Content Background 2 Workshop Framework Section I Executive Summary Section II - Workshop Proceedings Participants List Programme Schedule

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2 Conten Background Workshop Framework Section I Executive Summary Section II - Workshop Proceedings Participants List Programme Schedulee

3 Background DISTRICT PLANNING 2..0 Oct 31 Nov 1, 2014 It is estimated thatt in India, over six million cataractt surgeries are done annually resulting in a national average cataract surgical rate (CSR) of 5,0000 surgeries per million population per year. This high average masks the fact that this rate is extremely low in several districts with the result; the population in those districts are not getting even basic eye care. This situation is influenced by a number of factors like availability of Infrastructure, human resources, the productivity of these resources as well as the political eco-system. Enhancement of eye care services in such underserved districts is unlikely to happen organically by itself. Proactive measures and implementation in a project mode would be required to increase the eyee care services to the desired levels. Districtss with low CSR have been in that situation, chronically influenced by a number of factors. These include availability of infrastructure and human resources, especially ophthalmologists and paramedic staff; the productivity of these resources and the eye care leadership at the district level, either from the government or non-government sector. Change in this status quo and enhancement of eye care services in such districts is unlikely to happen organically by itself. Proactive measuress and implementation in a project mode would be required to increase the eye care services to the desired levels. This is the context for conceptualizing this consultation. A beginning was made about 2 decades ago by pioneering work done by the Government of India and DANPCB (of DANIDA) which resulted in the concept of District Blindness Control Society (DBCS) which has been established as a centrally supported programme across the States. The initial pilot in five States and scaling up the model across the country enabled us to increasee the cataract surgical volumes from 1.2 million in 1988 to the present six million a year. It is against this background, this new initiative, District Planning 2.0 is being proposed with a targeted approach to enhancing the cataract surgical rate of underserved districtss and the States. Key stakeholders working in eye care in India are committed to this new initiative and many of them have already added this systems approach as part of their strategic plan. The participants included officials from MoH, Government of India, officials from the districts and State governments (11 districts from six States Assam, Bihar, Chhattisgarh, Jharkhand, Orissa and Rajasthan), INGOs - Sightsavers India, CBM, VISION 2020 India, ORBIS International, Mission for Vision and Seva Foundation, US; Government resource centre RP Centre for Ophthalmic Sciences, AIIMS, New Delhi and national NGOs LAICO/Aravind Eye Care System, Madurai, LV Prasad Eye Institute, Orissa, Dr. Shroff s Charity Eye Hospital, New Delhi, Netra Niramay Niketan, West Bengal, Akhand Jothi Eye Hospital, Bihar and MGM Eye Hospital, Raipur. This workshop was organised by LAICO, co-sponsored by Centre for Systemss (CIPS), Sightsavers India, VISION 2020 and Seva Foundation US. Innovation in Public 2

4 Workshop framework The two days weree designed to understand the current gaps and challenges, case studies of interventions that have worked agree upon district specificc goals and list out concrete actionable next steps. The workshop was also designed to bring together all stakeholders and develop a common understanding. Day I: Gap analysis and what needs to be done to address the backlog Day II: Intervention plan and way forward 3

5 SECTION I EXECUTIVE SUMMARY The two day workshop, District planning 2.0 organised from October 31 Nov 1, 2014 had participation of the stakeholders working in eye care from the government (State and Central), INGOs and national NGOs coming together to develop a broad roadmap for the district planning approach targeting the underservedd districts from six States and draw commitment and support to take this pilot initiative forward. By the end of the workshop, one more State, Uttar Pradesh was also added considering a huge unmet need thus making it as 14 districts from seven States for the pilot initiative. I) Workshop proceedings: Day I of the workshop focussed on gap analysis and what needs to be done to address the backlog with existing resources in the select districts from six States. To do this, participants discussed on the key challenges faced currently and what could be done with the existing resources and what additional resources are required to increasee the cataract surgical rate to the present national average. Importantly, sharing of different interventional models that have been implemented elsewhere this was to stimulate discussions while thinking through key strategies to address the challenges faced by the districts. Models include: Theni district model: A district with 1.2 million population has eye care infrastructure available within a distance of 7 KMs anywhere in the district; had maintained a CSR of for many years which is now inching towards a CSR of 10,000 in recent years and fostered by a good partnership between government and NGOs/private providers Short term strategy for addressing huge backlog in North East States: Mired with huge challenges for decades with respect to eye care infrastructure, human resources, insurgency and transportation, etc. a twinning approach was implemented by the NPCB, MoH whereby established institutions like Aravind, Sankara Nethralaya adopted one of the NE States and performed cataract surgeries on a campaign mode for three to four years. This in a way enabled to address the mounting backlog as a stop gap approach Tripura Vision Centre model: Tripura with a population of three million had set up 40 IT enabled Vision Centres across the State to address the key challenges such eye care infrastructure, access and transportation; today patients are provided with access even for their basic eye problems. This assumes greater significance with more than 50% of the ophthalmologists in the State retiring in next couple of years with no replacements in place Public private partnership: Public private partnership between an INGO (Sightsavers), State government (MoH) and an NGO hospital (Susrut eye hospital, WB) led to creating infrastructure for eye care servicess at a district hospital in one of the poorest districts of Bihar, Kishanganj which saw a jump in cataract surgeries from 0 to 1200 in a year thus benefitting the community. This successful demonstration led to permanent posting of an ophthalmologist at the district hospital. However this success has not been translated in other needy districts due to bureaucratic hurdles and lack of commitmentt from the State and district leadership Need based planning for NE region: A platform that brought together eye care providers from NE States to enhance eye care delivery taking into consideration current 4

