Lecture: Strategies to Strengthen Outreach of Vision Centres

[Phanindra] Good evening, everybody. Thank you so much for joining this very, very important session on strengthening the outreach of vision centers. We will be discussing some of the strategies, very important strategies. I welcome you to this session on strategies for strengthening the outreach of vision centers. In technical corroboration with Mission for Vision. This webinar is at another very important to bring improvements in our outreach and strengthening the vision center’s functions.

We will be discussing three aspects into this session today. Particularly we will be learn these strategies to improve footfalls to the vision centers through the outreach activities of vision centers. And also we will look at the factors contributing to the success of vision centers. And also effective ways to manage the vision center that we will see from the experience of Mission for Vision.

I’m so happy to introduce our resource person the speaker, Mr. Franklin Daniel. Franklin Daniel is currently working with Mission for Vision as a lead for vision center program. He comes with 30 years of experience in eye health and rehabilitation field. He is presently responsible for expansion and the starting for 50 plus vision center program. It is known as Mission Jyot. It is being implemented in 13 states in our country. Taking this opportunity to thank Mission for Vision once again for its support. And I’m also thankful to Orbis for providing us Cybersight platform and we’re also thankful for our corporate advisory board members: Appasamy Associates, Aurolab, BioMedix, and EssilorLuxottica.

I’m now requesting Franklin to take over and have his presentation. Thank you so much, all, thank you.

[Franklin] Once again, I would like to thank Vision 2020, Cybersight, Orbis, Mission for Vision for giving us this opportunity and I also thank each of the participants that have taken time out of their workplace. I’ll share some of our experience that we gathered over three to four years. Some of them are really useful to implement and see excel.

The contents of my visual slides will cover around about Mission for Vision. We also, I would like to talk about the Mission for Vision in a couple of slides. The concept and need of vision center, Mission for Vision’s approach and support. Various strategies that we learned when we traveled across many partners and we learned many things which I will share. North East experience, but also I’m going to talk about. And factors which actually contributes towards the success of vision center. And vision center management. Some of the key learnings in what we learned. And also experience of our partner. This is all the presentation will be.

We all know the rationale of vision center. Primary eye care is critical which is provided by the vision center for the prevention of blindness. And majority of population in India live in rural and urban slums have really limited access to affordable and acceptable eye health care, which can be addressed through vision center. There are many research available that shows very clearly that outreach screening camps only reaches out to 7% of people who are in need. And the existence of primary eye care centers that is vision center ensures cost effective services. It aligns well with national and global priorities for the prevention of blindness and promotes universal eye health, WHOs, and also IAPBs new strategy of an integrated people-centered eye care approach.

And during the pandemic we all agreed that during pandemic the majority of eye health experts consider vision center the best approach for primary eye care. Because there are a lot of limitation happening in our missing camps and the number of people are turning into camps. And also we believe that we should provide continuous quality services to the communities. And also especially during the pandemic and also after the pandemic vision center strategy, and this is what we’re learning what we’re going to hear from different slides.

Vision center. A lot of this is not new, we all know that the vision center concept was quite, many organizations started it including this. But each implementing organization followed different definitions and some used to run a vision center once in every fortnight. Instead of calling them as a fixed camps, they also call them a social center. But all of the last 3-4 years a lot of efforts have been put into the vision center. Many organizations started implementing. That also helped to really fund the vision center.

There are a couple of things that we need to save and define the vision center concept. It should be permanent in terms of in case all the day the vision center should be functioning. And some of the vision centers, the vision center staff keeping the vision center open for five days, Monday to Friday. And Saturday they go to different villages, conduct the outreach activity, in addition to vision center. Which is fine, but the majority of the days the vision center is functional. And it should be established in the community where people can easily access. And also access the first point of interface of the population.

What is differentiating us from the local optical shop is the comprehensive eye care services that we provide. We not only focus on cataract and refractory, we also identify patients with significant blinding condition and refer them to base hospital. And it is many skilled eye care staff. They are qualified, they are quite experienced in managing vision center. And the vision center staff, they carry out different activities in the vision center as well as the catchment area. They create awareness in the community, develop linkages with the stakeholders, and conduct screening programs, whether we call it camps or school screening. They’re responsible to do various activities in and around the catchment area. They also conduct screening in the vision center. They do the refraction and also spectacle dispensing in the vision center. And they identify patients by diagnosis, they also counsel the patient and also refer them to a base hospital. They also continuously follow them up and at home. Their entire experience is premiere which talks about more different service in the system. The vision center place in both primary as well as community and including stakeholders.

Coming back to Mission for Vision and presence and coverage. We are now presently working in 21 states. We work in different geographic areas, we focus on elderly populations, school children, children with disabilities, and also heavy vehicle drivers. And we conduct a lot of outreach activities through our partner hospital. And we focus on tribal communities, and also many of our activities happening in rural areas and also in urban slums. And 21 states we cover around 160 districts, work with 25 partners and 38 eye hospitals. At present we are 104 vision centers, we cover almost 17 million population now, and also 2.5 million surgeries enabled at no cost. And we broadly feel that whatever we do we focus on the 50% of the beneficiaries should be women, baby and children they are getting services from us. We are also working in Nigeria and Bhutan.

And if you see the spread across, the geographical spread, in a few states we are not there. But almost, as I said, we are working in almost the needy areas in the country. If you see there the geography distribution almost 60% of our vision center established in the east and also northeast areas where we are eradicating blindness. We identify the areas where we in training with H.V Desai. We also identify a potential partner and we start working with them and that is how we establish our partnership.

