Impact of systematic capacity building on cataract surgical service development in 25 hospitals

The number of cataract operations in the developing world is far below the level required to take care of new and existing cases [1]. Using the increased volume and high quality approaches initially developed by Aravind Eye Care System (AECS) and LV Prasad Eye Institute (LVPEI) in India, ophthalmologists, along with a well-managed team, can double or triple their cataract surgical volume [2]. Simply demonstrating or describing how to improve productivity by underperforming institutions is seldom enough to stimulate and maintain change [3].

An engaged process with regionally available coaching and training, termed herein ‘capacity building’ has been used by 6 mentoring institutions to accelerate change in eye care services in an effort to meet population need and start on a pathway to organizational and financial sustainability [4].

Capacity building is defined hereinafter as an interactive process whereby an established institution is invited to utilize its staff to engage with and support the internal development of other institutions with which it usually has no financial connection. It is a structured, planned and often altruistic effort to help other institutions wishing to grow and improve productivity and efficiency. Capacity building therefore is distinct from capacity ‘development’ which is an internal process not involving explicit external involvement [5].

The institutions providing capacity building are termed “mentors” and hospitals undergoing the capacity building are termed “mentees”.¹ In this study 25 mentee hospitals located in Asia (16), Africa (7), and Latin America (2), were supported by mentor institutions: LV Prasad Eye Institute (LVPEI), Aravind Eye Care System (AECS), Sadguru Netra Chikitalaya (SNC), Vivekananda Mission Ashram Netra Niramay Niketan (VMANNN) in Asia, Kilimanjaro Centre for Community Ophthalmology (KCCO) in Africa and Visualiza Clinica de Ojos in Latin America. For the purpose of this study all of the mentee hospitals managed by the mentors that had undergone four or more years of the capacity building process by 2014 were included.

The mentees initiated the capacity building process in a variety of ways. Some mentees had long-standing relationships with mentor institutions through their leaders or through ophthalmology training programs; some mentees approached the mentor institution and requested the intervention, while others were recommended by outside governmental and non-governmental organizations.

Several key factors typically influenced a mentor’s decision whether or not to engage with a mentee: [a] leadership capacity or potential [b] willingness/desire to change, [c] willingness by the hospital to establish a separate bank account for the eye unit, [d] some infrastructure/personnel in place. Both private and government hospitals were included.

This study measures the cost and impact of the capacity building intervention on cataract surgical volume, surgical productivity and demand for services.

For this research we had three primary questions:

1. Did the capacity building intervention result in an increase in the number of cataract surgical operations per year?

a) by site, compared to baseline averages and provincial or national growth rates?

b) by ophthalmologist compared to baseline?

2) Does the capacity building intervention result in an increase in the total number and proportion of paying cataract surgical patients (‘direct’ walk-in patients) compared to prior years?

3) What are the capacity building costs to increase cataract surgical volume by region?

The CSV decreased slightly in year 1, increased steadily in years 2 and 3 (Fig. 1) and showed a more marked increase in year 4 due to two high-volume centers in India more than doubling their volume. Asia drove the overall increase in volume accounting for 89,109 (83%) of additional surgeries. Four hospitals did not increase their CSV by year 4, while 8 showed an increase of 200% or more.

The two Latin American countries saw a decline in CSRs (Honduras −19%, Peru −28%) while the CSV in the Peruvian hospital increased by 254% and the Honduran hospital decreased by 33%. The Honduran hospital did not continue to grow after the second year of intervention due a refusal to hire another ophthalmologist.

In India, CSR data is available at the state level. Of the eight states where mentee hospitals are located, CSR decreased in two states by 14%, mildly increased in five (range: 6–28%) and significantly increased in one (93%). Two of the 14 Indian mentees increased their CSV less than the CSR of their state. The other 12 hospitals increased their CSV at more than double the change in CSR (range of increase: 39–325%) (Table 2).

The capacity building intervention focused on strengthening organizational management, leadership, team building, equitable access and use of services, financial cost-recovery, and quality of care. How this transpired depended upon the local context; while general principles were followed in all settings considerable variation in setting of priority interventions was noted. In most of the South Asian settings the focus was on providing high quality surgery to all sectors of the population, introducing a tiered patient paying system and reorganizing patient flow for maximum efficiency. In African settings priority interventions focused on strengthening basic organizational, personnel, and financial management systems and designing practical outreach programs. Because the services were provided equitably and sustainably through service fees, they met most of the criteria of effective [11] and systematic [12] capacity building.

The capacity building intervention itself varied substantially from mentee to mentee and mentor to mentor, depending upon the local context and needs. Some mentee facilities only needed minimal interventions such as re-orientation and team building strategies, others required physical renovations and equipment, while most required outreach programs and clinical and management training. Nevertheless, in all settings, raising production targets and changing institutional attitudes to growth was a big part of the capacity building program. However, target setting for growth was more of an internal exercise to increase supplies, training, and efficiency, not an explicit attempt to meet population need. In all of the settings the need for large increases in eye care services, including cataract surgery, was simply accepted as a background reality in the planning process.