6 situation availability of resources and current performance, etc. and develop a plan that included both short term and long term solutionss with an assumption of greater support and collaboration from NPCB officials Deliberations on day II were related to the intervention approach, what sort of structure that should be in place and budgetary considerations to effectively make things happen. The two day workshop was concluded with a clear commitment by the stakeholders and also definitive next steps. The workshop was marked by good interactions by the participants who shared without any inhibitions, the challenges faced and possible solutions. Dr. Bachani, Mr. Chakrapani, Mr Thulasiraj and Dr. Praveen Vashist played the role of facilitators who readily shared their insights during the deliberations. Subsequent sections of the executive summary would outline the key challenges and solutionss to achieve desiredd CSR; stakeholders commitment and next steps. II) Target cataract surgical rate for the 14 districts Target cataract surgical rate for the select districts: Unanimously agreed by all the States 5000 The listed districts and their current CSR Table: List of 11 districts nominated; population and district cataract surgical rate State Assam** Chhattisgarh Districts Lakimpur Kabeerdham Population 1,042, ,753 CSR* *CSR collated from the State DBCS units ** Assam State would identify another Kanker 760, potential district to be included under this Jharkhand Palamu 1,936, initiative ***Since there was a short time between Dumka 1,321, confirmation and participation of Odisha Rayagada 961, representatives from Bihar, potential districts Baleswar 2,320, were not identified prior to the workshop; Rajasthan Jhalawar 1,411, those listed were selected by the Karauli 1,458, participating team during the workshop Bihar*** Saharsa 1,900, considering CSR less than This might be Khagaria 1,666, reconsidered by the team III) Key challenges and possible solutions (short term and long term): This section brings key challenges and solutions that were discussed. Detailed discussions of these sections are documentedd in section II workshop proceedings. Health system blocks Service delivery (gettingg patients, quality, infrastructure) Key challenges Demand side: Lack of awareness in the community, poor health seeking behaviour and transportation issues and poor access to 5 Solutions Short term: Carrying out needs assessment Enhancing referral mechanism and make the staff accountable for

7 Human resources Equipment, technology and suppliess care No outreach in government hospitals Supply side: Inadequate referrals from PHCs & CHCs; Lack of screening for eye care in most of these centres Unavailability of eye care personnel to provide care Issues relating to poor post-operative outcomes and infections Lack of good monitoring system Inadequate ratio of ophthalmologists to ophthalmic assistantss In adequate number of ophthalmologists passing out from these States and lack of training opportunities for the existing doctors Burdened by administrative and nontheir ophthalmic work Lack of accountability of staff to work Delay in procuring consumables due to existing process Equipment bought based on low cost and not the quality Poor maintenance and huge difficulty in getting equipment repairs done Poor OT infrastructure in some of the districts Unavailability of basic equipment/instruments at PHCs/ /CHCs 6 outcomes Involving ASHA workers in creating awareness and case mobilisation Ensuring post-op follow-up of patients to ensure quality Long term: Develop population based norms for infrastructure and resources Ensure availability of multiple eye care players Creating access for eye care by establishing Vision Centres at PHCs and CHCs Short term: Directive to utilise ophthalmologists and ophthalmic assistants only for eye care work; delegate administrative work to district coordinator of NRHM Guidance with respect to annual surgical output per ophthalmologist Upgrading ophthalmologists surgical skills Long term: Maintaining a healthy ratio of ophthalmic assistants to ophthalmologists Ensuring required number of ophthalmologists in the districts Increased output of ophthalmologists and ensuring their postings within the State for a specific period Short term: Carry out resource mapping Renovation of operating theatres as per the standards Centralised equipment maintenance at district level Long term: Establish good AMC process beyond warrant period too Creating a cadre of biomedical engineer in the government sector Redrafting the purchase policy to

8 ensure reliability of equipment and also timely availability of consumables Develop standard list of supplies and equipment (VISION 2020 to take a lead on this) Leadership & governance Lack of leadership commitment at district level No proactive monitoring processs Yearly plans does not reflect the real need Poor coordination between NGOs and government officials Short term: Bring in accountability amongst the staff for the outputs A monitoring system to measure the listed indicators for cataract surgeries and follow up Long term: DPM preferably be an ophthalmologist playing an advisory role; delegation of day to day operations to non-clinical personnel available through NRHM Information system HMIS does not function properly Lack of evidence based decision making No feedback to the reports submitted Specific items: Take up the issue with IT department at the central level through CIPS Interim: VISION 2020 India to liaison with NPCB to accept the reports as done previously Budget for eye care Budgeting is done as per the Put in place annual district planning delivery discretion of SPO and not necessarily based on district s needs exercise IV) Intervention approach: Steps to be followed Key discussion points relating to intervention approach for this initiative were: Form teams and carry out a comprehensive situation analysis at the district levels that would include socio-economic indicators, eyee care infrastructure, current performance block-wise, human resources numbers, cadres and dynamics, challenges faced both from provider s and patient s perspectives, partnerships, existing climate for collaboration Conduct district level workshopss to develop micro-level planning involving all the stakeholders from the district and the State Involve stakeholders from government, INGOs and NGOs in this exercise Develop a proposal with budget requirements and include it to the State PIPs with special mention to these districts; representations from these districts to be part of the visiting team to Delhi to discuss the significance of this initiative. The plan need to include both long term (5 years) and short term plans (2 years) using health systems framework 7

9 V) Suggested Structure for implementation of district approach: District level: A two person committee representing government and NGO/private sector State level: 1) One person to serve as anchor and work with the State leadership a person of high caliber who could effectively liaison with the government and other stakeholders. One option is we consider from the pool of Prime Minister Rural Development Fellows (who were placed directly under the District Collectors during their fellowship to assist them in executing specific programmes 2) Constituting a core group consisting of State Programme Officer, INGO representatives, and a representativee from a resource organization, etc. National level: Derive policy support that could be facilitated by CIPS for linking up with the senior officials VI) Budgetary considerationss for the pilot: It was decided thatt the planning phase of this pilot to be supported by the INGOs Sightsavers, CBM, ORBIS, Mission for Vision, etc. For the implementation phase of the pilot programme, a detailedd proposal needs to be developedd with budget requirements and incorporate it to the State PIP for the implementation in next financial year. While preparing the budget, it is important to add those components thatt are currently not being supported by NPCB. It is also important to look for other sources of funding beyond NPCB and also outside government. VII) Stakeholders commitment and next steps The stakeholders committed their full support to carry forward the planning processs and also laid out definitive next steps: : 1) Commitment of support by the INGO and the national NGOs to support specific States State Assam INGO ORBIS/VISION 2020 India National NGO Sankaradeva Nethralaya, Assam Bihar Sightsavers India Netra Niramay Niketan, WB and Akand Jyoti Eye Hospital, Bihar? Chhattisgarh Jharkhand Orissa CBM/Sightsavers India CBM/Sightsavers India CBM/Sightsavers India MGM Eye Hospital, Chhattisgarh Netra Niramay Niketan, WB LV Prasad Eye Institute, Orissa?? Rajasthan Sightsavers India and Mission for Vision Dr. Shroff s Charity Eye Hospital, New Uttar Pradesh Sightsavers India and Delhi Mission for Vision LAICO along with CIPS would carry out overall coordinationn of the initiative with the support of senior officials, Dr. Bachani from the MoH and Dr. Praveen Vashist, RP Centre, AIIMS, New Delhi An brief introduction about the INGOs and National NGOs to the participating officials from different States for a better understanding about their work 8

