Q&A: Cataract services

Dr Daksha Patel: Hello, and welcome to this Google Hangout session for the course on global blindness, planning and managing for eye care services. Sitting right here next to me is Professor Allen Foster, who is the director for the disability and eye health group. And he’s joining me, and along with us is Andrew Bastawrous on the other side, who’s also going to talk about Peek. So we’re really pleased that we’ve had over 3,000 participants on his course from well over 83 different countries. And many of you texted a range of questions to us.

But before we begin to start addressing these questions, I thought it would be a nice idea, Allen, if you would give us a brief overview of the cataract services that have evolved over the last three or four decades. And where are we now?

Professor Allen Foster: OK, thanks Daksha And hello, everyone who might be listening. I first did a cataract operation in 1974 when I was a young trainee ophthalmologist. That’s 40 years ago basically. And things have changed over that time for the better. And I think there’s been really three major surgical technique developments over that 40-year period. And a lot of the other developments can be put into one of those three main categories. So, the first one was the development of microsurgery. And by that I mean doing cataract surgery with magnification and with micro instruments and at times sutures as well. I can certainly remember doing cataract surgery with x2 loops. And consultants that were training me were doing the same.

So that magnification and microsurgery began coming in the 1970s, and of course expanded greatly in the 1980s onward, and it’s been a major reason for improvement in cataract surgery. The second big development was the use of intraocular lenses to correct refractive error. The first ones were used actually after the Second World War by Harold Ridley, but that caused problems. And then there was a renewed interest in the ’60s, particularly coming from Holland, with Binkhorst and Wurst. And they used an iris clip and anterior chamber lenses, both which gave a significant complication rate. And it wasn’t until the 1980s and the development of the posterior chamber intraocular lens that we began to have a really good and safe intraocular lens.

However, in the ’80s, it was expensive. Lenses were at least $100, sometimes $200 or $300 dollars a time and certainly not accessible or affordable to most people living in low- and middle income country settings. And it was really the work by Aravind and the Fred Hollows Foundation in the early 1990s that allowed low-cost, good quality intraocular lenses to become available for people living in low and middle income countries. And that was the 1990s. So the microsurgery coming in the ’80s, the intraocular lenses from the ’90s onwards in low-income settings, and then the third development has been small incision surgery to reduce astigmatism and therefore improve visual results.

And this has taken two forms, phacoemulsification from the industrialized countries and the development of small incision cataract surgery in low-income settings, and now both of those being used in different parts of the world, but the principle being the same, a small incision giving less astigmatism being used within the intraocular lens to correct refraction error and microsurgery so that we have good surgical technique. Those have been the three main developments as I would see them over the last 40 years, all of which have resulted in better postoperative visual outcome and therefore earlier surgery, people coming earlier because they know that the results are going to be good.

So combined with that surgical technique, I’d like to just touch on three developments from the public health side of cataract services. And I think the first important one was an emphasis on outcome and results. So we’ll move away from not just doing lots of cataracts, but actually getting good results, development by the World Health Organization of a classification cataract outcome so that we can measure it and norms and standards being put in place. And so people have looked to try and improve the results of cataract surgery.

The second development has been to try and make cataract surgery affordable for poor people, so an effort to reduce the cost through better productivity and cost containment in order that cataract surgery is affordable. And the combination of those two, that is, better results and lower cost, means cataract surgery is more valued by society, better quality, lower cost, better value. There’s been an increase in demand and, therefore, an increase in the number of cataracts being done, earlier surgery, and therefore worldwide, less blindness and vision loss from cataract.

So Daksha, I think that’s a kind of summary as I would see it over the last 40 years of changes in surgical technique but also how that’s resulted in changes in a public health approach to the problem of cataract blindness and visual impairment

Dr Patel: And some of the questions that were raised in this week’s sessions on cataract surgeries have certainly been around addressing the value of cataract surgery. So on one hand, we want to use all this new technology to try and deliver high volume, high quality services. On the other hand, there’s not enough human resources. There’s long waiting lists because of there’s lack of consumables. So it leaves a challenge in the those centers that they seem limited by technology in itself to deliver these services. What’s your view on how do you address technology issues and increase efficiency at the same time?