And this is the concept like Mission Jyot, we call it, like vision center program we coined the term as Mission Jyot. And this is the particular style and concept in our vision center. We have a minimum of one or two CHW, with one managing the vision center. In a couple of patient center we have more commitment for geographic area and partner preference. But minimum just one seen in the majority of our vision center. And opportunities with a qualified person and we also place in the center in charge and he takes care of comprehensive eye examination, diagnoses the patient, and also conducts refraction. And he’s actually faced multiple roles. As I said he’s not only the optometrist, he also works as a manager in the vision center and takes care of financial aspect of vision center and he also monitors CHW.

The community roles and responsible for reports, spectacle dispensing, house to house visit, outreach camps, documentation, awareness creation, counseling the patient. These two are very crucial HR that we have in the vision center. And if you see that we work, as I mentioned, we work with the partner hospital and ideally speaking we need to have a vision center 30-40 kilometers away from the hospital. But in India, there are many geographical areas it is not possible to have a vision center 30-40 kilometers because it’s a widespread area like the UP or Tasam. There are areas which require immediate services. But they are 120 kilometers away to get to there. But we still establish a vision center but we ensure that patients are getting accessible services.
And when they want to come to base hospital the transportation facilities are accessible to us. We need to take into consideration. We work very closely with our partner hospital and establish vision center. If you see vision center which I’ll talk in detail in coming slides, but it powers around 50,000 population. We have different strategy. The immediate detachment 0-3 kilometers we need to do a lot of screening and refer patients to travel 3-8 kilometers we can conduct camps. I will be talking more on these things in coming slides.

The vision center established the standard recruitments and standard operating protocol and we work with our partner like we have a common understanding between us. If they get involved we not only are supporting the partner financially but we also work very closely with the partner hospital. We feel very happy that some new vision center established and it is growing in terms of number of people it is reaching. We work with partner very closely and provisional support in terms of technical, financial, and also we are participating in the training aspect and want to be recruiting. Same thing with partner hospital, they take responsibility for recruiting and training the staff. On field implementation and provision of quality services, and they also do regular monitoring and reporting. This is how they enter reports in Mission for Vision.

Coming back to, as I said, the majority of it, the major equipment we support. It includes slit lamp, applanation tonometer, ophthalmoscope, retinoscope, trial set with trial frames, LED vision chart, glucometer and BP machine, computer, printer, and software. Vision center establishment includes furniture and fixtures. HR, as I said, that minimum we place one CHW. But if the partner hospital wants to have more help there or the geographic area requests more they’ll help us. Definitely they’ll recruit more healthcare workers. And this from the base hospital, this is where we’re also going to address on the slides. But managerial, there are people who are involved in managing the vision center. Different designations are there in each partner. There are coordinator, hospital administrator, senior ophthalmologists who also go to the field and monitor the patients and performance. And definitely finance team are in charge of monitoring the performance of vision center.

These are the partners with whom we are proud to be associated. These organizations: CL Gupta, HV Desai, KBH Bachooali, and also LV Prasad Eye Institute, Lotus School of Optometry, MGM Eye Institute, Sadguru Netra Chikitsalaya, Sewa Sadan, Siliguri Greater Lions. All these hospitals there are a number of vision center in Assam, Sri Sankaradeva, Tulsi Eye Hospital, Vivekananda Mission. Shija Foundation. These are all renowned organizations, a good number of vision center. We go there when we sit with the team we learn many things, strategies, what they’re doing, how their vision centers are performing well. This is what I’m going to talk in the coming slides, the different strategies that are implemented. All these really helped us the last 3-4 years due to COVID we also administered the vision centers and some organizations closed and started and totally increased their performance. All these strategies were piloted, experimented, and that is what I’m going to share in the coming slides.

Before getting into strategies, I want to a little bit on the catchment population. Vision center and we say vision center, it covers around 50,000 population. When we say 50,000 population, in many places when we visit, when we talk to community health worker, they say that they do door-to-door screening and catch a patient. Unfortunately they do a lot of hard work but it is not resulting in. For example you see in the blue walk-ins 4-5 kilometers, conducts door to door screening, we canvas around 40-50 people in a day. He’ll have a special intervention, but nobody is standing in the vision center. Somewhere we are in far less places, let us focus on the immediate need that we did earlier.

That is what we need to see. The density of population we need to take into consideration at the area vision center. And sometimes it varies if you’re having vision center come, they enter with 50,000 population you can find 0-3 kilometers, whereas if you go to rural areas, it can be spread across 5-6 kilometers. We need to follow different strategies, we really need a catchment area of 0-3 kilometers. The people who are living nearby a vision center need to be made aware and need to be screened, need to be referred to vision center.

If we do this for initial six months to a year, we will get a good number of walk-ins to vision center. What is also, I think, if we don’t follow this methodology, if we follow I see drivers 4-5 kilometers and then go to the screening. Definitely you will identify a cataract patient around here potentially bring the patient who has some potential blinding disease. They will certainly come. But vision center patient poll is different there. You need to get all the patient walk-ins in the center, especially the 40 plus age group. They should walk into the vision center, they should get that from vision center. That is all the vision center following the case. Wherever this is one thing that we always disappoint.

