India's eye care journey: What others can learn

NEW DELHI — While no two countries are alike, there are many lessons that other countries can learn from India’s experience in building its eye care system, which has been recognized as a leader in high-quality, low-cost care.

It has taken India decades to find the right business models, develop the right policies, and share lessons to allow for growth. While the country still has room to improve, it also can serve as a model for other countries, which may be able to achieve similar gains in a shorter period of time.

A lot of the systems and technology is readily available for other health systems and NGOs to pick up and adapt, allowing them to leapfrog some of India’s challenges, but institutional leadership is critical, said R.D. Thulasiraj, director of operations at the Aravind Eye Care System.

In conversations with leaders and experts on India’s path to growth in eye care, particularly in cataract surgery, three key lessons emerged: political and NGO leadership, addressing the human resources challenges, and building the right ecosystems for success.

Leadership

From NGOs to government, there has to be a commitment to improving eye care for a country to succeed, either through new policies or an organized effort for better quality of care.

A first step countries should take is economic modeling to estimate the impact of blindness on the country’s gross domestic product. Those models can be used to make the case for investment in vision care, as it did in India, where it was key to successfully receiving a large World Bank loan, said Dr. Damodar Bachani, who helped draft the proposal for the loan and ran the resulting program. Countries should also then carry out a structural analysis to identify key gaps in building the eye care system and create a plan to address them, he said.

Creating the business case for investment can help mobilize needed financing but countries must also create the right policy environments to enable growth.

In Ethiopia, for example, imports of certain supplies are only allowed once a year, making having the right lenses for surgery difficult as it is hard to predict what will be needed. That is a problem that government could solve, said Thulasiraj, who has done some work with Ethiopia on eye care.

Another challenge African countries will face is a logistical one, he said. India’s road systems and public transit are fairly good, but in Africa, transportation costs and a lack of infrastructure make it harder to get patients care and make the business models work. It is still possible, Thulasiraj said, but improved infrastructure would help.

In many countries, NGOs will be critical players, especially in isolated areas. India benefited from a core group of NGOs that worked together to get government buy-in and improve the system, said Suzanne Gilbert, senior director of the Global Sight Initiative at Seva. The Global Sight Initiative brings together hospitals and NGOs working to restore sight to 1 million patients each year by 2020, and through the initiative, Seva is working to help find and share best practices and build a network of mentorship in the field.

In India, a group of NGOs led by Aravind set out big goals that helped drive progress. Other countries and individual leadership need to think big as well, Thulasiraj said. Earlier this year, he led a discussion with eye care leaders in Kenya trying to set targets on how many surgeries doctors needed to do to help eliminate blindness from cataracts.

Today, doctors in Kenya are doing between 300 and 400 surgeries a year, with the World Health Organization setting the target at 2,000 surgeries a year. The problem, he said, is that it will take 5,000 to 6,000 surgeries a year to solve Kenya’s cataract blindness problem.

“They need to think about what is needed, not what is possible, because what is possible can change,” he said. “[A] major problem I see in those countries is not having visionary leaders.”

Human resources

In many countries, there is simply not enough medical staff to perform the number of surgeries needed, or the human resources that are available may not be used optimally.

India has had to contend with having too few surgeons, and countries can learn from its response. The government changed some regulations and allowed more ophthalmologists to be certified each year, but the biggest innovation was in the training of a new cadre of support personnel.

These “allied ophthalmic personnel” — nurses, technicians, and assistants — help support doctors, take care of many of the initial evaluations, and enable hospitals to carry out far more surgeries in a day. Other countries can create similar training programs to build the support staff that can allow a limited number of surgeons to do more surgeries.

Maximizing the efficiency of each surgeon is also key to ensuring that needs are met, especially in Africa where there are only three or four ophthalmologists for every million people and most are in the big cities, Thulasiraj said.

Given how few there are, “you would think they should be swamped with work, but in reality, they are underutilized. If you go by surgeries per ophthalmologist per year, it is criminally low by how few there are,” he said.

Building an ecosystem

In India, one of the keys to growth was figuring out the business model — and then finding ways to build a market to drive demand to allow the model to succeed. India pioneered the cross-subsidization model for eye care, where fees from wealthier patients help cover the costs of treatment for low-income earners. This is a model other countries could use, though it requires a high volume of patients to be successful.

A key to increasing the number of surgeries was also improving the quality of eye care. The government banned cataract surgeries at temporary surgical facilities, requiring that they take place in hospitals. As the quality of care improved and patients from different economic backgrounds had their sight restored, demand for the services grew.

In many parts of Africa, only about 4 of 10 people who have cataract surgery have their sight restored, where the success rate should be much closer to 100 percent, Thulasiraj said. The quality of care needs to be improved in order for the market to mature more quickly, he added.

It does work in some places. A Nairobi hospital that is doing outreach, for example, offers free transportation for the poorest patients and allows everyone to pay on a sliding scale. That hospital is self-reliant for its operating costs but still needs additional support for greater scale or new equipment, Thulasiraj said.

Many facilities can improve their operations — from finding the right culturally and logistically appropriate mechanisms to get patients to seek care, to building a treatment ecosystem, and generating the types of volumes that make the Indian model work.

Part of the challenge is in operationalizing some of the lessons learned, Thulasiraj said. While Aravind is studying how to help organizations do that, there aren’t easy answers. For example, University of Michigan’s Ross School of Business helped a hospital in Kenya monitor the acceptance rate for surgeries — how often patients chose to have recommended surgery — and found that if the hospital improved that rate to 70 or 80 percent, it would have the money it was trying to raise to expand the hospital’s property. Though hospital officials understand the benefits, they have not acted on the information.

“That’s what’s puzzling,” he said. “What are we not doing right?”

Devex, with financial support from our partner Essilor, is exploring challenges, solutions, and innovations in eye care and vision. Visit the Focus on: Vision page for more.