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Local Lions Club support the project in Jamaica

The Concept of Community Vision Clinics in Jamaica

Since 1981, Canadian Vision Care (CVC) has been working with Lions clubs across Jamaica plus with public and private health providers in Jamaica to develop a unique viable eye care delivery system. What started out as a training project for Optometry students from the University of Waterloo, has become a program involving eye surgery, training for Jamaican surgeons, clinics in all areas of Jamaica, and based on a concept pioneered in Linstead, a breakthrough in how both eyecare and healthcare can be delivered with a Personal Health Record (PHR).

Since 1981, CVC clinics in Jamaica have examined patients who could not afford eye care. Teams have provided more than 300,000 exams, 200,000 pairs of glasses and performed thousands of surgeries directly with CVC volunteers and indirectly many thousands more by donating surgical microscopes to public hospitals and Lions facilities. Equally important, CVC has trained hundreds of Lions and public health nurses to screen for vision problems and our surgeons have taught new techniques to Jamaican Ophthalmologists.

The challenge in the future is how can CVC be a better resource for training future volunteers with technologies that can revolutionize eye care programmes in both the developing world, and the developed world. The challenge is clear. How can we make eye care accessible to all by rising above the barriers of poverty and distance. Can a self-sustaining eye care delivery system be developed in Jamaica which diversifies into the fields of E.H.R. (electronic health records) and PHR (Personal Health Records) plus manufacturing, training and education, eye banking and social service, all converging under the banner of a Community Vision Clinic.

There are always challenges to such a vision becoming a reality. Yet, there are examples of such ideas that are working. One such system grew out of one man’s dream and a small 11 bed hospital in rural India. Started in 1988, is the Aravind Eye Care System. It is an impressive local project that succeeded. One of the inspirations for the CVC project is the Aravind Eye Care System. From it’s founder we quote:

“Intelligence and capability are not enough. There must also be the joy of doing something beautiful. Being of service to God and humanity means going well beyond the sophistication of the best technology, to the humble demonstration of courtesy and compassion to each patient. “ Dr. G. Venkataswamy. Dr. V has said, "When I go to meditation room at the hospital every morning, I ask God that I be a better tool, a receptacle for the divine force. We can all serve humanity in our normal professional lives by being more generous and less selfish in what we do. You don't have to be a 'religious' person to serve God. You serve God by serving humanity."

India in India while Jamaica is Jamaica. There are similarities, but also differences. One significant distance is location. Jamaica is an easy flight from most of North America. The only official language in Jamaica is English. While many experts have analyzed Jamaica’s economy, and argued why it’s per capita income is so low, the fact is the “brain drain” to Canada, the USA and UK is a high percent of the post secondary graduates from Jamaica’s excellent education system. The OD’s and OMD’s per million people is presented in the following table.

Country	Jamaica	Canada	United States	England
Population	3,000,000	35,500,000	323,500,000	63,500,000
Optometrists	31	5,663	32,400	11,000
Ophthalmologists	33	1,137	18,805	3,200
OD’s / Million	10	160	100	173
OMD’s / Million	14	32	58	50
Total OD & OMD	59	5737	51,205	14,200
OD&OMD/Million	20	161	158	223

What can be done to find more trained professionals to a country such as Jamaica where economic factors result in many trained health and eyecare professionals emigrating? Four sources will be considered. Volunteers, Local professionals made more efficient, Students of both Optometry and Ophthalmology, and as baby boomers ECP’s retire or slow down, Volunteer snowbirds.