This particular picture I want to show you. Our vision center like this, we do all of our wellness and state. We funded the immediate catchment areas and we are not doing anything. We assume that people know us. It is not true. Let us start when we establish a vision center, let us focus on the immediate catchment first, then slowly after a period of time you can expand our wellness team to far away places. This is one thing that we learned in a period of time. Why is some other vision center good for various other vision centers and they do a lot of hardship. But still why they’re not getting? Once we understand the catchment population, then you can first to focus on the strategies which I’m going to share now.

One definitely when we have our vision center, we need to have very clear defining the need. This is what our catchment system and they established vision center, they always promoting. We need 20-25% of population require eye care services. In that case if you’re covering 50,000 population, there are 10,000 people who require eye examination or something else that is for ours. Based around it we need annual targets and also we need disease profile, how many personage we are expecting glaucoma patient, DR patient, and what should be our spectacle conversion? Initially yes, you may have 60-65% conversion or increase.

Again, surgeries. Initially you may be doing less number of surgeries, but over a period of time we need a good number of surgeries coming. Referral to the person’s PWDs. All those things we need to put in there so that the vision center team should have a clear idea of what they’re supposed to do in the vision center. And also proactively they still need to complete the care loop. This is one thing that from day one we should focus on. Where we are identifying these things, we should ensure that they should get treatment. And that is all, just identifying and leaving them will not help us. We need to go back and follow them up, then ensure that the patient is getting services.

Develop and maintain a social map. This is one thing that we also see that community health workers, they’re working there in the vision center about six months to one year. But they both have unique clarity on how they plan the community. When you tell a very clear social map, in which the patient should be identified, done by weeks, and were already house workers there, where to conduct the screening program, go to the screening and follow the patient. This should be clearly mentioned in the social map. This also helps him or her to plan an active piece Monday to Friday, what are the community level in touch, that should be well defined. Unless you are a social mapping place unless there is a clear plan, it is not possible to plan things for the community intervention.

And also stakeholders mapping. We know that many of our vision centers there are a good number of stakeholders. We call them happy patient or community leaders, they all want us to do better. They want to refer some patients to our hospital. We need to identify them, conduct periodical meeting with them that is also very important. Some of our partner hospital they follow them once in six months. They call out 10-15 stakeholders to the vision center, they talk about the performance, they request them to refer more patients. This is how they are also working very closely with the vision center. They feel happy about the vision center doing well.

And finally keep our staff happy with us . Each CHW should be well trained and that I think they can send them out, but she also needs to know how well she can manage the vision center. Why there’s a social map? Many times we come across they don’t to be sick of streaming. Sometimes they use 6/18, 6/60. But 6/18, 6/60, we can identify patient with visual impairment or blinding condition but we are missing the potential patient who will need to come to vision center, the refractive error patient. The blue screening, visual problem with materials of six meter rope, duction chart, so that when they go to each house and meet for a visit the first time, they should be able to do the primary screen so that they can definitely go to the vision center.

And also using a simple newspaper like you start the numberation chart, they can simply use the paper or bilaterally they can identify patient and direct patient to vision center. And for the patients who are not educated, they can use the bowl of rice with some will ask you to remove. By doing the simple assessment, patient also understand that there’s some benefits at vision center. This is where the CNA campaign was significant. They don’t admit they need help. They won’t talk about admissions, nobody is going to come. They do this kind of activity 4-5 kilometers away, they are missing out. The patient will not come to us, they will go to nearby optical shop and get whatever they want. But the hardship of see how it goes, wait. We need our daily targets, weekly targets and properly monitor supported by the optometrist because the optometrist is sitting there, he or she knows what to see the patient, is she doing good, how many has she screened now, when is he done, how many are reporting? These are the things that she should look into.

Divide area and implement activities. This is one thing as I said that walk-in patient resides 0-3 kilometers so let us not conduct any camps there. Let’s go to each house and see them with the walk-in screen and refer. This is how when you can get a good number of walk-in. Again, 3-8 kilometers plan a camp or school screening event. Show that patients are coming to this hospital for surgical intervention. At the same time we need to, for example, 100-120 patients in the camp, they’re coming for an eye check. We know around 20 of patient would have a cataract surgery and they’re to transport to the base hospital. But what we are also forgetting is the fact is that remaining 80 add some eye problem that is why they walked to camp. These people need to be told about our vision center and refer to our vision center. Just imagine you conducted a camp 4 kilometers away, 120 patients came to the camp. 20 people identified for cataract surgery there, transported. The remaining 100 patients were explained about the vision center, importance to come to vision center for a check up because the camp team is not carrying all the equipment with them, they have to come to the vision center for proper comprehensive examination. They will refer all the 100 patient will require further examination at vision center.

If you refer onto at least 50 patient will come to you in vision center, this is how the follow up will increase. The wellness and culture and this is one thing that Sagura meant earlier they are successfully doing. But this is one thing that that slowly that awareness generation is happening in and around the catchment area and that is how you see that slowly the vision center will increase. And a couple of vision centers have reached in six months they’re about to get 15-20 patients. And the strategy, it really works in some places. And especially in the vision center.

This is one thing where it is not the only interesting point, the vision center is in the market area. There are 150 shopkeepers sitting there. But they don’t come to our center even though you go and tell them about vision center, they will not come to the vision center. But somewhere you need to fix one particular day say it is a special screening for shopkeepers, especially if you’re doing it for the old men. That is how we need to motivate them to come to vision center on a particular day. This is how the following increases. Once they come into the vision center to see, the seeing is believing. To see the treatment, to see the vision center staff, they also go and tell others about this.

