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Crisis or Opportunity?

Alcon Sponsored

Haiti Ophthalmology Symposia Karibe Hotel, May 18th - 19th, 2012

Port au Prince, Haiti

John Barrows, IEFRaheem Rahmathullah, IEF

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Situation Before and After

Incidence 10,000

Prevalence & backlog

50,000

3,500

(2005)

• Number of blind growing– CSR is - 400 per million?– 50% of blind in

Caribbean • Services divided by private,

government, NGO, missions, Cubans

• Quality, productivity, efficiency, do we have data

• Dependence on external

resources

3

Problems Different Than Before?• Why don't people use our services?• Can we be more productive?• Why is there a brain drain?• Why do costs escalate?• Why is equipment poorly maintained?• Do we rely too much on external resources?• What are the opportunities and options we

need to know about to make positive change?• How can we get consensus to move ahead?

4

Objectives• Review principles of sustainable eye care• Provide a model to consider, inspire a vision, challenge

you about processes, enable you to take action• Self reflection on

– what are the (+) things that can happen if action is taken

– what would make it easier to take action– who will approve and support these actions

• What we are/ would like to do in Haiti• Gain honest feedback and learn from you• Relax and listen; note questions/ thoughts on handout

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Which Way?

When you get to the fork in the road – take it.

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Redefine the Problem

"A stable but inherently unjust equilibrium exist in eye care in developing countries causing exclusion marginalization and suffering of both patients with eye disease and eye care providers who lack the authority, autonomy, resources or political will to change the situation. Patient choices include an unaffordable private sector or an inherently inefficient public system."

"Transforming Eye Clinics and Hospitals to Sustainability – The International Eye Foundation's Social Enterprise Model" European Ophthalmic Review, 2008

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ProblemPrivate Eye Hospitals

• Few patients at high cost• Private practitioners volunteer in charity

services• Are not willing to treat the poor within

their private practice.

You mean I’m going to start treating patients for FREE?

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Problem Government Eye Hospitals

• Dependent on limited budgets and donor funds

• Inefficient, unproductive, not patient-focused• Lack incentives to improve services

You mean I’m going to start charging POOR people?

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Social Enterprise SolutionCombine the best of clinical eye care practices w/ business planning & management systems to create a different approach to eye care delivery

• Public/government AND private eye hospitals choose to have a private side for paying patients and a social side for poor patients offering the same quality of clinical care.– Private clinics see paying patients and subsidize

poor patients.– Public hospitals have special facilities for private

patients and treat poor patients as well.• Patients choose where they access quality services.• Clinics achieve financial sustainability by offering a

range of services, and amenities at multi-tiered pricing including “zero cost”.

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What Are We Trying to Achieve?

Investment in the eye hospital/clinic’s

• Ability to grow, continue meeting the needs of patients, and accept doing this beyond donor funding (traditional charitable investments).

• Services that produce benefits valued by patients and stakeholders ensuring continued demand for services for long-term.

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Governance & Leadership

Financial Resources

Management

Service DeliveryTargets population, Building,

Comprehensive services,Equipment, Procedures,

Quality standards,Community Outreach

Dimensions and Components

Human Resources

LocationPopulationStakeholders Policies

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Leadership

“Leading is enabling others to face challenges and achieve results in complex conditions”

Sandra Dratler DrPh, SEVA and UC, Berkley, School of Public Health

FROM… TO…

Individual heroics Collaborative actions

Despair and cynicism Hope and possibility

Blaming others for problems Taking responsibility for challenges

Scattered, disconnected activities Purposeful, interconnected actions

Self absorption Generosity and concern for common good

Governance & Leadership

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Leadership

Personal Values• Integrity/ commitment• Respect/ trust• Courage to take

calculated risk• Openness to learning

Leadership in practice• Model way• Inspire shared vision• Challenge process• Enable others to act• Encourage the heart

Sandra Dratler DrPh, SEVA and UC, Berkley, School of Public Health

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Attractive and Functional Space

• Patients want an attractive, convenient, clean, safe place– Would you want to go there? – Build, rent and renovate or

expand. – Efficient space to create patient

flow? (OPD)– Can you reconfigure/ renovate

space to grow?

• Operating theatre a must…– Equipped and safe

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Appropriate Equipment & Supplies

• Careful selection of technology reduces cost

• Microscope + 2 tables• Cataract sets (4-5 per

surgeon)• Supplies (simplify, bulk

buy to avoid stock outs)

Factor Increase in productivity

% of eye units with

these factors in

place

2+ cataract surgical sets

2.65 X 46%

Operating microscope

2.44 X 78%

Community outreach program

2.13 X 20%

3+ support from nurses

2.00 X 33%

Source: Study by Kilimanjaro Centre for Community Ophthalmology for Sight Savers International

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Quality Service for Everyone

Patients want:• Quality and choice drives services and attracts

patients• Convenient

– Scheduling, waiting time, return visits, family members, amenities, information, reputation

• Differentiate services using multi-tiered pricing – Private - service, value, cost, price above cost– Social - service, value, cost, price at cost– Free - service, value, cost, price below cost– Package to reduce confusion and inconvenience