Professor Foster: I think that is a challenge. I think you’ve got to look at any individual situation and going into a place, and the basic question to ask is, is there a waiting list for cataract surgery? If there’s a waiting list, it means that the demand is greater than your supply, because you’re making people wait. Therefore, you’ve got to look on the supply side. You’ve got to look at how many operations can we do in a week? Can we increase that? Have we got enough staff for doing it? Have we got operating time? Can we improve efficiency? And actually look at what are the limiting factors to do more cataracts each week and therefore get rid of the waiting list.

That’s on the one side. Then on the other side it’s a situation going into a place and there is no waiting list. but you know from surveys that you’ve done that there are blind and visually impaired people with cataracts in society. And that means that demand is not there. For some reason, people are not coming. And then we use a kind of acronym to think about the values. And they go from A to G. So A is, are people Aware that they’re not seeing because of cataract and it can be helped? B is the Bad service, that is, is the quality of the results quick enough? Maybe people are not coming because they know the quality is not good.

Or are they just not being looked after well? That is, the non-clinical care as well, the way they’re taken care of. The third, C, is Cost. People are not coming because they’re too expensive. D is Distance. It’s too far away. E is Escort. They have not one to bring them. That’s usually for elderly blind people. F is the Fear factor. They’re just afraid if they go to hospital, somebody’s going to cut my eye, and people go to hospital to die, and so that kind of fear factor. And G is the interest in one of Gender. That is, women tend to come later and less often to cataract surgery than men.

There seems to be a cultural variance for women having the power to make the decision. So you need to look at all those barriers, but the key, too, I think, are the bad service and the cost. It comes back to that value. Good quality service, both in terms of clinical results but the way people are looked after, combined with low cost, you get those two right, and most of the others disappear. And those are the two particular ones to look at.

Dr Patel: I certainly think that the example that we shared from the Aravind System demonstrates that once you get that value right, it really does mean that there is a demand and uptake of services. And I’d like to bring Andrew Bastawrous into this equation. And Andrew, on the course, we certainly showed a little bit about Peek technology. And perhaps you can highlight a little bit on– some of the questions that were raised is, how can we use Peek technology to raise awareness about cataract services and maybe even use that to overcome the fear factor in different societies?

Dr Andrew Bastawrous: Yeah, I think it very much addresses the points Allen raised about A, D, and E and F in terms of Awareness, Distance, and also Escort and Fear. And awareness is created just by being in a position where you can perform an eye examination in a location where you may not normally have reached. And if the person doing the eye examination is well-informed and can counsel the people they’re doing the eye test on. this tends to encourage a greater opportunity for them to access care.

And one of our findings in the field was that just because the test was being done on a phone and it was novel would encourage people to offer themselves forward to have an eye test. And so we were going in to homes, examining people, and the neighbors would come out saying, can you test my eye as well? And so just in the fact that it’s novel, not because it’s necessarily better than doing it any other way, has created an increased interest in the areas that we’ve worked in. And the barrier of distance is often that the patient who is most in need of eye care is outside of a health system.

They’re in places where it’s very difficult to reach on road and it’s very difficult to have any main supply for electricity if you’re wanting to set up a temporary eye clinic. And with the solution being mobile based, we’re independent of the requirement of electricity and people can move on bike or foot to reach very distant locations and provide an eye assessment in areas where we couldn’t normally get to them. And by the very nature of them being connected via mobile phone, they’re able to share that information remotely with the local hospital provider to see if this is somebody who’s suitable for care.