10 2) Next steps to move forward with the planning process Activity Submission of the report to By whom the LAICO Ministry through CIPS Directive from the Ministry of Health and letters to the States (to include Draft letter from LAICO From the Ministry to States invitation to invite stakeholders) (through Dr. Bachani and CIPS ) Meeting at State level before carrying out situation analysis through VC/onsite discussion Finalise situation analysis template Sightsavers and LAICO Draft Engaging an anchor at the State level By CIPS Situation analysis & district level micro Core group planning (two year plans?) Approval of plans at district level Core group By when 8th Nov 14 8 th Nov 15 th Nov 15 th Nov 30 th Nov 31 st Dec th Jan 15 3) State Programme Officers to finalise and confirm the two districts to be included for pilot project; Sightsavers to consult with the State Programme Officer of Uttar Pradesh to nominate two districts for the pilot; criteria for selection of the districts are: district population one million+; CSR less than 2000; availability of eye care infrastructure and some resources; it is desired to select atleast one district with NGO eye hospital presence 4) A report on workshop proceedings to be circulated to the government officials and the Secretaries of the respective States by CIPS and LAICO would share the report with the INGOs and the national NGOs. 9

11 SECTION II - WORKSHOP PROCEEDINGS DAY I - OCTOBER 31, 2014: GAP ANALYSIS AND WHAT NEEDS TO BE DONE TO ADDRESS THE BACKLOG WORKSHOP INAUGURATION ( ) Welcome Address: Dr. R.D. Ravindran, Chairman, Aravind Eye Care System Dr. Ravindran gave a warm welcome to the participants. He highlighted how blindness has a negativee impact on the community and the country in multiple ways affecting quality of life amongst individuals and families; and economically due to lost productivity. He stressed that this meeting if followed up successfully, will change the future prospects of eye care delivery for a thriving large population in the country. There is no scarcity of resources in India. Two decades back, based on positive outcomes of a pilot initiative, Government of India went ahead proactively with actions that led to increasing cataract surgery output tremendously. Actions include - promoting cataract surgery with intraocular lens implantation; being supportive for manufacturing and supplying ophthalmic equipment across the country; putting in place enabling policies to make resources available for service delivery. These measures resulted in six fold cataract surgical output in two decades. Though the outputs and availability of eye care services has not spread out uniformly in all the States, it leaves a positive precedence. Dr. Ravindran hoped that the plans made during the two day planning would help to right people and set the contextt for extensive work we are looking up to accomplish in next ten years or so. The workshop framework involves sharing of knowledge by various players and arriving at solutions and way forward. He hoped that the outcomes of such work would contribute towards making India become prosperous, as eliminating blindness would help in reducing poverty and bear a positive impact on the country. Welcome Address: Mr. D. Chakrapani, IAS (Retd.), Director, CIPS Mr. Chakrapani in his welcome address listed out recent initiatives being carried out in collaboration with Aravind Eye Hospital and other like-minded organisations. CIPS and Aravind had recently begun working with Jharkhand State government in establishing IT enabled Vision Centres in collaboration with Common Service Centres Initiative (Special Purpose Vehicle); similar effort is underway in Telangana State for setting up Vision Centres in the primary health centres in collaboration with LV Prasad Eye Institute, Hyderabad. The consultation, District Planning is yet another effort to enlarge the reach of eye care service delivery to the masses. 10

12 He also highlighted a need to overhaul the system, how each one of us who are part of the system could work with zeal to change the status quo. He spoke about Dr. V and his inspiring work how a retired government medical practitioner went about setting up a world class eye care delivery system. With no dearth of human resources and technology, this should be possible for every person in the country. All it required is to remain committed to the cause. Secondly, the resources available in the existing set up should be put to a much better use. Today, remuneration in public sector is comparable on par with many corporates in the country. The government officials are paid five times more than average per capita of this country but productivity in public sector still remains low. He highlighted on low utilisation levels of existing resources in the public sector - for instance, surveys carried out in the public sector has recorded 38% non-attendance of the personnel on any given day. He raised an important question on why there needs to be a supervision to carry out day to day activities and not a self-supervision model. He had also pointed out the gaps that exist with respect to availability of continuous medical education and use of technology in the government set up. There is hardly any link between the medical institutions and the peripheral centres such as secondary care and primary health centres in public sector. He quoted successful models in the realm of continuous medical education that exist in organisations such as Christian Medical College, Vellore, Mahatma Gandhi Medical College, Wardha, etc. He wondered what ailed the government sector in emulating such preferred practices all these necessary for providing better health care to the community. Mr. Chakrapani also suggested how technology could be made use of intuitively to overcome limitations access, distance barriers, inadequate human resources, etc.; how one should explore avenues towards utilising the existing resources and funding from multi-sectoral organisations and other departments/programmes rolled out by the Governments both at Central as well as State levels. He hoped that at the end of two day deliberations, the group would come up with a blueprint aimed at enhancing eye care delivery in the underserved regions. Self-Introduction and Participants Expectation: Participants were asked to introduce themselves and also share what their expectation from this consultation. Their expectations included: Putting in place a better planning process to address existing gaps in eye care delivery and contribute to enhancing cataract surgical levels at district and State levels Develop better understanding about delivering high quality eye care services Evolve a collaborative approach to enhance eye care delivery in the underserved districts Looking forward for a continuous support from all the stakeholders involved in this workshop in implementing the action plan Looking forward to the ideas related to enhancing eye care delivery that could be incorporated for eye care as part of new healthh policy plan that is being under consideration 11

13 Keynote Address: R D Thulasiraj, Executive Director, LAICO Aravind Eye Care System Mr. R D Thulasiraj extended his warm welcome to the participants and dealt in length about the problem at hand; and what needs to be done. He highlighted prevailing variation in cataract surgical rate (CSR number of cataract surgeries per million population) that exists between various States in the country with many of them falling below the current national average CSR of The broad contextt of the problem is to understand the impact of this variation on the community people are denied access to eye care for no fault of theirs. However, it is possible change this situation with right application of our minds. With demographic contours undergoing changes especially in the older population, an increasing 50+ years age group, the national average CSR need be 9000 by the year 2020 in order eliminate avoidable blindness in the country. Some of the States are performing well with a CSR going beyond well beyond Hence it is in the realm of possibility and this growth would have to essentially come from the currently underserved States enabling them to achieve current national cataract surgical rate. To drive home the message, he spoke about government s concerted efforts in the past to address huge backlog and its impact. Until 1990, number of cataract surgeries performed annually remained 1.1 million with an incremental growth. Thereafter, India witnessed a six fold increase, touching six million cataract surgeries by the year This was possible only becausee of many changes that were introduced by the government in collaboration with agencies like DANIDA and World Bank in initial stages which was scaled up across the country as a centrally sponsored programme by Govt. of India: Embracing cataract surgery with intraocular implantation that gave better visual outcomes to the people when compared to aphakic spectacles they had wear earlier Making relevant ophthalmic equipment available and training people to use the technology Scaling up the cataractt surgical programme country wide after DANIDA s demonstration of successful district based approach in seven States where they could quadruple the number of surgeries during the project period; later funded by the World Bank for programme expansion Decentralisation of the programme implementation 12

