Background

Started in 1976 with 11 beds, Aravind Eye Hospitals have grown to be the largest eye care service provider in the world. In the past year alone, Aravind handled around 1.5 million outpatients and performed close to 250,000 surgeries. Two thirds of patient care is done free of cost or at very highly subsidized rates and yet, the hospital is self supporting. This is made possible by implementing strategies and using efficient systems of eye care service deliveries, based on the lessons learnt over these years.

Through the Lions Aravind Institute of Community Ophthalmology (LAICO), which is an integral part of the Aravind Eye Care System, these experiences are now being shared with around 120 eye hospitals around the globe, mostly in the developing world.

Prevalence and incidence of eye care burden is known to be very high in the developing countries which constitutes two thirds of the overall magnitude. At the same time, efforts taken to address this increased burden often times result in only incremental change. This could be due to other critical factors that also govern the poor outcomes such as lack of adequate resources - human resources and consumables, infrastructure, poor accessibility, pricing of the services, underutilisation of available resources, practicing inappropriate processes and procedures. In order to overcome the challenging factors, what is required is a paradigm shift in efforts by employing sound management principles.

Aravind Process of Technology Transfer

Aravind shares the business/operational model with the eye care programmes in a systematic manner by incorporating certain principles. The Capacity Building process starts with a site visit to the participating hospital. This is done by a team from LAICO typically consisting of an Ophthalmologist, a senior manager and a management faculty person. The objectives of the site visit are to understand the ground realities, assess the local situation, and understand the issues and opportunities. This initial needs assessment visit also looks at the management system and the overall governance of the organization. Armed with this understanding and the insight into who the decision makers are, a senior level team of 4-6 members from the institution are invited to attend the Vision and Capacity Building workshop.

Fig. 1: A Capacity Building Workshop at LAICO

This is a week long process and is always done at Aravind Eye Hospital essentially to give them a detailed understanding of another system which helps them to reflect on their own practices and come up with new ways of doing things. During this workshop the participating hospital first sets their target which is not based on their current performance but based on their capacity under ideal conditions and the community needs. The team then develops various strategies and action plans that will work for them. Each strategy is broken down into action plans, assigning a timeframe, a person and identifying required resources, thus making it actionable and not just an idea (Fig.1). Where the plan requires specific training to individuals, the same is organized. Follow up support provided through email and site visits. The following graph and table shows the impact of this process on the quantum of services is provided and sustainability through user fees which can be used as a surrogate indicator for both quality and efficiency (Table 1 & 2).

Tab. 1: Shows the increase in the productivity of surgical output following the capacity building workshops

Tab. 2: Impact of Capacity Building Process Ressource Utilisation.

Recognizing the importance of this Capacity Building from the management perspective, this process was designed in 1994 by LAICO. Since then many of the International NGO’s like the Lions, Sight Savers, CBM, IEF, Seva, ORBIS and WHO have sent several of their partner eye hospitals to this program. Over the last decade over 100 eye hospitals have undergone this process of capacity building and putting in place good management systems. The results have been dramatic with many hospitals doubling their output within 12 to 18 months and moving towards full financial self reliance through user fees, which is a surrogate indicator of quality and efficiency in most circumstances.

One should also need to recognize the reality that regardless of whatever planning, training or strategizing is done ultimately blindness is reduced when - one patient at a time receives a sight restoring surgery, a pair of glasses or preventive intervention as appropriate. This needs to be done 30 million times to eliminate the existing avoidable blindness (which is estimated at 80% of all blindness) and do the same for all new cases. For this 80%, there is proven clinical solution and hence the focus will now need to turn to making it happen. Following are two case studies done in different parts of the world, wherein LAICO has partnered with local hospitals to develop systems and strategies to make them more productive.

Case study 1: saduguru netra chikitsalaya (snc), chitrakoot, madhya pradhesh, India

The problem description

From operating out of an old shed in the 1950s to delivering eye care from its state-of-the-art eye hospital developed in 2000, the road has been long and the challenges many (Fig.2, Fig.3). It is only in the past couple of years that the challenges were identified and systematically overcome:

Some of these challenges were:

• Uncertain nature of financial support; almost two thirds of operating expenditure were dependent on external funding through donations
• High turn over of ophthalmologists and other qualified human resources
• Seasonal imbalance in service delivery (95% of the workload in winter months)
• Perception of SNC in the community as a provider of free eye care
• Lack of public awareness regarding quality of service and initiation of hospital activities in the newly constructed building
• Lack of advanced technology such as IOL (only 20% of the surgeries were IOL)
• Absence of Cost Recovery Model to generate sufficient revenue to cover operating costs (less than 50% cost recovery)
• Lack of modern management practices

Fig. 2: Picture of SNC before renovation.

