1. 1 Crisis or Opportunity? Alcon Sponsored Haiti Ophthalmology Symposia Karibe Hotel, May 18 th - 19 th, 2012 Port au Prince, Haiti John Barrows, IEF Raheem Rahmathullah, IEF

2. 2 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. 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. 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

5. 5 Which Way? When you get to the fork in the road – take it.

6. 6 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

7. 7 Problem Private 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?

8. 8 Problem Government Eye Hospitals D ependent 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?

9. 9 Social Enterprise Solution Combine 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”.

10. 10 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.

11. 11 Governance & Leadership Financial Resources Management Service Delivery Targets population, Building, Comprehensive services, Equipment, Procedures, Quality standards, Community Outreach Dimensions and Components Human Resources Location Population Stakeholders Policies

12. 12 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 heroicsCollaborative actions Despair and cynicismHope and possibility Blaming others for problemsTaking responsibility for challenges Scattered, disconnected activitiesPurposeful, interconnected actions Self absorptionGenerosity and concern for common good Governance & Leadership

13. 13 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

14. 14 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

15. 15 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) FactorIncrease in productivity % of eye units with these factors in place 2+ cataract surgical sets 2.65 X46% Operating microscope 2.44 X78% Community outreach program 2.13 X20% 3+ support from nurses 2.00 X33% Source: Study by Kilimanjaro Centre for Community Ophthalmology for Sight Savers International

16. 16 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

17. 17 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 Poor 20% Poor Very poor 20% Very poor 70% private public

18. 18 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 Location Population Stakeholders Policies

19. 19 Ancillary Services Optical services –Shop/workshop; Concession or own –Need excellent refraction Pharmacy Cafeteria, coffee dispenser, kiosk Accommodation (for outreach patients)

20. 20 Trained Staff Ophthalmologists FT + PT Technicians 4:1 New staff - Manager, Accountant, Counselor, Outreach, Stores, Maintenance On-job training Clarify structure &lines of authority

21. 21 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

22. 22 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

23. 23 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

24. 24 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

25. 25 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%)

26. 26 Surgery DNJ, Peru

27. 27 Patient Choice – Simplified Pricing DNJ, Peru

28. 28 Diversify Revenue DNJ, Peru

29. 29 Financial Self-sufficiency DNJ, Peru

30. 30 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

31. 31 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…

32. 32 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

33. 33 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

34. 34 Crisis or Opportunity? Have I? Modeled a way? Inspired a shared vision? Challenged the process? Enable you to act? Encouraged from the heart?

35. 35 Feedback What (+) 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.

36. 36 "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