14 All these were accomplished in a much shorter time span clearly demonstrating the realm of possibility with proper planning and commitment to implement the plan. With respect to implementing proposed initiative of district planning 2.0, he suggested that a deeper introspection need to be done to understandd the real gaps. This could be pertaining to human resources, infrastructure, eye care players, above all, absence of a plan incorporating need based targets, adequate resources with necessary accountability. Right kind of inputs and processes would result in achieving right kind of results. Understanding of the gaps would help to move forward to the ways to fix them with right inputs and processes to achieve desired results. Solutions to address existing problems need to be both short term and long term - short term solutions could be very helpful in kick-starting the collaborations and make quick impact addressing the problem at hand. Mr. Thulasiraj shared with the participants the approach adoptedd by Aravind in Maldives a decadee back. Initial assessment helped the team understand the bottlenecks the country had only one ophthalmologist stationed in the main island. It would have taken more than a decade if Aravind had worked only on long term solution of building infrastructure and human resources before commencing meaningful work. Instead, the approach includedd addressing the existing backlog in one area at a time in four year time period. He encouraged participants of the workshop to deliberate on both long term and short terms solutions in order to address pressing problems that hinders better service delivery in the underserved regions. There could be policy and personality related challenges in the current scenario that need to be recognised while planning future course of action. A positive plan with positive energy would surely enable in overcoming the impediments. It is in this context, the consultationn District Planning 2.0 has been planned. Mr. Thulasiraj concluded his keynotee address giving an overview of the two day deliberations and the expected outcomes that should be achieved. He proposed to the group to consider an aspirational district level CSR target and also evolve mechanisms to reach the target. He mentioned about the commitment pledged by many stakeholders resource centres as well as the INGOs to take this initiative forward. He stressed on the need for a structured follow- levels for taking things forward after this planning meeting. There are many players who are up plan at the State and district committed to tackle the status quo and make this initiative succeed which is also why it is being as considered as district planning

15 SESSION I: GAP ANALYSIS AND UNDERSTANDING UNMET NEED ( ) Understanding the ground realities: Sharing the findings: KM Sasipriya, Senior Faculty, LAICO Ms. K M Sasipriya made a brief presentation sharing the findings from the districts based on the data received through a simple questionnaire as well as telephone interviews with district officials. The objective was to collate information to understandd eye care delivery system in the nominated eleven districts eye care infrastructure, human resources and the cadres, cataract surgical performance and challenges. Telephonic interviews with some of the officials helped to understand the challenges faced in delivering care. Following were the key findings from 11 districts: Functional eye unit with a minimum of one and a maximum of four ophthalmologists in all the district hospitalss Presence of a government medical college hospital in Jhalawar, Rajasthan Only four districts had NGO/private eye hospitals (Baleswar, Paluma, Dhumka and Lakhimpur private eye hospital started very recently) One of the CHCs in Jhalawar has an ophthalmologist posted as the CHC medical officer and CHCs generally do not have equipment/instrumentation for eyee care District hospitals had usually 1 or 2 ophthalmic assistants assisting eye doctors in the OPD and another two general nurses in the OT who are trained in assisting cataract surgeries; the human resource mix may not have desiredd ratio because of which most of the clinical workload is handled by ophthalmologists in outpatient clinic as well as operation theatre. Not all PHCs/CHCs are manned by the PMOAs resulting in inadequate referrals from the peripheral centres to the district hospitals Even the available eye doctors are not adequately utilised and that is reflected by the low surgical output per ophthalmologist Districts with both government and NGO/private eye hospitals have better cataract surgical outputs Paluma: 4000; Dhumka: 3250; Baleswar: 1900 when compared to other districts. On a whole, there is a huge potential to increase the overall cataract surgical rate within the districts by manifold With respect to surgical performance, dataa received included only of the surgeries performed by the hospitals from the district and does not include number of surgeries performed through screening eye camps by eye hospitals from other districts and there might be some aberration to the actual cataract surgeriess performed. 14

16 Table: List of 11 districts nominated; population and district cataract surgical rate State Assam** Districts Lakimpur Population 1,042,137 CSR* 384 *CSR collated from the State DBCS units Chhattisgarh Kabeerdham 839, ** Assam State would identify another potential Kanker 760, district to be included under this initiative Jharkhand Palamu 1,936, Dumka 1,321, ***Since there was a short time between confirmation and participation of Odisha Rayagada 961, representativess from Bihar, potential districts Baleswar 2,320, were not identified prior to the workshop; those Rajasthan Jhalawar 1,411, listed were selected by the participating team Karauli 1,458, during the workshop considering CSR less than Bihar** ** Saharsa 1,900, This might be reconsidered by the team Khagaria 1,666, Some of the key challenges that cut across the districts were: a. Service delivery: i. Ineffective referral mechanism has highlighted above due to absence of personnel at the lower centres ii. Cataract surgeries not performed on all working days: since ophthalmologists posted at district hospitals need to perform other duties regular night duties, post-mortems and in some instances, deliveries, postings to general camps, legal and administrative responsibilities, etc. iii. Lack of adequate beds in some of the district hospitals and in some instances, admitting non-surgical patients leave less chance for beds for the patients requiring a cataract surgery. iv. Outreach - not a core functionn of district hospitals; making necessary arrangements for conducting an eye camp rests with of an ophthalmologist who is already burdened by other responsibilities v. Lack of awareness in the community about the services available at the district hospitals vi. Fear of poor postoperative visual outcomes induced by past incidents of cluster infections b. Human resources: i. Skewed ratio of ophthalmologists to paramedic staff ii. Ophthalmologists being accountable for non-ophthalmic activities both clinical and administrative related iii. Lack of training in recent advances, especially in surgical skills c. Equipment/consumables: i. Maintenance remains a key issue in most district hospitals a time consuming process; in some of the district hospitals, A Scan biometry, operating microscope has not been repaired even after six months 15

