Self-sustainable and inclusive eye care - Where equity meets excellence.

“If Coca-Cola can sell billions of sodas and McDonald’s can sell billions of burgers, why can’t Aravind sell millions of sight-restoring operations, and, eventually, the belief in human perfection?” – Dr. G Venkataswamy

About 2.2 billion people worldwide have vision impairment, at least half of which are avoidable. Current estimates of preventable causes of moderate to severe vision impairment or blindness include unaddressed refractive error (88.4 million), cataract (94 million), glaucoma (7.7 million), corneal opacities (4.2 million), diabetic retinopathy (3.9 million), and trachoma (2 million), but the bulk is attributed to uncorrected presbyopia (826 million)[1] Apart from personal and social impact, the annual economic impact of moderate to severe vision impairment and blindness is huge - $411 billion at purchasing power parity or 0.3% of gross domestic product.[2] The World Health Organization’s resolution on “integrated, people-centered eye care (IPEC), including preventable blindness and vision impairment” was adopted at the 73rd World Health Assembly in 2020. The essence of the resolution is to make IPEC the model of choice and to ensure its widespread implementation.[3]

It is estimated that about two thirds of population of India may require free or subsidized eye care,[4] and if they have no such access, they may suffer marginalization and exclusion. Affordable and accessible high-quality care delivered by trained eye health professionals, ably assisted by cross-trained support staff in the setting of community-based self-sustainable, time- and resource-efficient eyecare facilities, endowed with optimal infrastructure is the key to success in eliminating avoidable blindness.[5] However, such lofty ideals may suffer an undeserved premature end unless there is built-in financial stability.

Charity vs Sustainability: The Source of Funds

“When we want to help the poor, we usually offer them charity. Most often we use charity to avoid recognizing the problem and finding the solution for it. Charity becomes a way to shrug off our responsibility. But charity is no solution to poverty. Charity only perpetuates poverty by taking the initiative away from the poor. Charity allows us to go ahead with our own lives without worrying about the lives of the poor. Charity appeases our consciences. A charity dollar has only one life; a Social Business dollar can be invested over and over again.” - Muhammad Yunus, Banker to the Poor: Micro-Lending and the Battle Against World Poverty.

In a situation of economic imbalance, not charity, but economic self-sustainability is the key to survival. Economic sustainability is a direct derivative of two fundamental principles – income generation and cost optimization.[6] An eye hospital derives income mainly from patient care (of those who can afford to pay for services), accessory services such as optical and pharmacy, and by availing governmental schemes and subsidies.[6] Quality can directly impact sustainability by bringing in the sections of society that can afford to reasonably pay for their care and thus fostering an organic growth.[6] Increasing patient volume builds in the vital economics of scale into the equation of sustainability. While people may be unwilling to pay for preventive services and medical care, interventions with a perceivable and definitive outcome such as provision of spectacles or cataract surgery may be willingly paid for.

Brain of an Entrepreneur and Heart of a Philanthropist

Creation of high-quality, high-volume, low-cost, efficient, community-based eye care systems can help optimally take care of eye health needs of the entire spectrum of the society and support the care of the economically deserving subset of the population free of charge. Fee scale can be stratified with value-addition for different price points. Such models synergize the best of clinical practices with prudent financial planning and management to create an inclusive social–entrepreneurial approach to eye-care delivery.[5] Protocol-based efficient management practices, periodic monitoring and fine-tuning of systems, optimal utilization of human resources, and embracing low-cost technologies (without compromising on quality) can help bring about cost containment.

The business models of Aravind Eye Care System, LV Prasad Eye Institute (LVPEI), Sadguru Netra Chikitsalaya and many such organizations may be diverse in their operating philosophies but are bound by three fundamental principles – accessibility to care regardless of patient’s ability to pay, delivery of highest-quality of eye care services, and self-sustainability at all levels operations. These principles are embodied in Aravind’s vision statement “to provide compassionate and quality eye care affordable to all” while LVPEI stands for “Excellence, Equity and Efficiency”. Technically termed “customer segment cross-subsidization” model, such a system creates value for the entire patient base but derives value from only a part of the patient pool.[7] Profit generated by the patients paying for the services covers the costs of care provided for free or subsidized. Organizations embodying this model of business economics can provide free-of-cost or low-cost, high-quality service to 50-60% of their patients by using the profits generated from the 40-50% of paying patients – there lies the simple secret of economic equilibrium. Training needs, infrastructure development, growth, expansion, and replication of facilities are funded by grants, charity, and accrued profits. Principles of financial sustainability are outlined in Table 1.[8]

Table 1

David Green's Principles of financial sustainability

1. Collaboration, empowerment, and ownership

2. High quality + Large volume=Low cost

3. Cost recovery by understanding people’s capacity to pay

4. Multi-tiered pricing

5. Wise location of the facility

6. Compassionate capitalism

7. Changing the mindset and the practice of ophthalmologists

8. Use of high-quality cataract surgery to build reputation

9. Program planning for a standardized, replicable approach

10. Appropriate (and appropriately priced) technology

11. Accountability

12. Responding to consumer expectations

13. Per unit cost as a tool for evaluating efficiency, productivity, and quality

Adapted from Green D. Financial sustainability for High Quality, Large Volume, Sustainable Cataract Surgery Programmes, Quality Cataract Surgery Series, Aravind Publications/LAICO, Madurai, India, 2001

Live and Let Live

While all this happens, it is imperative to protect and preserve the local eye care economy, possibly by assigning a specific bouquet of essential services and categories of surgeries for free patients, reserving the higher-end value-added care for the paying patients, while ensuring quality of care and optimal outcomes for all. This would create an open ecosystem for paying patients to access other local eye care facilities at will, thus help sustaining other eye care systems that cater to pay-for-service patients.

Conclusion

A community-based eye-care delivery system with quality, efficiency, productivity and self-sustainability as corner stones and equity as the overarching goal can be an ideal model to achieve our mission of a world free of avoidable blindness. India has shown the way and how!

“There is no better way to thank God for your sight than by giving a helping hand to someone in the dark.”- Helen Keller, Light in my Darkness.