Again, inauguration. Unfortunately during COVID we did not pick an inauguration. But when we start a new vision center and people will come for the inauguration function, everybody knows this vision center is open by such and such. And vision center anniversary, this is one other step that many other vision center follow up. Every annual day or after a year they conduct a special event vision and diagnosis. Quickly again, come back and know the vision center existing. They’ll start coming to the vision center, schedule a new examination. We need to have a very clear schedule once in a week, a fortnight, or term, once in a month we’ll have a school screening program. Your team wants to recruit 50 patients. School screening event and know we’re conducting and quiz teachers, student, parents to vision, this is the vision center.

Identify, train, and strengthen referral from PHC/ICDS staff. And many organizations they do very well. Some organizations for ASHA, they give a 60% discount. Some organization they give free spectacles to ASHA workers. Because they hope that they will get good quality surgery and also they want to talk about us with patients. Identify, train, self help groups which really works very well. Identifying CBO/NGOs, et cetera. And tele follow up, WhatsApp group of all the patients, regularly informing them about transportation day and when they should come for a follow up, et cetera. This you can also use motivating patient to come to vision center for regular check up. And again using walk-in patients to spread awareness. Again this is wanting this up and the word comes in and examines them well and also ask them to refer patient.

Specific to northeast, we know the challenges: distance, lack of trained HR and facilities across the northeast. We have 12 vision centers with three partners. What we need to do a little different whatever the strategies we discussed. Apart from that we need a well-trained staff and their retention because getting good staff is a challenge. We cannot afford to leave them, we need to keep them and retain them. Involvement of ASHAs, again, they are spread across all the areas. And we need to motivate them to refer patients.

Expanding and consolidating fixed outreach centers. Instead of outdated camps in all the regions, we need to fix a couple of outreaches, and regular camps. We can also note here on a particular day that there will be a camp in this site. People can start gathering there, you also view that more resources are needed in that probably. Will require extra community level help because of the density of population. Like UP, other issues different, some is different. We need more HR helpers to come through. Mini camps, 120-150 in a camp is not a challenge in the UP. But whereas in some 40-50 members it’s a challenge. We need to do more mini camps and refer patients.

Regularized transportation facilities. The patient should also know that on a particular date that there will be a transportation facility. For example, a ⅓ of patients would be transported to hospital for surgeries. This information actually spreads out so everyone else knows we can reach the vision center. The people who request it can be transported.

Periodic monitoring visits, this is one thing that is spread across a big geographic area. And feedback also needs to be given. Tele ophthalmology definitely adds a lot of help to the vision centers. Local community involvement including benefits certainly helps. Aiming for gradual but sustained growth. What helps in that? We cannot expect seeing 15-20 patients from the day one, it slowly and constantly and gradually grows upward. Relocation is some particular vision center is not working after 2 to ½ years also putting a lot of effort, we also can plan a relocation.

Factors contributing. I’ll just take you through some of the factors that really helps towards the success of the vision center. One, credibility of the hospital partners: brand, quality, free and paying services. Because at the end of the day people know the vision center through what they know about the partner hospital. It’s really important that one of the factor is credibility of the hospital partner. Location access. Again, market place and good transportation. Certainly a good and clean ambience. Sometimes we see that the base hospital looks very nice but when you go to the vision center it looks totally different. We need to maintain quality in the vision center. Again, definitely as I mentioned, skilled staff. And that’s comprehensive exam, systematic community interventions.

Intense outreach activities demand creation tips. The equipment and standard operating protocol that what we follow so it really adds value. And pricing, this is where I need to little bit stress accessibility, how affordable a deal, accessibility. If you see four barriers, we take it off and our reliability and also accessibility. In these three we are able to address. What is happening is we’re missing the affordability plan. We establish a vision center, we have good staff in place, we have good equipments, but what they are forgetting when we fix prices for the spectacle, we keep the higher end of spectacle, so people who come to us they try to go to a nearby optical shop and get that. Instead we need to, before fixing any prices for spectacle, look and listen at the marketplace based on the marketplace we can fix the spectacle so that people. The thumb rule is nobody should walk from the vision center just because he or she is not able to pay. If the team knows this, they will be given doctors.

Referral mechanism again ensuring identified patients available services. Facilities provided free/subsidized, transportation, repeat follow up services. All these things that really are for the vision center. And technology, digitalization, tele ophthalmology, tele consultations. These are all for telephone in the vision center.

Again, I’m telling these one things that I really want to stress upon when we are worrying because we are managers to be seen. We also need to see what other thing they need to look in. It should be happening daily, weekly, monthly visits. Performance indicator. We should know that the manager should know what is the average patient examine in the vision center. What is spectacle conversion, what is surgery conversion advised and reported? What is referred to base hospital and who we are reported by? Persons with disability attended in vision center? Gender specific. How many women patients are attending? How many children are attending the vision center? You need someone to monitor, if you don’t monitor, if you don’t address the trends, then it is going to be difficult to rectify the mistake.

And also financially. This is also equally important. Because we want all of our vision centers to be financially stable. Registration fee, diagnostic charges, average pricing, value of spectacle, surgeries, cost deposit mechanism in the insurance sector. All of this needs to be clearly monitored by the manager.