17 ii. No maintenance contract in place and since the local officials are not involved in procurement process, ophthalmologists at district hospitals do not have means to get in touch with vendors at the time of breakdown iii. No preventive maintenance process in place iv. Procurement of consumables is a time consuming process Discussion points: In many districts there are non-performing surgeons because of the location where they are posted an ophthalmologist posted at a PHC/CHC cannot do any speciality work leading to underutilisation of specialists Across the country, a significant number of ophthalmologists do not perform surgeries and perform like an optometrist with a focus on refractive error correction. Only 50% of ophthalmologists in the public sector are surgeons and many of them perform surgeries only in their private practice o Couldn t we consider having a vision technician carry out simple tasks including refractive correction similar to what Aravind or LVPEI has been doing without any difficulty? Moreover she/he can be locally available. There seems to be a huge need to scale up the vision technician approach across the country That s possible for outpatient consultations, but what about surgical performance? o In many cases, doctors do not find an enabling environment to perform for instance when an ophthalmologist is confronted with a post-operative infection, the committee discusses about his performancee instead of discussing on safety protocols that should be put in place o I was posted in a Leprosy mission hospital at the time of my appointment. Since I was an ophthalmologist and wanted to be posted in speciality clinic, tried for a posting at district hospital. Once again, I was posted at a PHC where I was addressing the issue of Malaria and RCH programmes. It took fifteen years of servicee for me to get into ophthalmology so many years of my service wasted in performing non-ophthalmic work. Regular training of ophthalmologists is not in place and it is important this is put in place o In Odisha, ophthalmologists and ophthalmic assistants were trained thirty years back and no training has happened since then. Most of them would be retiring in next two to three years and what would happen then. 16

18 Theni district model: Dr. Dipankar Datta, Chief Medical Officer, Aravind Eye Hospital, Theni Dr. Dipankar Datta shared with the participants, eye care delivery model of Theni district whichh came into existence in the year 1996 (carved out of Madurai) serving a population of 1.2 million and predominantly an agriculture based economy. Dr. Dattaa gave a snapshot of Theni district s annual cataract surgeries and cataract surgical rate from the year The cataract surgical rate was consistently at and touching close to 10,000 in recent years. He then elaborated what those key factors were that led to this consistent performance over the years. There were no ophthalmologists until mid-80s except for a doctor making weekly visitss from Madurai town and screening eye camps conducted sporadically. The first eye hospital in the district was established by Aravind eye hospital in Theni town in 1985 followed by an eye unit in a government district hospital in a nearby town, Periyakulam in 1986 and much later a medical college hospital in another small town Andipatti in Key factors that influenced eye care delivery in Theni district: Generating demand: Proactively reaching out to the community throughh a. Screening eye camps by all the players with the support of government (including NPCB) for cataract; b. Screening of all age group through specific efforts such as school screening programme, workplace camps c. Screening for speciality eye problems such as diabetic retinopathy with other stakeholders, glaucoma, paediatric related, etc. d. Implementation of community based rehabilitation projects covering major part of the districts e. Observation of special days through awareness programmes such as world sight day, world diabetes day, etc. All these efforts led to better to better reach, awareness and case identification in the community; over a period of time these efforts translated into increasing footfalls at the base hospitals. Creating accesss to eye care: a. Availability of both government and NGO/private eyee hospitals and clinics b. Availability of some form of eye care infrastructure across the district primary eye care centres, secondary eye hospitals, outpatient clinics, etc. thus allowing people to access care in less than 7 KMs distance thus making it easier for patients to seek eye 17

19 care. For instance, seven primary eye care centres run by Aravind Eye Hospital, Theni examined 52,000 outpatients with 1700 patients undergoing cataract surgery at the base hospital. c. Such efforts have also brought in shift in health seeking behaviour with more patients opting to visit an eye care facility than waiting for a screening eye camp and to some extent fuelled by Availability of comprehensive eye care servicess in the district (cataract SICS & phaco; refractive errors; glaucomaa surgical and medical management; DR medical management, basic level cornea and uvea services) Building partnerships for enhanced eye care delivery between multiple stakeholders in the district examples include government NGO collaboration for screening eye camps (cataract surgeries) and technology based DR screening at 32 primary health centres; school screening programmes and close collaboration with community who have becomee partners in eye care delivery programme Availability of adequate ophthalmologists and ophthalmic assistants in the district 13 ophthalmologists (government 4; NGO/private 9 with posting of some Residents) and 44 PMOAs (of which 10 are in primary health centres) Commitment of district leadership that fosters eye care delivery with the participation of multiple players and extensive collaboration with community as well Discussion points: 1. While Aravind has invested Rs. 7 lakhs towards each Vision Centre, government has allocated much lesser amounts, Rs. 50,000 to 1,00,000 and how is it possible to set up good vision centres? a. Government has set up district innovation fund of Rs. one crore per district for a period of five years. The districtt hospitals could tap that resource for establishment of vision centres. Thesee allocations are made through NRHM and funding is available for innovative schemes. If someone is really interested, they could also approach industries, entrepreneurs, NRI who are interested to contribute to this project and should not be an issue 18

20 2. Vision Centres cannot work in isolation and should work in coordination with eye units to provide good eye care services. 3. Mr. Chakrapani briefly explained about the special purpose vehicle, Common Service Centres set up by Government of India, aimed to bridge digital divide and bring in transparency in governance. A total of 1,25,000 CSCs have been set up across the country with high speed broadband connectivity each CSCC managed by a village level entrepreneur offering services such as land record process, community certificates applications, booking tickets, Aadhar registration, etc. These entrepreneurs earn between Rs. 15,0000 to 60,000 a month. These CSCs could be utilised to set up vision centres in the respectivee districts and States. This has been taken up by Jharkand State to roll out vision centres across the State. Similarly, in Telangana, discussions were held with the Government and LVPEI to establish vision centres within PHCs. This collaborative approach could also bring down the setting up costs by a great degree. It is also important to consider technological solutions to address the issues 4. While it is important to discuss on role of vision centres in patient referrals for cataract surgery, it is important not to be focussed narrowly on cataract; but need to look at big picture taking into consideration long term goals too. Group work I - Distilling the gaps at district level Having listened to brief presentation on current status of eye care delivery in districtss and also the Theni district model approach, participants were split into six groups State wise to list the gaps and challenges at district/state levels against six health system blocks (1) service delivery (gettingg patients, quality, infrastructure), (2) human resources; (3) equipment, technology and supplies; (4) leadership and governance; ( 5) information system; (6) budget for eye care delivery Many of the challenges and gaps identified by the groups were similar cutting across the States. These were collated and presented to the larger group on day II of the workshop to initiate a discussion. 19