And also with it being done on the phone, the patient who’s been examined is then locatable through GPS positioning. And also we record text message numbers or whoever would be the escort or someone who is a key informant, if you like, in that area to ensure that if that person is suitable for treatment, they’re then appropriately linked to care. And then it really feeds back to the bad service and to the quality of care. We often don’t actually know how good the care is because we don’t get to see our patients if they’ve come from a far distance. But once the surgery has been done, we maybe take our one-day assessment and then they’re never seen again.

And those same patients who may go on to have poor result later on down the line will discourage others from coming forward for treatment. If we are networked in a way that we can find those patients early, then we’re having a problem of distance. We can try and do everything we can to make sure that those few cases are followed up and managed appropriately. Because so many of them, it is a treatable complication surgery. But without us being able to understand what’s going on at a distance and being able to order our services, it’s very hard to improve the quality. These are some of the ways in which technology support us.

Dr Patel: Fantastic. Some of the questions, Andrew, that were raised were what have been your findings or your experience from the pilot studies that you’ve been carrying out using Peek?

Dr Bastawrous: There’s been several key findings. And I’d say the most important finding is that technology doesn’t cure blindness. It’s people. And so you need good people, both operating the technology and receiving the information and providing the treatment. There’s never going to be a replacement for all the people that are doing hard work on the ground. It’s important to do more. The other major thing is that whenever you try something new, you will definitely get it wrong. But that’s OK as long as you’re prepared to learn from each mistake that you make.

And so we spent a huge amount of time getting it wrong in the field but learning from each mistake that we made to try and make the technology more appropriate to people’s needs. And just as an anecdotal example, we initially had our vision test as three-meter vision test. We were using the ambient light sensor on the phone, which would normally change your screen brightness for you. So if you move from inside to outside, it would make it brighter. We were actually taking light readings to know how bright the environment was.

And I found that despite me telling my team to always examine people indoors or in the shade, I could tell that a lot of the assessments were being done in bright light and everything, so they weren’t very accurate. And it was only when I went door to door with them that I realized most people’s homes weren’t big enough to do a three-meter test. And so we changed the algorithm to be a two-meter vision test, at which point over 90% were getting indoor tests and the results were far more accurate. And so the big learning for us was that you can’t try and implement change from a distance.

You really need to be working with whoever is providing care in that area, all the way from the community up to the hospital so that you try and work out whatever barriers at each step and are there certain barriers where technology would be appropriate to overcome them.

Dr Patel: Excellent. So that’s quite a lot to take on board. Some of the key questions that have come up, and you’ve probably anticipated this, is that the next thing everybody wants to know is where and when can I get hold of a Peek and how much does it cost?

Dr Bastawrous: So when thinking about Peek, there’s three components to it. And so we don’t provide smartphones. We’re working on the assumption that people either have a smartphone or can get their own phone. But we provide software tests, such as a visual acuity test. And we also have color and contrast tests. And we’ll soon be having visual fields, pupils, and then various imaging tests. And all of those tests are freely available to download. But before we make them available, we ensure that they have been validated in trials to prove that they’re effective. And so our visual acuity test will be coming online at the end of this month when the first paper on that becomes published.

And we also have our diagnostic tests, such as the imaging modalities where we can clip something over the phone. And so we have Peek Retina that allows you to do lens and retinal imagine. And our manufacturers are on course to have these ready to be released in October. So we’re working with various distributors, including the Standard List from IAPB to make this available to everyone from October onwards. And so that clip will be available then. And the current costs are around £70 to £80 so approximately $100 or so. And we’re also looking at seeing if we can do discounts to NGOs and to low-income providers of eye care and provided we can find a suitable model to make that affordable.

The other component is systems. So that’s the part which allows you to have done a test and then link that to a person. And that information goes back to somebody else to review and make a decision. And we’re currently working on systems particularly for diabetic retinopathy screening and for population-based outreach services. And those we hope we’ll have ready towards the end of the year. But having them ready and having them released are two different things. Because as I say, we need to go through a period of testing to make sure it works really well.

