Reading Material for the Prevention of Blindness Workshop

Making Eye Care More Affordable

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Making Eye Care More Affordable

Making eye care more affordable to those who can least afford it, requires specific strategies that target the root causes of both direct and indirect cost barriers. Such strategies might include the following;

Reducing the burden of direct costs

  • Promote community based screening and treatment – extend the reach of services into the community and reduce the burden of travel costs for patients

  • Provide financial support for transport and food – encourage those who are particularly poor to come forward for sur gery, by offering incentives that reduce the cost burden

  • Introduce a user fee structure that does not deny affordable access – implement a cross subsidy pricing structure (to include free service where necessary) where wealthier patients pay more to subsidise poor patients through the offering of value added services (e.g., private rooms)

  • Reduce unit cost of service provision – increase operational efficiency and volume of output (e.g., number of operations)

  • Reduce the need for repeated visits – create a ‘one stop’ referral and/or treatment service, to reduce the burden of unnecessary travel and time costs for patients

  • Mobilise community resources – encourage communities themselves to support the treatment of poor patients out of their own resources.

Reducing the burden of indirect costs

  • Raise awareness about the cost of blindness – motivate people to come forward early by advertising the cost of blindness compared to the cost of treatment

  • Promote ECCE with IOL surgery – the use of this surgery dramatically reduces patient recovery time compared to ICCE with aphakic correction
  • Identify and train community eye health carers – working closely with the community, identify motivated ‘carers’ to assist by accompanying patients coming forward for surgery/treatment

  • Introduce demand management strategies – structure service management to meet the variations of seasonal peaks in demand, to reduce patient waiting time.

There is little doubt that affordability significantly limits the reach of many eye care programmes. If Vision 2020 (The Right to Sight) is to achieve its very worthwhile goals, greater efforts are needed to reduce the costs of access, particularly in the design of service provision, so that eye care can truly become an accessible right for all.


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  2. Fletcher A E, Donoghue M, Devavaram J, Thulasiraj RD, Scott S, Abdulla M, Shanmugham CAK, Bala Murugan P. Low uptake of eye services in rural India. Arch Ophthalmol 1999; 117: 1,393–99.

  3. Cannon W, Orenstein J, Levine R (1997). A study of the availability, accessibility and affordability of refractive error correction in Jamaica. Help the World See consultancy report.

  4. Fletcher A E, Donoghue M (1998). Barriers to uptake of cataract services and proposed strategies to address these. Background paper prepared for WHO informal consultation on analysis of blindness outcomes, Geneva.

  5. Whitworth J, Pickering H, Mulwanyi F, Ruberantwari A, Dolin P, Johnson G. Determi nants of attendance and patient satisfaction at eye clinics in south-western Uganda. Health Policy & Planning 1999; 14(1): 77–81.

Cost Containment in Eye Care
MR D Thulasiraj MBA
A K Sivakumar MH
Lions Aravind Institute of Community Ophthalmology
1 Anna Nagar
Madurai 625 020

Voluntary eye hospitals committed to serving the community must understand the reality of increasing costs due to inflation, advancements in medical technology and changing expectations of staff and patients. However, these costs are often not matched by the patients’ paying capacity. While increasing income, through increased user fees or donations are financial options which will be considered, this article will focus on cost containment.

Conditions for Effective Cost Control

Though cost containment is influenced by the health care systems that exist, certain organisational conditions have to be in place for them to be effective. The leadership has a strong role in this. The organisational leadership must be within the eye care system and be available to the organisation whenever required (as opposed to hospitals run by Government or Religious Organisations wherein the leadership is often outside the hospital system and not readily available). Delayed or inappropriate decisions tend to increase costs and inefficiency. It is also important that the leadership promotes a culture of cost consciousness.
Standard clinical and administrative protocols are necessary to institute and review cost containment measures without affecting quality, productivity or patient satis-faction. The first table lists the various factors that influence costs.

Variable Costs

Variable costs are mostly made up of clinical consumables, stationary, etc. Cost savings in this area require good inventory management and group purchasing for better prices. Good materials management, to reduce wastage through storage and pilferage, will again reduce the variable costs.

However, reviewing the clinical protocols and eliminating investigations, procedures and medications that do not contri bute to quality, productivity, good outcome or patient comfort can result in greater reduc tions in variable costs. Setting up a good clinical information system is necessary for making such evidence based decisions.

Fixed Costs2

In health care organisations, the fixed cost could account for as much as 70% of the total recurring expenditure and hence deserves the most attention. Investment in infrastructure, size of the facility and staffing are the major determinants of fixed costs. While leasing out a part of the building, reducing staff or better negotiations of maintenance or salary contracts could be some of the options to reduce fixed costs, the focus in cost containment must be more on reducing the ‘fixed cost component within the overall unit cost’ of service through optimum utilisation of the infrastructure. This focus will lead to continuous efficiency improvements resulting in sustained cost containment. Seasonal variations in patient load affect capacity utilisation and thereby affect the costs. Salaries constitute the major proportion of fixed costs. Thus, the staff utilisation pattern, especially that of the ophthalmologists, has a direct impact on costs. The factor that has the most impact on ‘unit fixed cost’ is productivity. The simplified exercise,3 shown in the box below, illus trates that as productivity increases to match capacity, the unit fixed cost reduces to a fourth and the total cost comes down to almost a third.

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