21 Health systems blocks Service delivery (gettingg patients, quality, infrastructure) Human resources Specific gaps /challenges (across all the States) Demand side Eye care not a priority - due to lack of awareness in the community - no structured community based programmes about the services available; health seeking behaviour is very different in tribal population - low expectations due to lack of awareness and their lifestyle Referral system from PHCs/CHCs - not adequate - inadequate documentation on the referrals and no communicationn about referrals with peripheral centres - Poor coordination between district and tertiary care hospitals - ASHA workers are not part of the blindness control programme. Reaching out: - Outreach camps are not organized by the government - Community involvement is not much - Limited outreach work (by eye care providers from other districts?) - No public private partnership in place Supply side - Focus is not on providing comprehensive eye care - Quality - Lack of system to monitor the quality. Record for maintaining visual outcome doesn t exist; post-op follow up is poor and not monitored - Eye care players: - No NGOs are not serving in the particular district; in some districts, no eye care work happens - Scope of services: Only curative services are available but no preventive and rehabilitative services - Ophthalmic assistantss are unable to perform their clinical duties fully since they are also involved in administrative work - Poor visual outcomes and cluster infections led to stopping of outreach work/surgeries in many districts (for instance in Chhattisgarh) - PSUs wherever available limit their services to their employees; do not extend their services to larger community Availability and capacity of ophthalmologists & ophthalmic assistants: - Inadequate number of eye surgeons; those available in govt. sector, they are also involved in non- ophthalmic and administrative work leaving less time to carry out clinical functions; distribution of eye surgeonss skewed - Less number of postgraduates passing out from the States - No of Oph. Asst. in the district hospital and the district as a whole is inadequate. - No incentive to do surgery/do more work; no indemnity coverage for surgeons Training and career development - Inadequate training opportunities to upgrade skills for doctors and the ophthalmic assistants/pmoas - No regular CME programme - No training facility to develop ophthalmic assistants and optometrists 20

22 Equipment, technology and suppliess Leadership & governance Information system Budget for eye care delivery Procurement of consumables: Delay in procurement of consumables as it is a time consuming process; sometimes IOL powers are available in limited range Equipment - when purchased, selection criteria is for low cost and not the quality of equipment Maintenance: Difficulty in getting equipment repaired on time; no preventive maintenance process in place Poor quality of OT infrastructure Availability of equipment: Most often, required ophthalmic equipment/instruments not available at PHCs and CHCs to carry out ophthalmic screening and examination Organising eye camps and related work becomes a burden of the eye surgeonss Leadership: Lack of committed leadership at district level; in some instances, DPMs are non- eye surgeons and hence not involved in ophthalmic work Monitoring and accountability: There is no proactive monitoring process; roles not clear; no accountability at district level No need based plan in place Lack of coordination between NGOs and the government Reporting system is currently done manually Monthly reports are generated and sent to State officials; no feedback or discussion in place HMIS is not functioning properly Poor quality measurements?? Lack of evidence based decision making Budgeting for service delivery is done as per the discretion of SPO; do not have in place, a district's need based budget allocation Budget is not allocated for regularr maintenance Desired CSR at the district levels: R D Thulasiraj Objective of this session were (1) to estimate cataract surgical need & human resources requirements at the district level and (2) arrive at target CSR that each district would achieve within a specific time period. Mr. Thulasiraj facilitated this discussion engaging the participants to arrive at target CSR. He suggested that we look at CSR as a surrogate measure of eye care delivery and what that could be after taking into consideration key influencing factors. He also used a cataract estimation tool to lead this discussion. While the current national average CSR is around 5000 surgeries per million, the recommended national average CSR by the year 2020 is 9000 (a paper published by Dr. GVS Murthy, BJO, 2005) which would contribute to eliminating avoidable blindness. There is already a shift in practice with respect to when a patient needed to be operated for a cataract surgery unless in the initial years, patients are now operated much earlier due to changing lifestyle needs both in urban and rural areas. One big driver for cataract is the age group of 50+, which accounts to 16% of the total population in the country; and there could be some geographic variations with respect to onset 21

23 of cataract. Now with the two points of reference available current national averagee CSR and current data at the State and district levels, we could derive an ideal CSR as a target. One could validate this approach of with regard to nation s suggested average of 9000 by the year this rate has been achieved already by some States and still has not eliminated cataractt blindness. With increasing 50+ age group population, our existing systems are kind of reacting and not proactively tackling the problem. All these clearly indicate much higher national targett CSR than the recommended The survey nvolving 16 districts done in has estimated prevalence of blindness at 1 % for all age group and 8 % among 50+ population; with 62% blindness due of cataract. There need to be strategies to reach out to people who are not sensitized. Latest WHO guidelines should also be taken into consideration that has set out ambitious globall target of reduction of visual impairment by 50 percent in the year Mr. Thulasiraj also cautioned that we should never set targets that would turn out to be inadequate by itself; rather should be based on real need for services in the community rather than current capacity of eye care infrastructure. He quoted a previous experience way back in 1976, the target was somehow set as two cataract surgeries per 1000 population translating into a CSR of But the reality was that the target itself was inadequate and rate of blindness and need for cataract surgery kept mounting up, even though the targets were more than met. Districts Population % of Desired Desired No. of Current Current Cat Popln. Cataract Unmet CSR Oph. CSR Surgeries per Oph. 50 yrs Surgeries Lakhimpur Kabeerdham Kanker Palamu Dumka Rayagada Balasore Jhalawar Karauli Ref. Country: India 1,042, , ,421 1,936,319 1,321, ,959 2,317,419 1,411,129 1,458,248 1,210,193, % 15.70% 15.70% 14.80% 14.80% 17.70% 17.70% 14.30% 14.30% 16.00% 7,819 8,831 8,831 8,325 8,325 9,956 9,956 8,044 8,044 9,000 8,148 7,416 6,715 16,120 10,998 9,578 23,073 11,351 11,730 10,891, , ,462 1,567 2,031 2,455 1, , ,228 1,192 3,933 3,243 1,200 1, ,103,005 7,748 6,188 5,524 12,187 7,755 8,378 21,203 10,363 11,730 4,788, , , *Note: the current surgical performance is only indicative of surgeries performed by the district players and not necessarily by others actual performance might be slightly higher than this. Utilizati on % 11% 164% 79% 105% 144% 40% 36% 22% 58% The discussion was then related to setting up a desired cataract surgical rate for the districts and almost all the participants agreed to set current national average CSR of 5000 as the district target unanimously. Participants also highlighted few key areas of improvement that needs to be addressed - improving eye care infrastructure; involving multiple stakeholders within and beyond eye care (utilising the facilities of huge companies, etc.), addressing the basic issues such as availability of consumables, etc. 22