What we always say that let them use a dependable checklist. We come up with as many important things and they don’t carry anything. They sit there for two hours, they come back. But it’s not going to use, it’s not going to be helpful. They should follow a certain thing like we should see vision center ambience, signage board, direction boards, hospital services, all these things are clearly exhibited in the vision center. Equipment and usage, clinical protocol, usage of equipment. Supply chain mechanism: spectacle delivery, transportation of patients, percentage of conversion and what are the gaps? Community health staff skills, usage of screening materials, frequency of interventions, stakeholders.

And project outputs, are they following the targets, are they able to achieve the targets? What are the challenges? This is all the partner needs to monitor at the vision center. Meeting with beneficiaries, stakeholders, understand the concerns, challenges, good practices. And also measure the impact. If you follow all these six points, by using your checklist, will certainly do help. Also you can plan support which is coordinated from the base hospital and solve any issues. And build capacity of staff if you identify for care and document and follow up. If the managers are able to do the survey, they monitor and managing issues such is not a big challenge.

I’ll stop here. I’ll request one of our partners with H.V. Desai Eye Hospital. We have been working with them for many years. I request Dr. G.V. Rao to join and will share his experience of working with us and also managing vision center.

[G.V.] Thank you. Thank you, Daniel. Thank you Vision 2020 as well as Orbis for giving this opportunity to share our experience and our partnership with Mission for Vision. We started our vision centers a few years back but with Mission for Vision we have started around 6 vision centers where we’re at from 2018. At least five vision centers we established during the COVID period in 2019 and 20. And we have very good experience in terms of really managing these vision centers. These are mostly outside Pune and we are getting a good number of patients in terms of reaching out to that rural area as well as semi-urban slum areas to get these patients.

I must say that the strategies for vision center sustainability what Daniel has really outlined, most of these strategies we could implement in our vision centers. And we could really see the fruition of those results. Like for example he was talking about social mapping of a vision center and really reaching out and seeing that across 4-5 kilometers as six kilometers we should divide by the people population who are in need of eye care services. And identify the needy groups who require such services. We have done such exercise and intensive training has been provided by Daniel and his team. They have been coming regularly to help us. They don’t just inspect, they just give us the support in terms of how to improve, how to really take care of so that we can improve our services. I really like the way that Mission for Vision has been really supporting Desai Eye Hospital and managing these vision centers. From the top to bottom their management they’re including Elizabeth Kurian, who is CEO of Mission for Vision, has been supporting us and visiting these vision centers and giving us all the support.

Besides that, the main monitoring through this data management as well as regular updates on day-to-day data, how they are run, how much screening has been done, how much surgeries have been done? That regular monitoring has been helping us to improve our strategies. Whatever is not working brilliantly we take the next corrective action. We try to involve, for example, we were not involving ASHA workers and ANMs earlier. Now we have taken that strategy and we are able to really reach out to them. Then we are also trying to engage with PHCs in the area so that we can refer our cases and build up strong with a quality relationship with the government systems and see what we can benefit from them also.

There are various other strategies that have really helped us. Society camps. Vision centers can go to nearby society camps and get some paying patients. I’m very happy to say that the affordability, what Daniel was talking, has been taken care through this last six months. And we have given a discount to all our vision center patients so we could really get around hospitals 30% of the cases at affordable cost to the hospital with subsidies. They are paying but at a discounted rate. But still we count as a paying patients. We are very happy that besides the access and affordability also has been taken care very well through these strategies.

Besides that we also provide transport through accommodation to these patients. When they come from vision centers, they are putting on priority again. They are not just walking in and going to the general OPD. They are treated special so they come directly to the vision center OPD and they have been given special attention so that they get services on time. And that way some of the strategies and working with local leaders, NGOs, that focus also has improved getting more patients. We are now organizing camps through our mobile units as well as through our areas of optometrists who help us in getting more patients within this vision center area. We have contacted prior optometrists who are running their spectacle shop. We tell them you give us your subsidy references so we can take care of that free of cost. That has really helped us in giving more number of places.

One of the challenges we are facing in vision centers in remote areas is the staff. Although we have hired very good, trained optometrists and most of them are bachelors also and few of them are diploma. But retaining them is one of the crucial problems we are facing. We will be able to overcome because Mission for Vision is also supporting us through the start a course, a diploma in optometry and likes to assist. I’m sure, with their help in training we will be able to cover up more people, train more people to expand our vision centers. And we have a vision to really go up to 100 vision centers in the near future. Because in the last three years I can see we have come up with 15 vision centers and 30% of patient load is coming from vision centers.

All the credit goes most of it to international agencies including Mission for Vision, Saver, and CPM. And all those people who have been supporting us in this has been tremendous. And of course we are still learning and we are still hoping to take more strategies whatever is coming up from these international visits. And would like to really implement the next really vigorous manner.

That’s the experience I can say that it has really given us a boost to the hospital. Not only for reaching out to the poor people but also to say that we are really going to the people who need such services in rural areas. And at a very affordable cost and at their doorstep. This door-to-door survey also started so that is also helping us to get the real people that are reaching out, the people who use the services. Thanks, Daniel, for giving this opportunity and I will be open to any comments or suggestions in case there are any questions.

[Franklin] And to conclude to sum up. Each vision center is unique, is different and requires different strategies. We cannot copy paste. This is what we learned for our period of time. Same job now privations are not all equally built around the same manner. Clear plan, effective execution will certainly help. Involvement of local vision center team is highly essential. We cannot sit in base hospital and be fine, it is important specifically to vision center team and their strategies. Constant monitoring, daily, weekly, monthly must. The primary responsibility relies with base hospital. Intense community level interventions in initial two years certainly helps the vision center to move on.