But because all our software will be free and open source we do encourage people to test, become part of what we’re doing and to test it for us and with us to improve it so that everyone else gets the benefits of it.

Dr Patel: Excellent. So in a way, it’s going to be a tool that’s going to bind these teams together from the rural setting all the way down to the tertiary setting. And that actually brings us to the question about the team that does the cataract surgery. VISION 2020 set up guidelines and targets of numbers. Certainly for Africa it was 4 ophthalmologists per million population. Maybe a bit of background as to how that number came about?

Professor Foster: OK, well, first off, give a bit of background to ophthalmologists generally worldwide, the numbers, and then coming down specifically to that number if that’s ok. So worldwide, we think there’s somewhere between about 150,000 and 200,000 ophthalmologists. And so that gives us a figure between 20 to 30 ophthalmologists per million population worldwide if they were all distributed equally. But of course they’re not, so some parts of the world, particularly the Americas and some parts of Eastern Europe, can have 50 to 100 ophthalmologists per million population compared with Africa, where it’s often one or two ophthalmologists per million population. So why did this number, 4, come about or how did it come about?

Well, first of all, it’s a minimum number. It’s not the idea number, but it’s a minimum target. And it was based upon in order to address cataract blindness, it was felt that a minimum cataract surgical rate, the number of cataract operations per million population per year would be 2,000. Now, there is some evidence that if you just want to address cataract blindness in Africa where you have a young population demography, you may not need to have as many as 2,000. You’d almost certainly need to have at least 1,000. But maybe 2,000 is not required. But the figure of 2,000 was used in this estimate.

And then it was said each ophthalmologist would do 10 cataracts a week, as well as every other work that they do. So that will be 500 cataracts a year. And therefore to have a cataract surgical rate of 2,000, you need a minimum of four per million population. In practice, countries that develop good, comprehensive eye health tend to have at least 10 ophthalmologists per million and usually move into nearer 20. And that’s true now for both India and China. And it’s true for all of the Western European countries where it’s more than 20. But in Africa, we’re still at the figure of one to two. And our initial target is to get to four per million, well distributed.

And then when we get to that target, then we can think about moving up to 10 per million.

Dr Patel: Human resources remains a major challenge, particularly in eye care. And I guess there are no easy solutions to this because it boils down to the fact, can we attract enough people to work in the field of eye care, particularly as we’re faced with an aging population. And a recent study done by Serge Renikoff and his team found that there was a lack, a gap of about 200,000 ophthalmologists globally to meet the demand that we’re going to have from an aging population. So I guess we have a long way to go still in trying to achieve the agenda of addressing avoidable blindness globally.

In order to connect these remote ophthalmologists or remote eye health workers to each other, teleophthalmology, what do we see that’s as an option and perhaps Andrew, Allen, what do you feel? And that’s something that’s come up from the questions, is how useful will a tool like Peek be to connect these widely-dispersed ophthalmologists or eye health workers?

Professor Foster:Maybe if I start on that and then Andrew can take it on. I think, going back to the situation of Africa, where you’ve got a low number of eye specialists, ophthalmologists per million population, you’ve also got a low population density. So people are going to be scattered. So you’ve got this problem of distance. And naturally, ophthalmologists who have families and need to earn a living tend to move to the cities, to big towns where they can have their children educated and have a reasonable quality of life. So consequently, in rural areas, where most of the visual loss and blindness from cataracts is, there are not the eye specialists. So then it comes up on the eye care team.

And we train other people to deliver eye health in rural situations. And this has been done a lot in Africa, either with ophthalmic nurses or the ophthalmic clinical officers and even cataract surgeons. So first of all, I think to get to the rural areas, you do want to train staff who will deliver primary and secondary level eye care in rural areas. And they should be able to diagnose and treat the common conditions, including cataract. So there’s not then a problem with diagnosis, if you like, of cataract to teleophthalmology, But it’s more the connecting the person with cataracts with the cataract surgical service so that they can actually get the surgery.