CVC has successfully been recruiting volunteer OD’s and OMD’s since 1981. A few key volunteers have donated more than 100 weeks of their professional time, and a number have provided over 50 weeks of professional time. Hundreds of volunteers have donated 1 to 10 weeks of professional expertise. In 34 years, over 2400 Dr Days have been donated. This is the equivalent of 12 extra doctors practicing in Jamaica full time. Significant in that over 300,000 eye exams have been performed, yet not a significant increase in the number of OD’s or OMD’s per 1000 citizens. With a world’s “best” digital practice model, and a stable home clinic in Mobay, it is certainly possible to recruit more volunteers. Combining a family holiday with a commitment to do clinics from 8 AM to 1 PM daily is what CVC has been doing for years. The local Lions have been vital in understanding the balance between work and holiday, while the volunteers have been willing to give of their time, enjoying an “insider’s view” of Jamaica. The conversion of the Brenda Strafford Medical Center to an eye center would facilitate the recruitment of more volunteers. Providing CE credits and unique hands on learning experiences would make recruiting easier.

Local professionals are dedicated individuals who work very hard, with less than optimum equipment or resources. Optometry in Jamaica is an underutilized profession as the Optometry Act is almost 100 years old. Ophthalmology in Jamaica is stretched to the limits and beyond due to the low number of surgeons per population. Add in old inefficient equipment plus crowded, old public hospitals. Private surgical facilities exist in Kingston and Montego Bay, yet many Jamaicans who can afford it simply travel to the US, Canada or the UK for surgery. In a recent survey of OD’s and OMD’s in Jamaica, it was found most are still using paper records and advanced imaging equipment such as OCT’s and HRT’s are not common. This indicates the economic reality of practicing in Jamaica. Eye Doctors in Jamaica do not generate the type of income they could make if they bought a plane ticket north and examined eyes in the US, Canada or the UK. In such circumstances, a low or no cost technology that brought greater efficiencies to local ECP’s would be welcomed by most. Particularly if it could make their job easier and included peer to peer knowledge to help manage difficult cases.

Optometry and Ophthalmology residents are another source of manpower in Jamaica. In fact, this is how CVC got started, as a University of Waterloo summer clinic. For primary care, there are few places in Jamaica where a student would not get great benefit from the ocular health issues that present. For surgical residents who are now only seeing intra-capsular cataract surgery in their training, the opportunity to perform extra-cap surgery on patients would be of significant benefit and the advanced glaucoma cases would be great clinical experience. Having a surgical suite fully equipped for teaching would be a magnet for residents and their mentors. Designing a clinic to help teach OD’s and OMD’s in training would be a big step forward in also recruiting future volunteers for the clinic.

Finally, a virtually untapped source of volunteer help is from baby boomers. Both Canadian and US boomers who would appreciate spending part of each year in Jamaica on a project and emigrants from Jamaica who have a strong bond to the island want to give back. Demographers have studied “boomers” examining them at all stages in life. At CVC, we see boomers as a rich source of volunteers over the next two decades. Busy professionals will look to reduce the stress of their busy practices. Historically, many OD’s and MD’s practice well into their seventies. The 21^st century has seen a movement to “seeking balance” in one’s life. For professionals who have worked hard, retiring to golf is not always an attractive option. Working at the CVC clinic in the morning and golfing in the afternoon at White Witch or Tryall (at local rates) in the afternoon when it is below zero at home is a reality many professionals will find attractive.

In each of the four examples outlined, a permanent CVC clinic in Montego Bay would be a very strong positive to attract more volunteers, make local ECP’s more effective (and hence more profitable) and benefit all parties. For the Brenda Strafford Foundation, the dream of an eye clinic for the needy would be a reality. CVC would have a permanent base for equipment, supplies and storage that would a great benefit for better quality care and follow-up. To follow the Aravind model, sustainable care could be provided to the well to do in state of the art facilities and for those who can’t afford it, equal high quality care would be provided, effectively subsidized by those who can pay. The capital cost of the building has already been provided by the Brenda Strafford Foundation. The capital cost of installing state of the art equipment is a challenge, but one that the BSF, Lions (through LCIF) and CVC we can achieve success in the same manner as we did with the EyeTrain in the Philippines which has been paid for.

The “iCuC” Concept is for small businesses to be created at the Community Vision Clinic. The McMaster business plan for OSCAR was to create a “small business incubator” that provides local service to users of the software. The software is free, but the support and training must be paid for in a standard commercial manner if the program is to be sustainable. This is indeed the basic manner in which any professional practice works. To this end, the vision is to create at least 5 profitable businesses within the Community Vision Centre concept. These will provide sustainable jobs for Jamaica.