Comprehensive services, this is the uniqueness how we can differentiate ourself from the local competitors. Keeping an eye on both service and financial sustainability because we cannot run a vision center in loss for more than 2-3 years. That’s a burden on the partner hospital. Closing loops should be given high priority. We identify patient, we told them to go for treatment, if he’s not coming or she’s not coming to us, anywhere for treatment, this is really something. Vision center approach become the most cost effective strategy during pandemic as we discussed. Various strategies planned and implemented to not only give the confidence to staff but also to community that seek services. And the final onus, vision center is a very, very effective strategy for having primary eye care services, especially in the underserved areas. This is where I stop and I’m open for question and answer.

[Phanindra] Thank you, Franklin, once again for really making a wonderful presentation, bringing a lot of insights regarding these strategies that should be employed to run these vision centers very effectively. From your experience, I think that’s very grateful to Franklin and Mission for Vision. Also thanks to G.V. Rao for sharing your experience how these strategies that H.V. Desai Eye Hospital has been following for the past few years. And really increasing the footfall and making these centers self-sustainable, most financially and programmatically. Thank you, sirs, thank you so much.

[Anindita] Sir, so the first question is how many CHW will be allotted in each vision center?

[Franklin] As I mentioned that we always suggest one CHW at a minimum. But you can also have one more CHW. What happens at the vision center footfall when it increases, your CHW also needs to be where to sell spectacles because the opportunities to see in examination, somebody has to take on spectacle dispensing. Initial vision center can have one and then the ones who get more patients can increase one more CHW.

[Anindita] Second is could you please elaborate on stakeholders mapping?

[Franklin] Thankful for this question because when we’re 50,000 population you come across various stakeholders. It could be a happy patient, it could be a retired school principal, it can be a political leader. We need to mark them and then map. These are the areas where we have stakeholders. When we’re planning anything, a big event, awareness, school screening program, or screening program, we need to take their help. They are more than happy to help you. But if you have the area where you plan okay, after six months I’m going to have three or four camps in that particular area. Instead of using your own resources, you can always use the stakeholders who live there. That is why I said that mapping helps you. In that catchment area, over the period of 2-3 years we should have at least 13-20 stakeholders in the catchment area. They will be very helpful to the program.

[G.V.] Can I answer about stakeholders and what we have done? We also have various stakeholders like political leaders, teachers, headmasters, traders, and even various shop owners. That we helped make various segments of these people who we can reach and do the outreach as well as give them special camps like for elderly, government, our children, our persons with disabilities, all that. They are stakeholders, NGOs and local women’s groups. We had such groups and we made a list of all them. And then we held camps for them separately. Sometimes they went together also we called them. That’s a stakeholder. Even whatever label folks we were involved with however it is required.

[Anindita] The next is what is the minimum cost of setting up a vision center in a remote location?

[Franklin] This is a very tricky question. But still like 7-8 lakh you need to have for vision center which also includes equipment. And in the first year the recurring expenses, whether it is a service, and also the organization cost of the vision center. But if you’re remote you can always keep it another year because initial two years, depending on the support then once the vision center is established, more walk-in coming in, more spectacle coming. You can crest sufficiently. But minimum I would say 7-8 lakh for first year. We call it seed amount.

[Anindita] Then to establish physically the rental and security shoots up. How do we manage it optimally as it would strain the budget. But from the marketplace the visibility also in terms of footfall, it gets lower. How do we strike a balance of that?

[Franklin] This is again a good, interesting question because in Oshun, where I gave an example. Oshun where we established a vision center. We also come across there are good spaces but the rental cost is quite high. What we found the Oshun, where the city ends the rural area starts. We need to identify a good location there which also captures your urban population. Also takes care of the rural population and the rent also comparatively very low when you see the vision center location at the end of city. That is one thing. Also we need to be certain when we say market, we are not talking about a pushcar markets, those pushmarket areas. What we need is, it should be visible like you can establish a vision center in that area to 10,000 population in that village or town where we can find out a good location. Maybe not in the center of market area, but in the corner we can identify and establish that will bring down your rent costs of the vision center.

[G.V.] From our experience, we tried to really open in a semi-urban area where the rent is not too much. And sometimes we get that place free of cost from the local NGO or local temple or committee or the people who are interested in taking such services. That’s out of at least 10-15% of them are regarded as the collaboration free of cost. We, as a principle, we don’t pay any deposit. We give them only an advance of 2-3 months of rent but no deposit. And we try to be very minimal as you said, it is semi-urban/rural, so that we don’t pay too much of rent. That’s how we are able to manage these vision centers.

[Anindita] The next question is we are running a charitable eye hospital from last 16 years in Haryana. Recently we opened our first vision center approximately 30 kilometers from the base hospital. We want to partner with Mission for Vision as required to learn and upgrade our vision center.

[Franklin] Thank you. You can write to us at MissionforVision.org.in. We follow a certain protocol to identify partner and with a partnership. We will get that when you write to us and we’d gladly help.

[Anindita] The next question is how to approach eye care services for rural areas?

[Franklin] Dr. Rao, how do you see approach to rural areas?

[G.V.] Daniel, I can talk about seasonal in Puna district and even our nearby districts. Earlier we used to face the same problem that seasonal variation the patients come down. For the last eight months because of vision centers and because of intense outreach programs, there is no reduction in the patient, either it was in May month or June month of July our summer of rain. It has been constantly we have been getting from the centers 2,000 patients for various services to the hospital. That credit goes to the vision centers and to our strong outreach which has been connected with the vision centers. Which was you also taught us how to do it and that really helped us. There is no such seasonal barriers for us it is in this year. Our numbers have gone up, in fact.

