye care
useful to consider the cost centre's total chart of accounts that reflects the needs
managers benefit from a solid under-
expenses and total income to see whether of the project. Some examples are
standing of accounting and financial
it is running according to budget. Quickbooks, GnuCash or WebERP.
management as it will help them to work
• An account is a record of financial Quickbooks is commonly used in
in, or supervise, this important area.
transactions, including payments companies and NGO projects; details can
(expenses) or deposits (income). Each be found at www.quickbooks.intuit.com.
Basic accounting
transaction is specified by date, type GnuCash is an example of an open source
It is not possible to provide a comprehensive
(cash, cheque, etc.) and detail, such as and free software system which runs on
introduction to accounting in this article. A
purpose of a payment, e.g. fees for all platforms (http://www.gnucash.org/).
few definitions might, however, be helpful
surgery. Typical examples of accounts WebERP is also free and is a large system
as a starting point for further reading.
include petty cash, bank accounts or which runs on a server in a network
• Budgeting is an essential process and stock accounts. It makes financial (http://www.weberp.org).
should always happen when a new management easier if you set up
activity is planned. A budget is an different accounts for different Further reading
estimate of future expenditure and activities. The listing of the account More information can be obtained from
income. Each activity needs its own names is called the chart of accounts. the Mango website (http://www.mango.
budget. The budget is what you check • Double entry: whatever is taken from org.uk/) which offers several articles,
your income and expenditure against one account has to be received by courses and tutorials about financial
when running the activity, to make sure another account. For example if salaries management and accountability in
you have enough funds and are not are paid, expenses increase in the non-profit and related projects. Another
spending too much. salaries account and at the same time starting point for a more general intro-
• Cost centres are different departments funds decrease in the bank account. duction can be Wikipedia: https://en.
or activities. Examples of cost centres • A ledger is a book or computer file wikipedia.org/wiki/Accounting. Finally,
include the outpatient department, the where all monetary transactions for each some software solutions, such as
operating theatre, and outreach. A cost account are recorded. Transactions must GnuCash, are accompanied by helpful
centre will have its own account.It is be approved and accompanied by receipts. introductions and tutorials.
Accounting challenges in donor-funded projects
1re Kpeoertpiinngg a fcucnudrsa steelpyarate – and ldiaobniolitr y( ia.ec.c tohuen st etrravicckess dtoe bbtes dtoe ltivheer ed). Bellers
Different donors (or partners) will require A statement of expenditure on Lance
different financial reports about the respective activities should be issued
activities they fund – often at different once a month. These expenses can be
times. posted from the relevant sub-account in
It can be a challenge in eye care the liability account to the income
programme management to keep track account, meaning that a debit is
of spending and to generate different assigned to the liability account and the
reports for different donors with just a credit is offset to the income account.
general income and expenditure With this approach, the donor liability 2 Dealing with different currencies
statement. account always shows the current state For different currencies, different
A practical solution is to post donor of different donor funds. If necessary, a accounts must be used. If average
funds, after they have been received, into report can be consolidated either in the exchange rates are used internally,
a liability account, with sub-accounts general account or in a supporting reporting becomes complicated because
for each donor. A liability account tracks document. [Note: receiving donor funds expenses vary over time according to
how much a person or business (in this is not yet an income since these funds changing exchange rates. A solution
case, the eye care programme) owes a are designated for specific purposes and could be to use only one ‘reporting’
creditor, in this case the donor. The become an income only when spent.] currency in agreement with the donors.
© The author/s and Community Eye Health Journal 2013. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.
ICO Foundation Assessment Poster 2013 Final 2:Layout 1 26/3/13 17:01 Page 1
E T
International Examinations h
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I
a n
t
m e
r
n
a
The new On-Line i t
n i
o
n
a
a
Foundation Formative t l
C
i
o o
u
n
Assessment n
c
i
s l
o
f
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This new online assessment is mostly for first year trainees.It is available 24/7 and candidates o
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can use books or search engines to answer the 84 questions (336 options) in up to 20 r h
t
minutes each. A compulsory“confidence indicator”which rewards those justifiably confident h
a
O
of their knowledge. lm
Questions are a statement,a scenario,many with a picture,diagram or video. When the o
p l
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examination is completed,candidates will be issued instant results,A*,A,B,C,D or F and a
g
h
detailed analysis. y
t
h
Subjects
a
l
A GeneralMedicinerelatedtoOphthalmology B Ophthalmicpathologyandintraoculartumours m
CommunityMedicineandPublicHealth Intraocularinflammationanduveitis
InternationalMedicalEthicsandGoodPractice Retinaandvitreous
EpidemiologyandStatistics o
Genetics
l
o
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C Trauma,externaldiseaseandcornea D AnatomyoftheEye,theOrbitandrelatedstructures i
Glaucoma EmbryologyandDevelopment s
Lensandcataract Neuro-Anatomy
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PrinciplesofGeneralPhysiology
s
Vision,OcularPhysiology,Biochemistry,CellBiology
PathologyandMicro-biology
E Pharmacology F Neuro-ophthalmology
OpticsandRefraction PaediatricophthalmologyandStrabismus
Basicdesign,constructionanduseofinstruments Orbit,eyelidandlacrimaldisease
Commonlyusedtestsinophthalmology
The emphasis of the questions will be on basic and practical ophthalmology
that is essential knowledge to be gained in the first year of training.
Applications can be made online by logging into the
ICO Examinations website www.icoexams.org
The International Council of Ophthalmology
11-43 Bath Street,London,EC1V 9EL,England
Tel + 44 (0) 207 6086949/6959 Email:[email protected]
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Burns History Acid, alkthermal ithe eye Vision Reduced Torch exRed eye cornea
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imary l of eye Blunt injury History Injury by blunt object,e.g. fist, stone, etc. Blood in the front of the eye (anterior chamber hyphaema) Vision Reduced Torch exam Blood seen in anterior chamber. Pupil may be dilated
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P Foreign body History Foreign body sensation. May be conjunctival, corneal or sub-tarsal (under the upper eyelid) Vision Usually normal but can be affected if central cornea is involved Torch exam Foreign body is seen on conjunctiva or cornea, or under lid
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50 COMMUNITY EYE HEALTH JOURNAL | VOLUME 26 ISSUE 83 | 2013