OSCAR Service Provider: To train and provide support to all clinics
Optical Dispensary: Let local optical shops bid OR create a co-op dispensary
Pharmacy: Let local pharmacists bid OR create a co-op pharmacy
Surgical Centre: Provide surgical suite for out patient surgery for a fee
Optometry Office: Provide full examination lanes to provide eye exams

In conclusion, this is no small project, yet it is a doable project. The local Lions are keen, CVC is keen, Barrie Strafford has long wanted an eye clinic on this site, and the timing is right for a new use for the facility on Lloyd Young Drive in Montego Bay. The next step is to get an agreement in principle, and then set a committee to work representing all parties. A deadline must be set and a realistic plan put in place. Legal matters must be dealt with.

The Basis For An Agreement in Principle

Lions in Jamaica agree to partner on a long term basis on the clinic
Lions take responsibility to oversee local issues from cleaning to security
Lions with CVC create a non-profit company in JA for this project
Lions agree to provide ongoing volunteer support of clinics
Lions agree to promote clinic locally as their major sight project
CVC takes on responsibility to create a joint venture with all parties
CVC takes on responsibility to create an IT infrastructure for the project
CVC takes on responsibility to recruit volunteers to help staff the project
CVC takes on OSCAR server projects and continues to install as needed
CVC takes on recruiting volunteer experts for CFO and CIO positions
CVC takes on developing relationship with UWI &/or UTech in Jamaica
CVC communicates with residency & internship programs for students
BSF agrees to lease the building to the Lions & CVC on a long term basis
BSF agrees to fund the capital cost of the Community Vision Clinic
BSF agrees to fund the ongoing building maintenance for duration of lease
BSF agrees to fund the ongoing janitorial and security issues on the site
BSF agrees to fund the ongoing staff for the clinic as it currently does
Local OD’s and OMD’s recruited to work at clinic for increased efficiency
Use of state of the art “out patient” surgical suite is supported by local Docs
Sustainable funding for the clinic’s charity work comes in part from fees from using the facility by local surgeons and speciality tests referred in.
Ongoing funding from CVC via the Dr’s Choice royalties AND profits earned by providing CE to volunteers, residents and interns.
McMaster IT department agrees to provide IT programs, cloud platform and PHR for the Jamaica project which CVC funds as needed

Appendix A:

The Brain Drain

From Wikipedia: Over 80% of Jamaicans with higher education live abroad. However, it is noted that these nationals pay valuable remittances. In Jamaica, the money sent back amounts to 18% of GNP.

Following is a BBC article published; 23 July, 2007 by Sir Ronald Sanders

The writer is a business consultant and former Caribbean diplomat

Brain drain or export earnings?

The United States has become the principal beneficiary of the migration from Caribbean countries of its best educated people. But the US is not the only developed country that has benefited from the Caribbean’s investment in the education of its people: Canada, Holland and the United Kingdom are also beneficiaries.

The figures for migration of secondary and tertiary educated people are high for every Caribbean country. The most recent study shows that Suriname led the field for migration of tertiary educated people at 89.9% followed by Guyana at 85.9%, Jamaica at 82.5%, Haiti at 81.6%, St Kitts-Nevis at 71.6% and Antigua and Barbuda at 70%. Of the Commonwealth Caribbean countries, only the Bahamas and St Lucia were below 40%.

Remittances

By the same token, many Caribbean countries profit from large remittances sent back to the region by its people who live abroad. In fact, in relation to its Gross National Product (GNP), the Caribbean area is the largest recipient in the world of remittances. The largest single source of such remittances is the United States. Of the Commonwealth Caribbean countries, Jamaica gains most from remittances.

In 2003, remittances to Jamaica represented a wopping 18% of its GNP, higher than aid and higher than foreign investment. Guyana, Grenada and Barbados followed with contributions to their GNP of 8.1%, 5.3% and 4.5% respectively.