However, that is not true for other conditions, particularly diabetic retinopathy or glaucoma where it may be more difficult to make the diagnosis. And then I think there can be a role for Peek as a kind of form of diagnosis from a distance and giving advice from a specialist in a city situation to an eye health worker in a rural area. And maybe with that I hand over to Andrew, and he can say a little bit about that.

Dr Bastawrous: Yeah, and I think it’s worth being clear on the definition of teleophthalmology as opposed to, say, mobile health. For a teleophthalmology program, it requires both the user and the recipient of the information to have good connectivity. So that’s often going to be limited. So there won’t be sufficient bandwidth in all the target regions to be able to share high resolution images or videos in real time. That limits the possibilities there. And given most conditions that we’re dealing with within eye care are not going to be acute conditions that require an immediate response to. I think the role of teleophthalmology is limited.

I think what is important is that we’re able to ensure that patients who have received the diagnostic test are then linked into the health system the way that we don’t just do a test we make sure that if their test means they need treatment, they are guided towards receiving that treatment. An example I’ll give you is the work we’re currently doing in Tanzania for their diabetic retinopathy program, where they have a central retinal camera, which fits in the hospital in Moshi and goes out to 18 satellite clinics. And it spends between one and two weeks in each of these clinics throughout the year.

That means in any one of these sites that 50 weeks of the year, there is no diabetic retinopathy service. So what we’re doing there is putting Peek in each of those 18 satellite clinics and allowing for opportunistic examination of anyone who’s diabetic by someone who is a diabetologist or a non-ophthalmic person to collect retinal images, as well as visual acuity and other information. They also collect patient demographic data and contact phone numbers. And as soon as they have connectivity– so it doesn’t have to happen in real time. It could even be days later when they move to a place with connection.

All that information is shared centrally in Moshi where somebody is able to scroll through the images, as they would if they had a large inbox of emails, and grade each image as to whether– and importantly, not necessarily the grade of retinopathy, just whether it’s referable or not. Because our decision-making process at this point in time is really all down to, does this patient need to come to overcome that barrier of distance or don’t they? And giving a very definitive diagnosis or severity of retinopathy is not necessarily going to change that final decision. And so all we ask in this system is that they make a decision on whether this person should move from home to the hospital.

And at the moment, that decision is made in an automated system of SMSes, is sent to the patient, the carer, and to that local clinic to advise that this person needs to be attending. And the hospital remains aware of those who have attended and those who haven’t so they can flag up those who haven’t and send further reminders. So I think in that system it’s appropriate. But as I mentioned in an earlier question, we’re going to learn a lot as we do it, and I expect we’ll get a lot of it wrong. And we’re open to doing that and continuing to improve it to get to a point where it’s actually useful for every day

Dr Patel: I think that will be quite exciting as we go along from here and see what you find from there. We’ve been gathering a few questions over the week as we’ve been going on. And many of the participants said they couldn’t directly get involved in the live session due to download speeds. But they did post a few questions. So if I just raise one of them here. And that is, what is the role of NGOs in our health, personnel development for government settings?

Professor Foster: It’s a good question.

Well, let me speak from personal experience.

And I can only blame myself, not blame others. I worked for an NGO, and I worked in Tanzania. And we trained nurses, and we trained cataract surgeons. And we trained them outside of a government training program. If you like, they called it informal in-service training. And the nurses would come for three months, and some come six months, and I think the training they got was very good. The problem was that when they went back to the place of work, they had this certificate from us, and it was not recognised by the government, and they were not going to get any incentive or remuneration, all this training they’ve had. So they may have better job satisfaction.