The Solution

SNC wanted to overcome these challenges without deviating from their mission of providing eye care as service to mankind. With the joint efforts of a team from ORBIS and LAICO, an initial needs assessment in the year 2000 helped in identifying these challenges to a great extent. The team also recommended development of a detailed strategic plan for the hospital. These were:

• Retention strategies for doctors
• Recruitment of professionals in key management areas
• Introduction of multi-tier paying system
• Outreach camps in summer months
• Promotion of 100% IOL surgeries
• Training of administrative and managerial staff
• Introduction of sub-specialty services

In addition to conducting a Vision Building Workshop to plan out strategic direction, LAICO - Aravind Eye Care System supported SNC’s ophthalmologists perform high quality surgeries through onsite and offsite training, facilitated change process in introducing appropriate systems and integrating comprehensive MIS system etc.

Fig. 3: Picture of SNC after renovation.

The Result of Change

From 2000 onwards, the hospital began to show marked improvement in all the defined core areas and some remarkable achievements highlighted the short span of 2000- 2004. Statistics clearly bring out that the new strategies of introducing fees-for-services based on local paying capacity, conversion to ECCEIOL surgery from an exclusively ICCE surgical facility, and initiation of outreach community cataract screening programs to address seasonal imbalance in patient uptake of services, had enhanced the hospital’s capacity for high quality services, stronger outreach and financia sustainability.

Introducing fees-for-services did not make a lasting dent in the patient volume as was initially feared. SNC now recovers 100% of its total operating costs and has attained financial viability (Table 3). With all these changes, SNC embarked on its transition from an institute enmeshed in only utilizing organizational resources for operating costs to one that utilized organizational resources for capital expenditures, new developments and most importantly, for expanding service delivery to reach the underserved.

Case study: 2 shalina eye clinic, lubumbashi, Democratic Republic of Congo

Tab. 3: The impact of the effect of capacity building on the working of SNC.

The Beginning - The Power of Partnerships

Congo has about 56 ophthalmologists for a population of 63 million. 375,000 people suffer from cataracts, while only 12,000 surgeries are being performed per annum. Such an abysmal situation demanded the need for affordable, sustainable and quality eye care.

Shalina Laboratories understood the need for eye care in the region and donated a 3,500 square ft. building in central Lubumbashi for the development of its first Eye clinic to serve all sections of society in providing free, paying, and subsidized / or zero cost services to all sections of society.

A broad tripartite partnership, between LAICO, Shalina laboratories and Right to Sight (RTS) was conceptualized to make this a reality and remove needless blindness in the region.

Based on the Needs Assessment Report, LAICO, advised on the renovation of the building and plan for the eye clinic design with 12 beds initially. A floor plan was developed within the existing infrastructure and building renovation was completed by the end of October 2007. A team of Congolese and Indian Expatriate staff were recruited and trained in Aravind Eye Care System.

Basic requirements for the Shalina Eye Clinic were strategically planned, developed and requirements like state-of-the art equipments, instruments, medicines, spectacles and consumables, finalized, procured and shipped to Lubumbashi for the scheduled inauguration on 8th December 2007.

Results

Currently, the Shalina Eye Clinic is getting an average of 80-100 Outpatients/Day. Two Congolese and one Indian Expatriate Ophthalmologist supported with local Congolese staff run the Eye clinic. It is expected to develop into a model hospital, on the lines of SNC (Fig.4).

Fig. 4: A Congolese patient after eye surgery at Shalina Hospital

These are a few examples of the benefits of these kinds of partnerships and LAICO envisages that these partnerships will grow and make a difference

In retrospect, this approach seems to bring in a paradigm shift in the way eye care is delivered. Structured outreach, a focus on quality, productivity and sustainability all get integrated into the way of working. It yields immediate short-term results which are also sustained over time, not just the performance but in many instances the growth as well.