24 SESSION II: Case presentationn on few Intervention Models ( ) Surgical eye camps at District hospitals as short term intervention in the North East States of India - Mr. R D Thulasiraj & Dr. Dipankar Datta Mr. Thulasiraj shared briefly about the short-term approach adopted in the North East States of India to address the huge backlog of cataract. Most of these States faced multiple challenges that were difficult to address within a short span of time lack of adequate ophthalmologists and eyee care infrastructure coupled with difficulty in transportation facilities and other political challenges such as insurgency. As per this short term approach mooted by the NPCB, each State was twinned with large eye hospitalss such as Aravind Eye Hospital, Sankara Nethralaya, etc. to perform cataract surgeriess on a campaign mode for few years in order to address the problem at hand. Aravind Eye Hospital was requested to support Tripura State for a period of three years between 2005 and Dr. Dipankar Dattaa who led the surgical team from Aravind narrated Aravind s experience of working together with Tripura team headed by Dr. Sukumar Deb, the nodal officer at Indira Gandhi Memorial Hospital, Agartala. These camps were also conducted in conflict hit areas with the visiting teams given military convoy security during their travel. As a first step, Dr Datta made an initial visit to carry out an assessment of existing situation with respect to infrastructure, OT set up, support staff, local political climate, etc. to develop a plan of action and preparations to the onsite surgical visits which happened as follows: Phase I: 4 surgical days from 23 rd Dec, nd Jan 2006 Phase II: 4 surgical days from 30 th May 12 th June 2006 Phase III: 4 surgical days from 12 th Nov 24 th Nov 2006 He explained how a team of two doctors, a team of paramedic staff and a manager from Aravind doctors prepared for their initial visit. They carried with them surgical instrument sets; consumables, etc. from Madurai to Tripura in order to optimise the time and perform high volume surgeries this they felt would also help the local team in their preparations for the subsequent visits. During these four visits, Aravind team performed close to cataract surgeries. Local team was well prepared for the subsequent visits with all the required consumables and instruments. He also shared with the participants some unforgetful moments they had during these camps, including an incident of operating on a young girl who in turn brought her grandfather to the campsite for his surgery. This collaborative approach also helped the local team to explore ways of improving eye care delivery - invitations extended to different stakeholders to create eye care infrastructure through public private partnership being one such effort. 23

25 Creating access through Vision Centres in Tripura: Dr. Sukumar Deb, Nodal Officer, Vision Centres, IGM Hospital, Agartala (through video-conferencing from Agartala) Dr. Sukumar Deb shared with the participants, the experience of Tripura Vision Centree project - rationale for this initiative, how it was implemented, what the outcomes are and recent action points that are being planned to further enhance the services. Tripura with a population of 3 million plus 20 ophthalmologistss performed less than 1500 CSR for a long time due to inherent challenges faced - shortage of human resources with an impending crisis of 10+ ophthalmic surgeons retiring in next couple of years without any replacements available; difficulty in retaining paramedic staff who seeks employment in better towns; low awareness levels in the community about eye care, low priority to eye care; huge population residing in rural areas, lack of good transportation. etc. It was against this background, the Tripura Vision Centre project was conceived with setting up first Vision Centre at a place called, Melaghar in 2007 and 40 Vision Centres were established in a period of three years covering the entire State. These Vision Centres were modelled on Aravind s IT enabled Vision Centres. These centres are equipped with broadband connectivity, dedicated servers located at IGM hospital in Agartala and an un-interrupted power supply and back-up. Initial internet connectivity was through exclusive Wifi towers which were later replaced by highh speed broadband connectivity provided by the State. This initiative won many accolades for its innovativeness and impact on the community. This initiative has enabled patients seek eye care since the Vision Centres are easily accessible and close to 50% of these patients are women which was much lesser in screening eye camps and government hospitals. Each year, the number of patients (new patients) seen by these Vision Centres are on rise. Last year alone, a total of 74,000 outpatient visits were managed by these centres. From its inception to till date, about 7000 patients have undergonee cataract surgeries, referred by the centres. These Vision Centres were also able to diagnose other serious ailments that were not diagnosed otherwise. In order to increase the uptake of services, Dr. Sukumar and his team have come up with new initiatives that includes school screening programme, awareness creation measures, organising surgical eye camps at the districts, etc. Situation analysis in North East States: Dr. Praveen Vashist, RP Centre, AIIMS, New Delhi Dr. Praveen Vashist shared with the participants, about the outcomes of a VISION 2020 workshop that brought together States from the North East of India. The key objective of this workshop was to bring together all the stakeholderss and evolvee a three year target taking into consideration the current situation and gaps. The stakeholders included government departments/officials, INGOS, local NGOs and 20 hospitals. 24

26 Situation analysis ( ) across the States included blindnesss rates, current performance against the set targets, contribution by multiple players, availability of eye care infrastructure and human resources and budget allocation. Magnitude of blindness ranged between 0.77% in Tripura to 3.07% in Assam In terms of overall performance, when compared to the well performing States like Tamil Nadu and Gujarat, most of the States in North East had performed less than 15% except Assam and Mizoram 35% against the set targets (as low as 8%) achievement. In terms of contribution, 48% of surgeries are performed by government hospitals in the region and NGO hospitals contributing to 36% of the total surgeries Most of the States except Assam and Mizoram in the region did not have any corneas collected Most of the States in the region do not have adequate number of ophthalmologistss only two States Mizoram and Manipur have one ophthalmologist per lakh population which is still below national averagee In terms of infrastructure for eye care, availability does vary from State to State and the State of Assam has a maximum number of eye hospitals both government, NGOs and private and to some extent in Meghalaya and Mizoram Prior to fixing up new targets, key approach considered was to build the capacity of existing human resources (ophthalmologists and optometrists) through training and enhancing existing infrastructure & equipment; clarity on NPCB norms for imbursement as part of 12 th Five Year Plan and greater involvement of State Project Officer and INGOs. About nine eye hospitals had submitted a three years action plan. The combined targets thus set were: Cataract surgeries Refractivee errors Cornea collection Childhood blindness Diabetic retinopathy Glaucoma Baseline , , ,233 4,777 37,384 Target for Increase by 28,007 49% 576, % % 2, % 28, % 78, % Public private partnership: Kishoreganj experience: Prasanna Kumar, Director - Programme Operations, Sightsavers India Sightsavers India chose to work with Bihar once they devised a programme strategy of systems strengthening approach that involved working together and hence move away from the initial strategy of working only with NGO eye hospitals. Key reasons to select Bihar State for the proposed public-private partnership approach was dismal situation pertaining to eye care infrastructure and personnel. Kishanganj district in Bihar State was one of the poorest in the shortlisted districtss of the State. And in terms of eye care delivery, it was nil at the time of intervention with no ophthalmologist in the district. This experiment of partnershipp between multiple stakeholders government, INGO, NGO eye hospital to provide technical and onsite support for a specific period led to strengthening the system with the State administration ordering for a permanent full time ophthalmologist at the district hospital. 25