They were enjoying their work more and they knew more. But it did not help their career development. And I think in hindsight, that was a mistake. So ideally, NGOs who want to put resources into training eye health workers, particularly in Africa, but anywhere, need to do it in collaboration, agreement with the government. And that means now with them saying who do they want to train, how long do they want to train them for, how do they want it done, and then to try and support that training program, be it financially or be it with expertise, skills, and training.

The thing is that’s sometimes a slow and difficult process, and sometimes governments can be a barrier and block to that and not necessarily wanting to directly solve the problem with the country but rather wanting to copy what the West has done, which may not be appropriate. But one’s just got to go through the kind of dialogue and working with them and then trying to get a good, meaningful training program accepted by the government, where people can come in, get well trained, and get appropriate career development and remuneration for their work, because that’s the way people will then stay in their own countries and not look to move as well. But it is a challenge. It’s not easy at all.

Dr Patel: And it’s certainly, when you want to change the efficiency of cataract services, inevitably you’re going to do a lot of task sharing, even task shifting to a large extent. Often it’s good to keep the bigger picture in mind as to what may happen to the individual and their career pathway after they’ve moved away from their own setting. So an interesting question that came back was, certainly as clinical staff, we’re not trained to deliver on raising awareness of communities or what community programmes have to do. And so they have to depend on bringing in other cadres to do this. So as one question put it, who should really take charge of this whole question of raising awareness within communities?

Should that be directly the ownership of the hospitals? Or should that be within the health system? What are the practical ways to do this? From your experience, what would work and what hasn’t?

Professor Foster: Well, let’s go to the kind of task shifting within the hospital. And there’s a point that was raised of the bad service. The analogy I often have is about going to a restaurant for a meal. We go out for a meal. We go to a restaurant. Well, what do we want? We want good food, not too expensive, and good service. We don’t have to wait too long, and the person is polite to us, and they smile, and that’s what we’re looking for. Well, it’s exactly the same with eye surgery. That’s what people want. They want good, quality surgery, not too expensive, and they want it delivered quickly and nicely, politely, and so on.

What we end up doing, well, we end up doing the equivalent of somebody works in a restaurant and they’re told, here’s the menu. Take it home. When you come back tomorrow, you can get a meal. And then when you go back tomorrow and say, I’d like this meal, we can place the order now. Come back the day after, and the food will be ready. And that’s maybe convenient for the hospital, but it’s not for the patient. And doctors and nurses are busy doing that clinical work, so we need non-clinical people to be getting alongside the patients with the kind of counseling and the advice and helping them through the system.

And this has been very much promoted in India, again, that counselors who are– sometimes people have already had the cataract surgery themselves. Therefore, they know everything that happens. And they also know the questions that people have. And they come alongside the person wanting cataract surgery, and they basically take them through the process. You come here. You wait here. Your doctor will see you. Afterwards, what did he say? You need this test. After that, OK, now we’re go in here and do this, and so we’re basically just taking care it. That includes the service going through. So there’s that aspect of looking after at the hospital. Then you’ve got the side of creating awareness in the community.

Let me just say if you do that at the hospital, the patients leaving the hospital and going back home create the awareness. Because they go back and they say, it’s fantastic. I can see. It wasn’t expensive. People look after you. That’s the awareness created for it. If you want a kind of system to do it, then I actually think the best system to do it may not be the health system, but rather what we call community-based rehabilitation.

These are the programmes within a community that are helping people with disability at the community level and often run by people with disability themselves or the caregivers of people with disability, and they’re looking to include people with disability into society and help them get all the services that they need with their health or education or employment or whatever. But if you’ve got a good CBR programme, service then they are the people who will know the blind people and create the awareness and enable the people to come to that programme. And so that’s what I think is probably the best delivery, if you can develop that.

And of course, it’s got other advantages for society because it’s not just dealing with blindness. But it’s actually addressing all the people with disability, who are more than 10% of the population.

