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Transforming Eye Clinics and Hospitals to Sustainability
to the transition process so that when internal and external challenges
arise, the process is not thrown off track. The leader also must ensure About Visualiza
that the quality of care and services are maintained. Without quality
results, patients will not seek or accept eye care, even if it is free. In 2002, Mariano and Nicolas Yee, ophthalmologist brothers, had
a two-room private practice in a shopping mall in Guatemala City.
Management and Accountability They wanted to incorporate services for the poor, but wondered
Strong management is critical to success. Ophthalmologists should focus how to afford it. They invited the IEF to help, and over the next
on treatment and surgery and ensure that professional eye-care three years the IEF’s technical assistance and an investment of
managers handle the administrative and management responsibilities. US$180,000* transformed their practice, Visualiza, into a social
The IEF’s initial investment supports the creation of manager positions enterprise. The needs assessment and business plan included a
until income sustains their costs. Quality service is critical to customer move to a larger facility in 2002 in order to have their own
satisfaction, ensuring that patients are seen in a timely fashion, are operating room instead of losing revenue by renting space at
treated with respect and will recommend the service to their friends and another hospital. A social side was established with a walk-in clinic,
family. Quality indicators monitor surgical and visual outcomes and counsellors and a sliding fee scale. Between 2002 and 2007,
efficiency metrics. Efficiency strategies focus on all areas, especially outpatient exams increased by 344%, from 6,312 to 28,040.
patient flow-through in the outpatient department and turnaround time All surgeries increased by 761%, from 464 to 3,997;
between surgical patients in the operating room. The standards and paediatric surgeries increased by 211%, from 27 to 84; and
protocols monitor progress and accountability. cataract surgeries increased by 573%, from 255 in 2002 to 1,717
in 2007 (see Figure 1). Guatemala has 150 ophthalmologists and a
Patient Counsellors reported cataract surgical volume of 11,000 annually. Therefore,
Counsellors are introduced to advise patients, alleviate anxiety and Visualiza now performs 16% of all cataract surgery in the country.
address needs contributing to overall patient satisfaction. They are the Revenue increased by 1,024% in the five years, from US$168,316
liaison and face of the organisation within the community. Our in 2002 to $1,064,122 in 2007 (see Figure 2). After all expenses,
experience shows that patient counsellors significantly increase cost recovery in 2007 was 109%. Of revenue earned in 2007, 14%
acceptance rates of patients needing treatment, surgery and optical came from outpatient exam fees, 40% from surgical fees, 35%
services. The costs of counsellors are also supported by the IEF until they from optical services and 11% from other sources such as
can be covered by earned revenue. pharmacy (see Figure 3). In December 2007, with 48 staff including
five ophthalmologists, two optometrists and two administrators,
Outreach Visualiza moved again, to a large building with two operating
Community outreach programmes are critical to increasing patient rooms in order to accommodate their growing practice. The
volume and marketing services to communities. They also establish the business plan requires that 80% of profit is reinvested in the
hospital’s credibility, accountability and confidence at the community practice. In 2005, Visualiza hired a full-time qualified paediatric
level. Outreach programmes are established to identify the unreached ophthalmologist. Now, children with congenital cataract and
and increase the number of patients examined and referred. glaucoma, squint and eye cancers do not have to be referred to a
Well-planned screening campaigns enable the highest visibility and specialist, who was previously often unaffordable for the family.
immediate return of patients to the base hospital with their friends Visualiza‘s initial goal of incorporating poor patients into their
and neighbours for further treatment and/or surgery. By alleviating fears practice has been achieved. Approximately 80% of patients were
related to travel, surgery and cost, women, children and the elderly are subsidised by earned revenue (see Figure 4). There is a roughly
more easily able to access care. equal distribution of male and female patients (see Figure 5). The
IEF elevated Visualiza to a ‘Regional Demonstration Centre’ in 2006
Revenue Generation to provide workshops and backstop new clinics in IEF’s SightReach
Activities to earn income are introduced in government and charity Management network.
hospitals, where all care was traditionally provided free of charge. The
IEF’s public sector partners in Malawi now earn some revenue and still *Part of grant funds awarded to IEF’s SightReach Management programme from
treat the majority (over 90%) of their patients for free. Major revenue
USAID and the de Beaumont Foundation recognising effective use of donor dollars.
sources include new optical services for eye patients and the general
public. A sliding fee scale with ‘zero cost’ as a price is established and is
based on the lowest 60% of the population’s ability to pay. The fee scale services can be a great income generator if managed professionally. Profit
may be stratified into different pricing categories with added value and can cross-subsidise the outreach and eye-care services for patients at the
amenities at each price. The IEF invests in establishing other lower end of the economic scale; this way, no-one is denied service.
revenue-generating services such as a cafeteria that is owned by the eye Additionally, the ophthalmic service can control the quality of frames,
clinic. Earned income covers expenses and profit is put towards patient lenses and prescription spectacles, and also contain prices.
care costs, in effect stretching the budget to treat more people.
Standards and Protocols
Optical Services It is important to have a standardised protocol for every activity, with
In many countries, optical services are separated from ophthalmology clearly defined roles and responsibilities. It is also important that the
and operate independently in the private sector. The IEF establishes clinical team get involved in planning and implementation. They
optical services as an integral part of the eye-care service itself. Optical should have the opportunity to come up with ideas for change, and
EUROPEAN OPHTHALMIC REVIEW 9
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