Community Eye Health J Indian Supplement 2006;19(58): s77-s79

A comparison of static and mobile facilities for primary eye care & refractive error services

Mehul Shah, Shreya Shah, Bharat Gadhvi, Arvind Chavda, Harshad Upadhyay and Avadh Parikh
Drashti Netralaya, Ophthalmic Mission Trust, Chakalia Road, Dahod-389 151, Gujarat, India

Introduction

The Vision Centre, catering to a population of 50,000, is envisaged as a sustainable primary eye care model at the community level. The main functions of the Vision Centre include recognition of eye problems, refraction and optical services and referral to the networked secondary and tertiary eye care facilities where comprehensive eye care is provided. The vision centres would be manned by a locally identified and trained person from the community, and in the long term could become sustainable. The Vision Centre concept has also been accepted as a viable model under “VISION 2020: The Right to Sight” global initiative and in the Plan of Action of the National Program for Control of Blindness in India.¹It is proposed to set up 20,000 Vision Centres by the year 2020 as per the plan of action in India.²

The vision centre concept is based on the idea of a sustainable, static semi-permanent to a permanent eye care facility as close to the community as possible with their full participation, Drashti Netralaya, on the other hand, piloted the concept of a mobile facility that would provide predominantly refraction & referral services and carry out information, education and communication activities that could serve as an alternative to a static facility in those remote underserved areas till a sustainable model can be put in place.

This article looks at the utility of a mobile facility versus a fixed facility for providing primary level eye care services at the community level in difficult areas.

Methods

Before establishing the mobile facility, Drashti Netralaya started a static Vision Center in Zalod, a tribal block of Dahod District in September 2002. This Vision Center provides basic eye care service to people of Zalod and surrounding villages. The mobile facility was thought of because of the coverage and utilization of eye care services in the areas. 78% of the population in the project catchment area, primarily tribal, lives in inaccessible rural areas without even basic facilities. People tend to ignore eye problems because it is not possible for them to travel to access treatment. Due to lack of proper information and education, timely intervention does not happen, thus often resulting in irreversible vision loss.

The mobile facility was designed to cover a population of 4 million people in 3 districts of 3 states: Dahod (Gujarat), Banswada (Rajasthan) and Jhabua (Madhya Pradesh). These three border districts are clearly underserved and lack good eye care facilities. Dahod, Jhabua and Banswada are dominated by the Bhil tribe, with the population residing mainly in rural areas. Medical facilities are available only at the District Headquarters. The literacy rate in the region is 45.65%, and among the scheduled tribes it is 18%. About 29.9% of the population lives below the poverty line.

Why a Mobile Facility?

Since the fixed vision centre service was accessible to a limited area only, it could not provide eye care services to the whole rural population of Dahod District Therefore, in view of the following factors, a mobile refraction facility was planned:

Larger coverage area that would allow to extend eye care services to the larger population
Forthcoming community support and participation
Reaching the patient rather than waiting for the patient

Results The following analysis compares the mobile and static facilities for the period of 7 months in terms of:

Establishment expenditure;
Recurring expenditure;
Work output;
Income generation

Static versus Mobile Refraction Facility (January to July 2005)

Particulars	Static Facility	Mobile Facility
Establishment Expenditure	US $ 10659.6 (Rs.501,000)	US $ 28206.7 (Rs.1,325,713)
Recurring Expenditure	US $ 642.4 (Rs.30,194)	US $ 1721.4 (Rs.80,904 )
Equipment	Auto Refractometer Ophthalmic Chair Unit Slit Lamp Biomicroscope Keratometer Indirect ophthalmoscope Direct Ophthalmoscope Retinoscope Trial set with trial frame Remote control vision drum Lensometer	Auto Refractometer Ophthalmic Chair Unit Slit Lamp Biomicroscope Keratometer Indirect ophthalmoscope Direct Ophthalmoscope Retinoscope Trial set with trial frame Remote control vision drum Lensometer Constant Power Supply
Human Resources	One technician - looking after the Clinical aspects Support staff - Support and optical shop management	One technician - looking after Clinical aspects 2 Support staff - Support and optical shop management Driver
Activities	Works five days a week Provides primary eye care services	Monthly mobile visits each month at block level PRE VISIT ACTIVITY: Formation of local working committee. Planning : No. of visits, date, location, identification of sponsors. Production and distribution of handbills and other communication materials
Community Support	Formation of a village level committee at the working place.	Formation of village level committee at each place visited by the mobile unit Involving local NGOs, various youth clubs, village panchayat and village leaders for better community support
Types of services	Screening Refraction and prescription of glasses Referral to base hospital Scheduling for surgical cases Primary eye care and treatment Diagnostic camps at regular intervals	Screening Refraction and prescription of glasses Referral to base hospital Scheduling for surgical cases Primary eye treatment In case of emergency, the patient is referred on the same day and brought in by the mobile unit

Work output: January to July 05 OPD Performance: Static & Mobile

Particulars	Static Facility	Mobile Facility
OPD	352	3739
Surgery performed	50	114
Representation in total OPD of 34,345 patients at base hospital	1.03%	10.88%

Capital and running costs (US $ 1= Rs. 47)

Particulars	Static Facility	Mobile Facility
Capital expenditure	US $ 10659.6 (Rs.501,000)	US $ 28206.7 (Rs.1,325,713)
Recurring expenditure	US $ 642.4 (Rs.30,194)	US $ 1721.4 (Rs.80,904)
Total expenditure	US $ 11302 US (Rs.531,194)	$ 29928 (Rs.1,406,617)
Monthly average recurring expenditure	US $ 91.8 (Rs.4313)	US $ 245.9 (Rs.11557.71)

Income

Particulars	Static Facility	Mobile Facility
Consulting charge/patient	US $ 0.64 (Rs.30)	US $ 0.21 (Rs.10)
Income generated	US $ 141.7 (Rs.6,660)	US $ 840.53(Rs.39,505)
Average Monthly Income	US $ 20.23 (Rs.951)	US $ 120.09 (Rs.5,644)

Average cost of service. Recurring expenditure per patient

Particulars	Static Facility	Mobile Facility
Total recurring Expenditure	US $ 642.4 (Rs.30,194)	US $ 1721.4 (Rs.80,904)
Total OPD	352	3739
Recurring expenses per patient	US $ 1.82 (Rs.85.77)	US $ 0.46 (Rs.21.63)

Conclusions

To conclude it appears that a mobile facility is more effective than a static facility as it provides eye care services to a larger population with almost the same set up and equipment. Even though consulting charges in a static facility are three times higher than that at the mobile centre, the static centre recovers only 22% of its recurring expense whereas the mobile centre recovers 49% of its recurring expenses in the short term.
The mobile facility allows for a higher level of networking with other NGOs and more community support.
Although in the short term it seems to be efficient and covers a larger population, the longterm sustainability of this model needs to be worked out. This experience provides some insight into the practicality and feasibility of having a mobile option to serve the eye care needs of the underserved populations until a sustainable model can be put in place.

References

1. National Programme for Control of Blindness in India, October 2004, Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, New Delhi.

2. CME Series (No-9): Vision 2020-Right to sight: All India Ophthalmic Society, India. www.aios.org/cmefiles/cme_9.pdf