These remittances are vitally important to every Caribbean country. They help to keep the country stable by ensuring the survival of unemployed or low-paid workers, paying for housing of persons who might otherwise be homeless, circulating capital in the economy and in some cases buying food and medicines.

Key funds

No country could afford not to receive these remittances which may be even higher than official calculations since remittances are often not sent through the banking system or even through the money transfer companies; some are hand delivered by friends and relatives travelling between countries.

If remittances were not being received the level of poverty, crime and social instability in many Caribbean countries would be worse than it is. Therefore, governments, undoubtedly, welcome the remittances. Nonetheless, Caribbean countries are facing a dilemma over the migration of their best trained and educated people. Simply put, it is this: while countries welcome the significant and irreplaceable contribution that remittances make to their social welfare and political stability, they devote large sums of money on the education of their people only to see a large number of them migrate to developed countries, and they lose people who are needed to help make businesses more productive and profitable.

Even governments suffer from the loss of skilled and qualified people whose technical skills are needed in a range of areas including in formulating and implementing fiscal and trade policy. And a solution does not boil down to restricting the migration of qualified and skilled people. Any such decision by a government would be an infringement of basic human rights. It would fuel social discontent within countries, and probably lead to a host of illegal activities for migration.

Brain drain or skills export?

The Caribbean could take the view that the ‘brain drain’ is simply another export industry. Just as rice, sugar, bananas are exported in return for foreign exchange earnings and economic growth, a reality would be that people are trained for export to the work force of industrialised nations and their remittances would constitute the earnings that Caribbean countries receive. Indeed, Caribbean countries are accustomed to exporting people to jobs. When the Panama Canal was being painstakingly dug, much of the back-breaking and often fatal labour was performed by Caribbean people who migrated to the job opportunity.

There were other significant movements of people to the United States Virgin Islands when a refinery was built there, and, of course, after the Second World War, large numbers of Caribbean people went to Britain to fill the breach for able-bodied people to carry out a range of tasks in transportation, construction and health services. In all cases, the migrant workers sent money back home.

Migrant profile

The difference with the present problem is whereas in the past the labour that was being exported was largely unskilled, the current migrants are highly trained at great cost to their Caribbean countries of origin, and the loss of their knowledge reduces the capacity of the Caribbean to compete in the global economy.

So, the economists would question whether the cost of production – the amount of money spent educating people for work in the developed nations – is justified by the amount of money received in remittances.

Whatever the economists conclude, the fact of life is that people move away from economic, social and political conditions that trouble them. In part, these conditions across Caribbean countries are pushing skilled people away from their homelands.

It is also a reality that people are pulled to industrialised nations by better circumstances such as well-paid jobs, employment that matches their skills and training, and good social conditions such as health care.

Keeping skills at home

Clearly Caribbean countries have to come to terms with two realities. First, every country in the region has to improve conditions to keep more of its skilled people at home. This means health and modern education facilities have to be improved and the environment for investment and business has to be strengthened.

And, second, it has to be accepted that some skilled people will continue to migrate however much conditions in their home countries get better. Of course, many more will migrate if the domestic conditions do not improve or if they worsen. If the brain drain is regarded as a reality, then there may be merit in seeing it as an export industry, and a case should be made to the industrialised countries who gain to contribute meaningfully to education and training in the Caribbean. This would take the full burden of education off the shoulders of Caribbean countries and share it with the countries who are also its beneficiaries.

Appendix B:

Express Healthcare January 2012

Sharpening India’s Vision

The late Padmashree Dr G Venkataswamy (Dr V) was a known warrior who waged a war against needless blindness in India. He not only conceived a vision to eradicate needless blindness from India, but also a unique viable eye care delivery system, that today has won admiration from all over the world. Taking the concept of social marketing to new heights, Dr V instituted the Aravind Eye Hospital (Aravind) in 1976 at Madurai, after his retirement from the Government Medical College, as the HoD of Ophthalmology. Over the years, Aravind became synonymous with Dr V as well as cataract surgery, and made eye care accessible to all by rising above the barriers of poverty and distance. This self-sustaining eye care delivery system grew as a chain of hospitals, new hospitals came up at Tirunelveli, Coimbatore, Theni and Pondicherry and diversified in the fields of manufacturing, training and education, eye banking and social service, all converging under the banner of a holistic Aravind Eye Care System.

