Managing barriers

SPEAKER: In this presentation, we look at barriers to cataract services. By the end, you should be able to relate to the provider and consumer barriers that impact on cataract surgical rate. Across the world, and particularly in our units in low and middle income countries, the cataract surgical rate has remained low. Why is this the case? Well, broadly speaking, there are two possibilities. The first is that there is no demand for services. Patients are simply not coming to the eye unit. Another possibility is that there is a long waiting list, that the eye unit is not functioning effectively or efficiently. We need to understand the reasons for both patient and provider barriers in order to improve our eye care services.

Evidence from different places has allowed us to identify reasons why there are not enough patients coming for surgery. These can be understood in six broad categories. Lack of awareness, patients don’t know that cataract blindness is treatable or even that treatment is available near them. Beliefs. These vary from country to country but reports indicate that elderly people are often resigned to sight loss, believing it just be part of the ageing process or that there is no need for good vision when you’re old. Cost is a repeated barrier as patients experience both direct and indirect costs if they wish to get surgery. And sometimes other family priorities are regarded as more important.

Distance from the hospital or lack of transport remains a challenge, particularly for remote and rural populations in many regions. Outreach programmes are sometimes the only way to reach these patients.

Easier access to alternative care is a challenge in many settings. For example, patients may prefer to see traditional healers which means that they are exposed to couching practises which can inflate many complications. And overall lack of knowledge about cataract and its treatment can result in a fear of surgery. There may be many other barriers specific to your own setting, and it is important to attempt to understand these so that appropriate services and health education activities can be developed to help overcome them. Options for managing a lack of demand for patients include, awareness, promoting your services. Beliefs, providing health education in a culturally sensitive manner. Cost, identify ways to minimise the payment burden for patients or reduce costs in the clinic.

Distance, considering outreach or transport options for patients. Easy access to traditional healer, improving hospital access. And fear, counselling for patients.

Provider related barriers are often due to poor planning and management in five key areas. Manpower, materials, management, motivation, and money. Under manpower the key questions to consider are, are there enough personnel to manage the theatre and clinic? And how efficient is the theatre? An efficient theatre should be able to do at least four cataract surgeries per hour.

To calculate the maximum volume of surgery we multiply efficiency by the total number of surgery days available and by the number of surgeons. This, when calculated for the surgeon and available time, provides an understanding of an eye care services capacity. Surgical output is dependent on how we use materials. For example, the number of operations per theatre per year, the availability of regular and good instruments, functional equipment, and a regular supply of consumables. Challenges in this area need to be identified and solutions found. Management is key for an efficient flow or work in any eye unit. Identifying and addressing bottlenecks and gaps in patient flow and operating theatre layout helps maximise use and improve efficiency.

Motivation is closely linked with the conditions that people work in and to how the team functions. Opportunities and career maps also play a role in ensuring retention of staff. Money often poses the most challenges. Sustainability is a balance between income generation and expenditure.

We need a multi pronged approach to improve service delivery and meet demand. Areas that need to be covered include the recruitment and training of staff, the supply, use and maintenance of instruments and equipment, appropriate funding options for patients, for example, tier payments or insurance schemes, patient flow rates, surgeries per hour, more theatre days, more theatre tables, and task sharing, task shifting, and the team approach to eye care. It is important that the planner or manager of an eye unit has a clear understanding of the reasons why the cataract surgical rate is low before they proceed to address them. Sometimes both kinds of barrier may need to be addressed to create patient demand and to balance it with good service delivery.

Equity is central to cataract service delivery. Equity can be defined as ensuring the fair distribution of services without discrimination against age, gender, ethnicity, and so on. There are several models in eye care to ensure equity. Wait for the patient in the clinic. Although this is not always effective, either for increasing output or ensuring equity. Screen in the community and refer. This can be a target activity but it has been done regularly to be effective. Screen and operate in the community. Again, this sort of outreach activity has to be sustained. Screen in the community and transport to static unit. This model is usually most effective where transport is a huge problem, especially for the poor.

Community based health workers and referral to the eye unit. This is an effective model as the community worker is known to the community and local people have confidence in them. Satellite hospital in a rural setting. This model is usually expensive to set up but does provide comprehensive care. And finally, mobile services such as the ORBIS plane, the Mercy Ships, or the Lifeline Express. These are often externally organised and they cannot become a permanent option. In conclusion, to increase demand for surgeries, patient barriers need to be understood and addressed. To increase supply of services, eye units need to assess their own efficiency and effectiveness.

And management of both of these activities is central for a coordinated and sustained impact on the cataract surgical rate.