[Anindita] The next is after establishment of vision center, how many years are ideally required for sustainment of vision center?

[Franklin] Some of our vision centers it takes almost a year to sustain them given the cost. I would say comfortably 2-4 years.

[G.V.] From our experience also it takes 3-4 years to become financially sustainable as well as programmatically sustainable.

[Anindita] How can we compete with local opticals? Any marketing tips?

[Franklin] I spoke in the presentation itself. The patient who are walking to our vision center need to identify the differences. If the same patient goes to an optical shop, the optical shop maybe using a year an assess, they don’t do comprehensive examination. This is where whenever a patient comes to our vision center, they should be made aware of what the services we provide in the vision center. That should be, the patient should feel like when he pays 20 rupees or 30 rupees to the vision center and gets his eye examination by a qualified person using different equipments in the vision center. He should feel happy about that and he then starts understanding the difference. We should do it consciously so that the patient also will understand the difference of visiting our vision center.

[Anindita] The next is after serving the patients who have been diagnosed with eye disease, even after they will not return for treatment. These are the issues that they are facing.

[Franklin] Yes, this is a common challenge. I see this as a big deal, this is a challenge come across by all the vision center staff. What we need to do is to keep following them. First time the patient comes to understand that he has an eye disease that requires surgical intervention. It’s a normal process because of here, because of other worries not wanting to go to base hospital. But a good counseling, a good regular follow up. And also you can use the operative patient who has undergone surgery and they can be used as a chain maker. They communicate and they counsel patient returns. We need to use our intention should be following them regularly and ensure that they get treatment.

[Anindita] The next is how will we implement the door-to-door screening?

[Franklin] Door-to-door screening. This is what I said then the new vision center start focusing on 0-2 kilometers. That is where we need to focus on and so if a social map we have their communities already identified. He or she should be planning for example if there is a community has 300 households, if she covers even 30 households every day it will take 10-14 days to complete the community. Let her plan in such a way so that for Monday to Friday she will be going to this community and cover almost all the houses there. If not living in any houses, if somebody is refusing, some of the door is locked, she can keep moving on. But she should know that it is her responsibility to cover the entire population of this community.

[Anindita] Then on positive and negative for relocation of vision center.

[Franklin] When you are relocating any vision center, there should be some reasons. Maybe you are not happy that the vision center is not performing well, or suddenly where you set the vision center is creating some issue, you need to change the vision center. In that case you don’t have any other option you change it. Maybe you are getting a good number of patients still, you have to relocate. In that case, also, you will be relocating your vision center just nearby only so that you won’t lose the patient because 100-200 meters away and like the area for a vision center. The last is it’s not functional well, last two or three years and implementations are very low. You don’t have any other option and you have to relocate. Of course you will be spending money to relocate, you have to refurbish, you have to pay the deposit, there are some issues. Everytime you relocate make sure it’s for a better purpose.

Now in a location you did all the efforts for around two years but still you are getting 6-7 patients in a day and you’re running your vision center in last months, so you cannot afford it for longer you have to relocate.

[Anindita] Can an optometrist be good enough to manage a vision center or a co-manager required?

[G.V.] Optometrist is the leader of the vision center and he has to really manage either a health worker or assistant. He is good enough to manage the entire VC, the team. He has to lead. You give them that leadership quality is also to that optometrist. In all our VCs, the leader is optometrist.

[Anindita] The next question is what was the average OPD numbers in the vision center per day?

[G.V.] That is from seven patients to 20 patients. Starts anywhere from 7-20. But our aim is to get to around 15-20.

[Panelist] Per day.

[G.V.] Per day.

[Anindita] Next, someone is asking, how can we involve pediatric population to vision center and how can we make it sustainable?

[G.V.] We do school screening programs as well as children screenings in the communities but they have to be brought to the vision center and get a tele ophthalmology check up. And then the children who require further check up and treatment has to be brought to the hospital. We bring them in the vehicle to the hospital for further checkup. Because pediatric thing we cannot do in the community screening. We bring them to the hospital.

[Anindita] The next is when can we see that the vision center is sustainable, that is the key benchmarks have been met, average volume OPD, percentage of conversion from optical and surgeries?

[G.V.] The answer is in the question itself. Once you really reach out to the people who need the services and you have at least 15-20 patients and economic break even per term. And you’re reaching out the people who use the services or its use. Then it becomes viable. And you have made an event in the community.

[Anindita] Is there any software that the vision centers have? And if yes, whether it will be sponsored?

[G.V.] I think I ask MISS which we are using and also with the government of India we have India they developed our PC and MISS also. We have both MISS going on and Mission for Vision also has MISS which we are also using. Daniel can throw some light on that.

[Franklin] Sorry, my internet connection lost.

[G.V.] She was asking VC MISS so you have and where they can get it.

[Franklin] Yes, Mission for Vision we use the vision center, like Aravind’s vision center software. There are many like with different partners. They also having their own vision center software because it should be linked with the base hospital. That is how different partner use in different software. But same thing the vision center which do not have software we are recommending them to use Aravind’s patient centered software.

[Anindita] The next is how can we overcome the seasonal barrier as the patient flow decreases to low amount?