In terms of the volume of work done—number of patients examined and number of surgeries performed— Aravind is the world’s largest eye care provider. It boasts over 32 million outpatients served and four million surgeries performed, right from the inception till date. The famed institute is the ultimate choice for many international patients as well as researchers and faculty members. It houses many well equipped speciality clinics run by very efficient professionals, all sharing the same vision of Dr. V. There is tremendous amount of work done, both in terms of complicated surgeries and ground-breaking research. It is known for its unique community outreach programme and the self-sustainable strategy, balancing cost and efficiency as well as drawing surplus profits to feed its ambitious growth plans. Dr S R Krishnadas, Director, Human Resources, Aravind Eye Hospital, Madurai shares the group’s growth story.

Please tell us briefly about Aravind Eye Care System?

Aravind Eye Care System (AECS) is the largest and most productive eye care facility in the world. Founded in 1976 by Dr Govindappa Venkataswamy, today, AECS encompasses eye hospitals, a manufacturing centre for ophthalmic products, an international eye research institute, eye banks and a resource and training centre that is revolutionising hundreds of eye care programmes across the developing world.

What is the rationale behind launching this company?

In the early 70’s, the prevalence of blindness in India was around 1.5 per cent and 80 per cent of India’s population was rural, while almost all of the country’s medical services were in the urban areas. There were several barriers for the rural population to access the services. Low awareness and limited affordability combined with a lack of human resources made it difficult to provide sustainable, quality services. In a developing country like India, the government alone cannot meet the health needs of all owing to a number of challenges like the growing population, inadequate infrastructure, low per capita income, aging population, diseases in epidemic proportions and illiteracy. Realising this, Dr Venkataswamy wished to establish an alternate healthcare model that could supplement the efforts of the government and also be self supporting. Following his retirement in 1976, he established the GOVEL Trust under which Aravind Eye Hospitals were founded.

What was the source of funding for the company?

Mortgaging the family properties provided the initial funding to set up the hospital. As the organization developed, it became financially self-sustainable. Nearly 2/3rd of the patients are treated either free or at deeply subsidized rates. Revenue from the paying patients cross-subsidies the free and subsidized treatment.

What are your primary goals?

The primary goal of AECS is the elimination of needless blindness by providing compassionate and high quality eye care for all. Lions Aravind Institute of Community Ophthalmology (LAICO), Aravind’s consulting wing aims to promote improved management practices in eye care worldwide through training and capacity building. Research activities at Aravind are committed to finding new ways to reduce the burden of blindness. The manufacturing arm of Aravind – Aurolab too contributes to the organisation’s mission by making high quality ophthalmic products affordable and accessible worldwide.

Please tell us about the company's growth over the years.

The evolution of Aravind Eye Care System can be roughly classified into three phases with the first one focussing on the setting up and development of hospitals and community outreach. Cataract services were of primary concern during this time. Internal refinement and scaling up constituted the second phase with the establishment of LAICO and Aurolab. Education and training programmes developed into a full- fledged scale by the time. During the third decade it scaled up, going outside the boundaries in a more proactive manner through the establishment of Aravind Managed Eye Care Services and Dr G Venkataswamy Eye Research Institute as well as the growth and development of speciality care services.

What is the present scale of the company?