Hospitals and eye units worldwide use cataract surgical volume (CSV) as an indicator of overall eye care activity level. It reflects hospital performance and efficiency including patient choice and acceptance of surgery as well as the quality of ophthalmic professionals, patient experience, equipment and supplies. CSV directly depends on the number of patients attending hospital outpatient departments and community outreach activities, often termed diagnostic/screening ‘camps’. Attendance at outpatient and outreach, in turn, reflects interaction with the service population regarding eye diseases and their awareness of treatment options. While mentee hospitals and eye units gathered and used these statistics for their own improvement, the complexity and variability was too great to include in this initial, broad level, assessment study.

The capacity building intervention was systematic [12] it resulted in an initial decrease in cataract surgical volume in 11 of 25 institutions due to key clinical staff undergoing training off site, physical alterations to the hospital building and installation and training on new equipment, as well as service populations learning to accept paying fees for previously free services (though free services were still provided for patients too poor to pay). Despite widely diverse population density, disease prevalence, and eye care infrastructure [13, 14] the capacity building intervention show a substantial increase in cataract surgical volume by year 4 in Africa (164%) Asia (66%) and Latin America (136%).

The proportional increase in CSV observed exceeded the change in cataract surgical rate (CSR) over the same time period in all but three jurisdictions [6–10]. CSR is a widely used, population-based measure, while CSV is simply the number of operations per year in an institution, without the population denominator. Nevertheless, the comparison provides a reasonable way to assess mentee growth rate to background eye care system growth in the same geographical area, thereby controlling for broad political and economic changes during the study period. CSR remains unchanged or declines in settings such as Madagascar and Tanzania where most eye care services are part of government hospitals where eye care is a low priority, equipment is not affordable, and active outreach does not occur. In settings such as India, CSR is steadily rising, albeit much slower than the mentee institutions studied here, because of substantial government and private investment in establishing high quality eye care services and broad distribution of eye care services to the primary health care level.

Surgical productivity (defined herein as cataract operations per ophthalmologist or cataract surgeon) also increased in all regions by year 4. This reflects improvement in a range of internal hospital features including training, clinical protocols, patient flow within the hospital and operating room, and reallocating less-skilled tasks from the ophthalmologist to the rest of the eye care team [15]. Surgical productivity is also dependent upon the burden of disease in the population and there is strong evidence that the incidence of cataract (age and sex adjusted) in many African populations is two to four times lower than in other populations [14].

Direct, walk-in patients who pay for some or all of their care reflect a number of different conditions, some hospital related and some related to the local context. Where transport systems are efficient and effective “direct-paying patients” or their family members have chosen to seek care at the mentee facility over other local and distant treatment options and to use their own money to pay for services. This choice indicates good hospital reputation regarding quality, cost and efficiency of services. Eye care institutions such as AECS in India achieve a cash surplus with only 30–40% of their cataract patients as direct paying patients [16]. As has been shown in different settings in Africa, direct paying patients are generally fewer in number as compared to South Asia. Poor transport systems, long distances, advanced age at development of cataract, and inadequate social support all contribute to a relatively low proportion of direct paying patients [17–19].

Of the 14 hospitals that reported direct paying patient information, more than half reported that paying patients made up 15% or less of total cataract surgical patients prior to the capacity building intervention. Many of these hospitals were founded as charity hospitals that provided services to the poor and therefore did not seek payment from patients leaving the hospitals vulnerable to changes in external funding. In the African countries, government hospitals (4 of the 7) had minimal funding for eye care, mostly consisting of covering salaries. In most instances, early discussions between mentors and mentees included conversations regarding implementation of fee structures and payment options suitable to the hospital context and fiscal demographics of their catchment area. Restructuring patient fees to provide a tiered payment system (particularly in South Asia and Latin America) includes taking into account what top, middle and low income earners would be able to pay for surgical intervention based on the most up-to-date demographic information available for the hospital catchment area and building pricing structures on that while still providing an option for free surgery for those who cannot afford the least expensive option.

The assessment of the return on investment of this capacity building process would suggest that the South Asian sites had the best value-for-money. As noted by Lewallen and Thulsiraj [13] there are a considerable number of factors that limit the ability of directly apply practices from India to different settings in Africa. Comparisons within similar settings may be a more valuable approach to assessing value-for-money. Nevertheless, in all of these settings capacity building proved to be a relatively inexpensive form of increasing the number of people who received cataract surgery.

In summary, the capacity building interventions resulted in a proportionally similar increase in cataract surgical volume and productivity across diverse settings in three distinct geographic regions. Its wide applicability, and moderate cost make it an attractive means to rapidly and substantially increase eye care services to meet VISION 2020 goals.