[Franklin] Is this working, yes, like if you see somewhere generally we get less number of patient that are coming to vision center. This is where we can increase our outreach activities. For example, from November to March you are planning to conduct two camps in a month because you know that footfall will be increased, more patient are coming in. But during summer, the same two camps should be increased to four because you know very well the camps you also have less number of patient walking in. But if you have more rural camps you’ll be able to maintain the numbers.

[Anindita] The next is which one is more sustainable? A mobile van unit or the vision center?

[Franklin] Certainly vision center. Because as I said that you can establish it into a partner location. Over a period of time people also understand that they can walk-in and the quality of services at the vision center. Whereas in mobile vans, yes, mobile van works in certain area like hilly mountain area where you cannot always plan. But in the normal plain area, vision center will be more sustainable.

[Anindita] How do we select a location to open the vision center criterias?

[Franklin] There are likely in Mission for Vision we follow certain checklists when we establish a vision center. One definitely realizing the population density, the floating population. That particular place should have 8-10,000 population and also it should be a market area where you are getting a regularly footfall population. That will certainly help you. And also you need to see the accessibility if patients should be able to reach to the vision center easily and from there we can also be transported to base hospital.

Also when we establish a vision center we also look if there are any good quality eye care service provider is having a vision center there. It’s not a good idea to start a vision center there because maybe people are getting good services. Instead of establishing vision center there, we should look into another area. Before initiating establishing vision center, we also need to look into other optical shops or what are the other service are available and what is the magnitude of blindness, what are working in that particular area. Based on that we need to identify more than three locations, do our assessment and then finally we can establish a vision center.

[Anindita] How to influence or convince patients for paid eye surgeries in vision centers?

[Franklin] This is one thing I gave an additional panel for. We definitely know that the goal requires to pay. We are more worried about the patient who cannot afford the cost, they need more motivation, more support. At the same time there are some patients who can pay, not the full cost of the spectacle, but they can pay a little bit. If they are told very clearly this is the sublevel, this is they can afford, they can pay and get the services. Out of 10 patients if you are able to motivate who are free and also subsidize, that is fine. But that should not be a forcing point for the partner hospital or the counselor. They should not refuse to the patient who cannot afford the procedure. It’s a very, we need to balance it and we need to counsel the patient based on when he or she has a discussion with the patient, they themselves will know what is their condition based on that payment amount.

[Anindita] The next is is there any need to have some communications, skill in hands when training for the vision center optometrist?

[Franklin] Certainly, because what happened we also come across the fresh optometrists arriving with one or two years experience. They are very good in clinical aspects, there is no doubt about it. But when it comes to counseling, convincing patient, that requires even optical dispensing, it also requires proper training. In Mission for Vision we regularly conduct the training for the optometrist who are working in vision center. Not only towards this, they also when they are managing a vision center, it has many aspects. One, clinical screening. Second thing is managing the finance, optical dispensing, maintaining the store register and everything, and also he should be able to manage the HR, maybe interviews. All this needs to be training because they’re coming out with only clinical training. They need to be further trained to manage the vision center properly. That piece is very important.

[G.V.] Communication state is also very important. They are the ambassadors, they are the lead person for the hospital in the community who are reaching out to the people, the grassroots. We need to give them all the communication skills. And they should know all the services and all the things that are available at the hospital so that they can communicate and inform people about the services.

[Anindita] The last question is suggestions have been done but reporting at vision center is less. What strategy can we adopt in order to reach this cap?

[Franklin] Thanks for this question, this is what I told in my presentation. Many times our CHW do a lot of hard work in the area and that they identify the patient. But they are not coming because the missing what they’re doing is that they are doing also is equally important. They cannot do a similar kind of activity four or five kilometers. If patients are identified and referred, if they are not coming means somewhere there is a gap. We need to identify whether the CHW is not using proper materials to assess, whether the CHW is using their entire community level intervention, the nearby area, following all the protocol, whether the CHW is able to communicate properly to the patient. All these things we need to see on based on so we can treat the gap.

[Phanindra] I hope really all of you enjoyed it. And the lessons from the experience of Mission for Vision are the lessons and challenges H.V. Desai Eye Hospital has faced and as G.V. shared his experience. All of you, I’m requesting all of you to really take use of it and try to adapt these kinds of strategies which will definitely improve the performance of vision centers, particularly the outreach element including the referrals. What are the kinds of issues that you’re facing? I think there is an answer now that we have now today in this webinar. To most of issues, of course the issues keep coming, but as Dr. G.V. mentioned there is still challenges in terms of staff intervention finding out the clinical cost and although the issues keep coming. For all of that I think I find really this session very, very interesting and very thoughtful. And I’m really thankful to Mission for Vision, Franklin Daniel, Dr. G.V. from H.V. Desai Eye Hospital for sharing. And all of you for joining this webinar. Thank you so much.

[Franklin] I really would like to thank Vision 2020: A Right to Sight-India and Cybersight, Orbis. You, the participants, who attended this, taken time out and asking a lot of questions. Thank you. And our donors, our partners, without whom we cannot share these experiences. And MIV management, thanks to my colleagues who work for Mission for Vision and also the partners with whom we closely work with. Also the communities which give us opportunity to serve.

[G.V.] We would like to thank H.V. Desai, the Mission for Vision, Orbis, as well as Vision 2020-India for giving us this opportunity to share our experience on vision centers. And I’m sure we all together can learn and really lead more vision centers in coming days. Thank you.