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Economic Distribution & Targets

• Modify for Haiti• Target middle 70%• Nobody turned away

Very rich 10%

Upper middle 10%

Middle 10%

Lower middle

30%Lower middle

Lower middle

Poor20%

Poor

Very poor20%

Very poor

70%

private

public

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Understand Patient Population

• Realistic catchment area – Epidemiology/ gender/ age– Competition

• Characteristics of population and patients– Household income of lowest 60% population

• Behavior detriments– External/environmental detriments - distance,

knowledge, – Internal detriments - behaviors - why some

accept and others do not accept services

LocationPopulation

Stakeholders Policies

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Ancillary Services

• Optical services – Shop/workshop; Concession or own– Need excellent refraction

• Pharmacy

• Cafeteria, coffee dispenser, kiosk

• Accommodation (for outreach patients)

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Trained Staff

• Ophthalmologists FT + PT

• Technicians 4:1

• New staff - Manager, Accountant, Counselor, Outreach, Stores, Maintenance

• On-job training

• Clarify structure &lines of authority

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Manager and Systems

• Relieves ophthalmologist of administrative responsibilities

• “Line manager” monitors systems/patient flow daily– Registration, VA, refraction, diagnostic studies,

exam, treatment, surgery, optical sales, discharge, administration etc.

• Only when monitor can you expect improvement

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Demand - Find More Patients

• Purpose of Outreach – Stimulates demand for services and

provides visibility – Reach hard to reach populations

• Balance between Services and Outreach

– Develop services first and use outreach to benefit the clinic

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Diversify Financial Sources

• Self-earned revenue enhances independence – reinvest into practice

• Explore options - fees, optical, pharmacy, cafeteria, community support for outreach

• Manage donors, government, business

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Efficiencies & Reduce Costs

• “Increase volume, lower cost”– Reduce price, lower cost to lower 60% – Evaluate cost effectiveness

• Standardized practices improve efficiency– Surgery and patient flow through– Equipment, medical supplies, outreach

• Focus on services done well, e.g., cataract and avoid distractive projects

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Does this work? Regional Examples

• Peru – 5 year incr. surg. 655 to 2,229 (240%); revenue incr. 290%

• Mexico – reduced waiting time 44% by reorganized flow 1 day

• Rapidly growing experience– Asia, Egypt, Africa– Mexico, Guatemala, Honduras, El Salvador,

Nicaragua, Peru, Equator, Paraguay, Brazil

• Guatemala – 6 year incr. surg. 464 to 5,680 (1,124%)

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Surgery

-

1,000

2,000

3,000

4,000

5,000

6,000

2006 2007 2008 2009 2010 2011

Cataract Surgery All Surgery

DNJ, Peru

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Patient Choice – Simplified Pricing

0 500 1000 1500 2000 2500

2008

2009

2010

2011

Free Subsidized Paying

DNJ, Peru

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Diversify Revenue

0 200000 400000 600000 800000

2006

2007

2008

2009

2010

2012

OPD Surgery Optical Other

DNJ, Peru

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Financial Self-sufficiency

0

100000

200000

300000

400000

500000

600000

700000

800000

2006 2007 2008 2009 2010 2012

Income Expense

DNJ, Peru

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Managed Change Process

• Starts with an ending/ manage transition

• Are there problems implementing this? SURE

• What is worst case scenario? IMPROVEMENTS

• Will this work in Haiti? LETS FIND OUT

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What About Haiti

• Cap Haitien experience “Vision Plus”

• Private and social clinic/ 3-4 lanes

• Operating theatre

• Optical sale P & S

• Coordinated with government service and medical missions

• Vision for the Poor, IEF, Deseret Fnd, Visualiza, room for others…

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Challenges

• Funding • Shipping and customs• Establishing duty free/ Foundation status • Multiple demands on too few people

(missions, projects, meetings etc)• Test market assumptions

– Patient population - paying, subsidized, free– Other providers– Enabling policies

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Future Plans?

• What we would like… might do…• Demonstrate sustainability planning• Evaluate capacity and feasibility of 5

clinics with ORs• Conduct sustainability workshops• Develop sustainability plans w/financial

and productivity projections• Facilitate technical intervention and

exchange training

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Crisis or Opportunity?

Have I?

• Modeled a way?

• Inspired a shared vision?

• Challenged the process?

• Enable you to act?

• Encouraged from the heart?

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FeedbackWhat (+) things might happen if I apply this approach?

What (-) things might happen if I apply this approach?

What will make it easier for me to apply this approach?

What will make it more difficult to apply this approach?

Who will approve/support me to apply this approach?

Who will disapprove/hinder me from applying this approach?

I believe I can apply this approach.

I don't believe I can apply this approach.

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"The burgeoning rates of blindness, 90% of which is in developing countries, can only be addressed when the quality of eye care is that which patients will seek, accept, and for those who can afford, be willing to pay for. While training more eye care professionals is a piece of a larger puzzle, the root causes of current inefficiencies, poor quality, and under-utilization of services lie in the poor management and the lack of financial sustainability of existing services."

International eye foundation monograph 2005

Thank You