Dr Patel: And it doesn’t then do any harm in being aware of what are the dynamics within that community. And I remember from my own experience when I was delivering eye care in Eastern Province in Kenya, and we would have set up card tables for these outreach clinics that we were running and never took into account at that time what were the harvest seasons, what was the sowing season. And it was to our surprise that we arrived there after having travelled 150 miles to find five patients sitting there waiting for us. So I think it’s really essential to know your community a little bit better and then preparing services for that particular community, reaching those needs there.

Andrew, you’ve worked now in Nakuru for quite a long time. Do you have any particular thoughts on this?

Dr Bastawrous: I think it all comes down to relationships. I think having someone embedded in a given community who is always going to be your contact person, and that can be the person who you go to to ask, not we’re going to do an outreach, but do you need an outreach? Do you have people with eye problems who want it? Can you raise awareness for us? And when is the right time to do it? Is there a particular day of the week or period in the year which would make it more suitable?

And to make our work in Kenya, we used to have someone go two or three weeks in advance of our advance team going, so almost a pre-advance team, going and meeting the village chief or the elder or someone in the church or headmaster who could be a responsible person for that community. And they would help identify someone who would partner with out team to go door to door finding people with visual impairment. And I think having those things set up in advance of going somewhere is critical. And the most important person in that entire pathway is someone that already lives in that community.

Because they will be the same person who, when you do half of the people who have come forward with surgery and have had a good result, and the other half comes forward saying, OK, now I’m not afraid. I’ll have mine done. You need that key contact person you can go back to and say, OK, you’ve been through the process. You know what to do. And they can also serve as the escort. They can become a champion in their area. They don’t need to have any knowledge of eye care, and they just need to have strong relationships. And I think finding that person or persons in any given community is key.

Dr Patel: I guess we can’t possibly stop the session without having you talk about cost. So there are a few questions that are coming up here. And that was on cost. There are different cost models in different hospitals. And certainly cost is a big element for achieving universal eye health and moving forward when a large portion of the cataract blind are really not able to pay for the services that they desperately require, so when the idea of universal eye health came about, what was the thinking? How are we going to address the issue of cost?

Professor Foster: So part of universal eye health is that the service should be available at a cost which is economically OK to society. Now, economically OK means not necessarily free of charge but that the cost does not make people poor. And of course, if you’re poor to begin with, then cost is a big issue for you. So in trying to make it affordable, there’s certain principles which then have to be applied in very different situations that you find around the world. And a basic principle of any business is if you’re producing something, be it a bicycle or a shirt or whatever. And in this case, it’s a cataract operation. Then there is a cost to making that product.

And the cost would be a mixture of the salary costs and the kind of things that are needed, so consumables that go with it. And particularly in cataract surgery, the salary costs is quite by far the largest bit. So the first business principle is to contain the cost, to keep the cost low. And that takes two forms. One is that any given salary, the more you can produce, the lower the cost. If you’re paying an ophthalmologist, and we’re paying in a month a certain amount, and in that month he does five cataracts, obviously the cost per cataract is much less if you’ll do 20 cataracts in the month. Productivity lowers the cost of that cataract.

So productivity is one side of cost containment. The second is the actual consumables that you need, to look at, is everything really essential? Or are there some things we’re doing but actually they don’t affect the quality? The example I use is you’re making a shirt, and you put on extra buttons somewhere. I’ve got two buttons on my shirt. One is that extra button there. Do I need that? No, I don’t need it. So why am I doing that in the cataract? Why am I having that cost?

So if you look at only those things that are essential, and then once you’ve got the essential consumables, then look for bulk purchase and generic purchase and not using trademark or brand names, but try to get generic. All those things will lower the cost– productivity, generics, bulk purchase, only the essentials. Even when we’ve done all that, and depending again on the place, the cost of cataract is going to be something between– the lowest you can kind of get it is about $15 maybe up to about $100 if you’re doing that well. But it’s linked to the cost of the salaries of the team. That may still be unaffordable for poor people.

