by Daphne Wang
One aspect of global health intervention programs highlighted by Dr. Prakalapakorn’s lecture was sustainable development. In the field of global eye health, there is concrete knowledge on the interventions to prevent or treat visual impairment, and the overwhelming cost-effectiveness of these treatments. When tackling such global health challenges with known effective treatments, it is even more imperative to focus efforts on creating intervention programs that are locally sustainable, for both cost-effective and ethical reasons.
A common theme observed across many organizations that provide ophthalmological care in low-income settings is a focus on training local eye care professionals. The Aravind Eye Care System is one of the most productive eye care center and teaching facility in the world. In order to help replicate the radical “McDonald” model of eye care elsewhere, Aravind offers both clinical and non-clinical courses on topics such as management, community outreach, and instrument maintenance. In this way, Aravind not only trains the local workforce to sustain the growth of the institute itself, but also encourages the development of similar facilities in other underserved areas. Another organization, Orbis International, is well-known for their Flying Eye Hospital, a fully equipped eye hospital and surgical teaching facility. Orbis targets the adequate training for healthcare professionals to build eye care capacity in the places that it works. By providing the training from a team approach, Orbis improves the efficiency of the surgical team and the health outcomes for the patients. Education and training are essential aspects for creating a sustainable global health intervention by building the local workforce and sharing proven methods for increased healthcare efficiency and better patient outcomes.
Another consideration when creating a sustainable healthcare model in a low-resource setting is the acquisition and management of donated goods. Many instruments required during vision exams and surgeries are expensive and complex. To ensure that donated instruments have the most benefit, the Community Eye Health Journal developed guidelines: “Donations of consumables and surgical instruments: how to ensure you really benefit.” One informing principle is to consider the standards of eye care and the ease of maintaining the donated goods. Donated medicine should be of comparable quality to those used in other parts of the country. Eye care facilities receiving donated instruments should be able to maintain, fix, and use the instruments. It is not sustainable to simply accept items unless these items will be used and maintained reliably, and that the healthcare outcomes of the donated medicine are comparable to the results of medicines in the native country.
Perhaps even more importantly compared to concerns of cost-effectiveness, sustainable global health interventions have ethical impacts. Would an intervention provide more harm than good if a patient was diagnosed with a treatable condition, but was unable to receive treatment due to program sustainability reasons? If the benefits of the short-term intervention end with the end of the intervention, is the program still beneficial to the local population? If a donated medication arrives only intermittently, should this treatment be offered to the patients? There are fewer ethical concerns if treatments are sustainable and available in the long-term. Until additional guidelines can be developed for sustainable eye care in low-resource settings, interventions that provide training for local eye care professional and practice effective management of donated resources are crucial aspects of a sustainable program targeting the reduction of visual impairment in underserved regions.
Reference
Cordero, I. (2011). Donations of consumables and surgical instruments: how to ensure you really benefit. Community Eye Health,24(76), 41.
Great post, Daphne. Sustainability is something I have been thinking about for a long time, especially within global health. Solutions are, no doubt, more valuable when their impact is lasting, but I often question how we get there. There seem to be a few common pillars in a sustainable solutions, like those taken by Orbis and Aravind. Encompassing these pillars is the idea of regeneration- the ability to reproduce results once the initial resources have been used.
ReplyDeleteEducation is at the forefront of sustainability and works through regeneration. Teaching is an excellent way to allow local communities to be involved in addressing their own problems, and this knowledge can be passed on to following generations.
It is more difficult to regenerate materials because accessibility to materials requires existing infrastructure, dependable supply chains, affordability, etc. Sometimes we try to build that infrastructure, and sometimes we work withing the existing construct to determine which locally available materials may provide a solution and potentially decrease costs, e.g. the water filled lenses mention by Dr. Prakalapakorn.
Another method of ensuring regeneration is through policy, which is particularly important in the protection of human rights. For example, policy may allocate spending that improves access to healthcare. This route faces its own problem of enforcement, whether that be through policing or tracking that funds are used appropriately.
Certainly, the list of approaches to sustainable solutions contains many more pillars and must be modified for each problem and setting. These are just a few ideas that have stood out to me in my limited experience in global health and global development. What else do you guys think is important in developing sustainable solutions?
Thanks for the response, Happy! I really appreciate your point about the need to regenerate materials in sustainable interventions. Another aspect that makes the Aravind eye care system outstanding is that it operates the Aurolab, which supplies the intraocular lenses that the Aravind eye hospital use in cataract surgeries. Aurolab was established with the support private and nonprofit organizations. Lens production in Aurolab lowered the price of lenses by 98% (imported lens at $200 per lens to $5), making lenses much more affordable and broadening the access to cataract surgeries for people in LMICs. Today the Aurolab also makes other optometric products and exports these affordable and high quality consumables to more than 130 countries (http://www.aurolab.com/). I find that the self-sufficient model of the Aravind and the wide impact of the hospital truly impressive. Perhaps another way to improve sustainability of global health interventions is to assist LMICs with the production of quality medical supplies at affordable price ranges. More effort should be focused on means of production in LMICs rather than the donation of consumables or medical instruments from wealthier countries.
DeleteI echo Happy's thoughts on this being an excellent post, Daphne. I think that another important consideration is understanding where biomedical engineers fit into the solution of making interventions in LMICs sustainable. A lot of the maintenance and understanding of how to keep processes and equipments running can come from the expertise of biomedical engineers. Often, I feel in my own opinion, we neglect to include biomedical engineers at the table to get their opinions on how they think we should go about including technology into LMICs. Especially in regards to surgery, a specialty that is incredibly technology intensive, we need to figure out ways to make sure that equipment can be maintained properly and perhaps inviting our colleagues from the BME discipline could be a way to remedy this issue.
ReplyDeleteThanks for the excellent post. I think a major aspect of providing sustainable development is through individual and community empowerment. Empowering people to help themselves will ultimately promote a self-sustained model. The problem is actually providing the skills and tools necessary for an individual or community to be able to make those changes. Referring back to the anecdote, "if you give a person a fish they eat for a day, but if you teach a person to fish they eat for a lifetime". I agree with Daphne's emphasis on training eye care health workers in LMIC for this reason. The problem is, you can't teach a hungry person to fish. A small amount of aid needs to be provided initially until the operation can get up and running, but as the community is able to take more responsibility for the operation the amount of aid needs to subsequently decrease. This is where many international nonprofits fail, because if they do their job right they essentially work themselves out of business. Nonprofits are businesses too but need to realize that their assistance is needed in other locations and that it's actually a good thing to work themselves out of business in a certain area, because that will mean sustainable change has been achieved.
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