Aravind Eye Care System today encompasses a network of eight eye hospitals, 40 vision centres in rural areas, seven community eye clinics, a PG Institute of Ophthalmology, a manufacturing centre for ophthalmic products (Aurolab), an international eye research institute (Dr G Venkataswamy Eye Research Institute), eye banks and a resource as well as a training centre (LAICO) that is revolutionizing hundreds of eye care programmes across the developing world. In the year ending March 2011, Aravind’s eye care facilities handled over 2.6 million outpatient visits and performed over three lakh surgeries. During the same year its outreach department conducted over 2,600 camps through which over seven lakh patients were screened and over 76,000 patients underwent surgery. Over 6,500 candidates from 94 countries have undergone some form of training at Aravind. Aurolab’s cost-effective ophthalmic products are exported to 120 countries and accounts for a total of 7.8 per cent of global share of intraocular lenses. The research activities at Aravind reflect its commitment to finding new ways of reducing the burden of blindness. Aravind Eye Banks procured a total of more than 4,300 eyes of which more than 1,500 were utilised for corneal transplantations. LAICO works with over 280 eye hospitals in India and other developing countries through a structured process of consultancy and capacity building. It is conservatively estimated that this resulted in an additional 500,000 surgeries being done annually in these hospitals.

What are the challenges faced by you? How do you overcome the challenges?

The main challenges that Aravind faced were—serving a large population with poor or zero paying capacity and delivering it in a manner that is accessible, acceptable, affordable and yet efficient and sustainable. To a major extent, our outreach services addressed the problem of reaching out to a vast majority of poor people and taking eye care service to the doorstep of the community free of cost. Aravind’s unique model of combining high volume with the highest quality standards enables it to provide affordable treatment to all—rich and poor. Aravind follows the principle that large volume, high quality services result in lower costs and sustainability by applying market fee structures for wealthier patients, and subsidised charges for the poor. In the early 90s when the IOL (Intraocular lens) were introduced, the lenses were very expensive for the common man to afford. To address this challenge, Aravind started Aurolab adopting technology from the west and could manufacture IOLs which cost only a fraction of the market price at that point of time.

Please tell us about your future plans.

Aravind has set a target of performing one million surgeries annually by the year 2015 and is gearing up to achieve this target by establishing new hospitals. With the increase in awareness about cataract, Aravind has begun to shift its focus to more comprehensive outreach services, such as Diabetic Retinopathy camps, eye camps for children and refraction camps. Aravind plans to extend its outreach services to include all speciality areas of eye care. An initiative has begun to set up permanent primary eye care facilities, so the community does not have to wait for a camp. So far 40 such vision centres and seven community centres (outpatient clinics) have been set up in rural communities. This will be scaled up further to cover the entire service area as an alternate strategy to eye camps to reach the community. Dr G Venkataswamy Eye Research Institute will give significant thrust in research of basic sciences like genetics, biochemistry and immunology; drug development; clinical trials for assessing efficiency of intervention options; population based studies and health systems research for designing an effective delivery system. Looking ahead, product development and manufacturing to address other conditions like Glaucoma, Diabetic Retinopathy, etc., will take place. A low cost Green Laser to treat Diabetic Retinopathy has just been launched at half the current prices. This will be refined further to bring down the costs. Similarly, efforts are on to produce an affordable retinal imaging system. On the education front, Aravind is in the process of obtaining deemed university status. Aravind is beginning to expand its capacity building process to include speciality areas such as Paediatric Ophthalmology and Diabetic Retinopathy. LAICO has also started helping other institutes to build their capacity in research. It has also begun an initiative to help set up Centres for Community Ophthalmology across the developing world which will cater to the training and capacity building needs in their geographic areas. LAICO is also looking at ways to partner with the public sector in order to increase the resource utilisation of the government eye hospitals.

Where do you see the company in the next five years?

Aravind plans to sustain the growth and double the service delivery capacity in the next 10 years by expanding to new locations and expanding the telemedicine technology-based primary eye care model for universal coverage and follow up of patients with chronic eye diseases. Better systems for the diagnosis and management of chronic diseases like Glaucoma, Diabetic Retinopathy and age related Muscular Degeneration would be created. There will be different centres of excellence in speciality eye care services through pioneering clinical and basic science research. Aravind is to become the premier institute for ophthalmic residency education and fellowship training. In the face of changing technology, the organisation continues to develop cost effective solutions to keep the eye care affordable for all.