So then you’d come in with the second slide, is can you subsidize that cost for that person? And that’s an aspect of income generation. How do you generate a subsidy so that you can in effect get this cataract operation at a price that’s lower than your actual cost? And different ways are done for doing that. The most popular recent one has been the so-called tiered cataract service in a hospital. So it’s a bit like flying an airplane. You’ve got first class or business class or premium economy or economy, right? And you pay different amounts depending on the service that you get. But actually everybody flies from A to B.

So everyone gets the cataract surgery, but the first class patients, the VIPs, are paying a cataract level that subsidizes the economy people. But there’s many other ways of income generation. So you can generate income on non-essential eye care, so provision of spectacles and making a profit on spectacles, provision of eye drops and making a profit on eye drops. You can make money for non-clinical care, having a coffee shop in the hospital or providing accommodation to bring in money. And that’s everything that you can do yourself. And then, of course, you can begin to look for outside support, be it through governments or be it from NGOs or local philanthropy or other business endeavors like that.

So those are the kind of principles. But just go back through it again– start with cost containment. Try and get the cost down, improve productivity, buy in bulk, only the essentials. Then look for income generation, a subsidy for the poor. And it can be your own clinical services, non-clinical services, or possibly some kind of outside help as well.

Dr Patel: Good management.

Professor Foster:Easier said than done, though.

Dr Patel: Yes, absolutely.

Professor Foster: Theory is always easy. Now, so we’ve not had any new questions posted in. But now I think we’ve covered quite a large number of the questions that were put in place. Andrew, there were some questions on technology that were raised. And certainly Naomi Corbin from the Channel Islands had raised the issue of having used two different types of technology in their settings. I think they’re called the Complog and the Thomson Software Solutions. Any thoughts on that?

Dr Bastawrous: Yeah, they’re very good vision tests. They’re laptop-based visions tests. And I think they work very well in a setting where you have infrastructures and if you can place a vision chart in a hospital or in a clinic. And taking a laptop into the field where it’s still potentially quite cumbersome and battery life could be limited, it can be harder to deliver those kind of tests in a community level. But I think there’s an appropriate use for them certainly in settings with greater infrastructure.

Dr Patel: How are you going to get Peek charged in the fields then?

Dr Bastawrous: This was an important learning for us when we were there. So we are able to use solar-powered rucksacks or external charges, which initially we were asking our health care workers to charge the phone between patients. But we found it wasn’t actually a good solution because it meant they were plugging the phone in and out very frequently, more than phones are designed to do. Most people plug their phone in once a day. And so they would still end up getting a low battery, and it would end up damaging the USB port. So what we did is make sure we had phones with replaceable batteries. And we would charge a backup battery.

And we’d ask them to use the phone until it was almost flat and then just swap the batteries around. And then the near-flat battery would be charging in the solar-powered rucksack. And also there’s usually even in very rural areas there will be people who are phone providers and vendors that also provide a charging service where you can go and charge your mobile phone or charge something else. And so there are ways to have it done.

Dr Patel: So anything from the team ?

Jo Stroud: We’ve had a few questions coming in

Dr Patel: OK. So, great. I think if there are any additional questions, please feel free to put them into the comment boxes into the modules that we’ve got. I think this week they’re doing refractive errors. It just started yesterday. So we look forward to hearing from your comments on refractive errors, but that doesn’t mean you can’t still go back to cataract. And then the following two weeks, we’re going to be going back to maybe our case study, which is Zrenya, and seeing how can we apply all these things that we’ve talked about and learned about to that case study of Zrenya So thank you very much to all the 28 people that have managed to join us live.

And we look forward to hearing from the remaining 2,000 plus. OK, thank you.

Professor Foster:OK, bye. Thank you.

Dr Patel: Bye-bye. Thank you, Andrew, for joining us.

Dr Bastawrous:Pleasure. Thank you.