27 Initiative s results: An increase of outpatients from 80 per month in 2009 to 1100 per month in 2014 Increasee in cataractt surgeries from 0 in 2009 to 1000 in 2014 No PMOA in 2009 to 2 PMOAs in 2014 Government of Bihar creating a post for an ophthalmologist in Kishanganj in 2014 Creating access to eye care for the community who otherwise would have to Lessening the financial burden of the common man to undergo cataract surgery Key learnings from this experience: Strong political will & ownership at the government level is critical for initiation of such partnerships Considerable time required for advocacy for buy-in Regular review of progress allowing room for mid-course correction and strengthen project implementationn The major challenge faced in this initiative was the need to work at various levels of the government machinery to get a buy-in for instance, approval at the State level does not really translate into cooperation at the districtt level. Another challenge was about the difficulty in convincing the government to allocate resources to sustain such an effort expects perpetual support from INGOs/NGOs to deliver the programme. And finally, there is no interestt from the government side to scale up such an initiative where there is a huge need for eye care services. SESSION III: Enhancing services in the districtss ( ) Group work II Enhancing the services - What is possible with the existing resources? - What more is needed to achieve the desired CSR? Having unanimously agreed to a target CSR of 5000 for the respective districts, participants also had an opportunity to discuss various intervention approaches as a way to distil ideas from such experiences and apply that to their respective context. To do this, participants once again went back to the same working groups to come up with key strategies to enhance eye care delivery in two key dimensions what is possible to achieve with existing resources and what additional resources would the district need to achieve the target CSR. The groups built their strategies on the challenges thatt were already identifiedd during the group work I. The strategies weree again collated against the six health systems blocks and presented back to the larger audiencee on the day II for feedback and inputs. 26

28 DAY II Nov1, 2014: Interventionn plan and way forward Presentation of the consolidated strategies - Specific gaps/challenges - Enhancing eye care services Consolidated strategies were presented back to receive feedback and also inputs from the larger group as listed below: SHORT TERM STRATEGIES Service delivery Needs assessment for cataract services (need to look into local dynamics) Enhance the referral mechanism & monitor the same Involvement of ASHA workers/sub Centres/ PHC staff Involving private/ngos doctors to perform surgeries Conducting outreach with the support of ASHA workers & local NGOs Community awareness - Using ASHA workers & deploy standard digital posters or banners Ensure follow up services for all the operated patients and record the BCVA post- assistants to operatively HUMAN RESOURCES Ophthalmologists & ophthalmic be utilised only for ophthalmic work There should be some guidance with respect to annual surgical output per ophthalmologists Training and career development: upgrading the skills of ophthalmologists and ophthalmic assistants in latest techniques Involving the ophthalmic assistants at the base hospital in outreach work Promote team approach ophthalmologists to delegate administrative work and focus on clinical work - delegating administrative work 27 LONG TERM STRATEGIES Population based norms need to be developed infrastructure & resources requirements at each level incorporating accountable mechanisms Starting an additional cataract surgical facility through NGO involvement where facilities are limited Establishing Vision Centres in PHCs Equipping all PHCs and CHCs with basic ophthalmic equipment Awareness creation on eye care through mass media such as radio, television, FM radio and newsprint HR planning and a process should to ensure continuity of required number of eye doctors at the district level to achieve current national average of 5,000 in five years To put in practice a healthy ratio of ophthalmic assistants to an ophthalmologist Allocate number of PG seats for ophthalmology with a caveat to work at least for two years in the same State Ophthalmologists to be posted as eye surgeons and not as medical officers To post ophthalmic assistants in all the PHCs Improve quality of residency training

29 SHORT TERM STRATEGIES to NRHM district coordinators LONG TERM STRATEGIES programme Fostering PPP collaboration between public and NGO hospitals in programme management and clinical services Accreditation of ophthalmic assistants training programme Training non-operating ophthalmologists in surgery (understanding the details) EQUIPMENT, TECHNOLOGY AND SUPPLIES To carry out resource mapping and ensure adequate equipment and instruments are in Establish good AMC process for equipment maintenance place - OPD and OT Put in a place a process to ensure three years Renovation of operating theatres to the desired standards and maintain it warranty from the companies and also three years additional AMC for all the ophthalmic Setting up centralised equipment equipment and computers maintenance services at the district level to provide both preventive and breakdown Creating a cadre of biomedical engineer in the government sector maintenance Purchase policy can be redrafted to ensuree Source biomedical technicians locally and utilise their services? smooth process, procure reliable equipment's( both right quality & right price) come up with right specifications Come up with standard list of supplies, instruments and equipment (VISION 2020 India could take up this initiative, similar to IAPB standard list) LEADERSHIP & GOVERNANCE Bring in accountability amongst the staff for the outputs DPM should preferably be an ophthalmologist who will play a role of Put in place a monitoring system and measure the listed indicators for cataract surgeries and follow up advisor and not deal with day to day operations; for day to day activities, existing NRHM - DPM cadre can be utilized or a similar cadre can be introducedd INFORMATION SYSTEM Listing of the metrics to measure performance at district level Computerise the data recording and monitoring system; and ensuring accuracy of dataa Adopting MIS that is functional and provide adequate training in using the system Specific items: Take up the issue with IT department at the central level through CIPS Interim: VISION 2020 India to liaison with NPCB to accept the reports as done previously BUDGET FOR EYE CARE DELIVERY 28

30 SHORT TERM STRATEGIES LONG TERM STRATEGIES Budget allocation to be planned based on the yearly targets set out enabling the districts to achieve target CSR of Infrastructure and resource mapping - Primary and secondary levels and recommendations and allocate budget accordingly To have in place annual districtt planning Discussion points: There was an extensive discussion with participants sharing concerns and need for ntroducing many changes to the existing practices: Human resources: There should be a mechanism to address behavioural and non- cooperative staff the numbers of support staff numbers are less Surgical outputt per surgeon should be atleast 6000 surgeries per surgeons Should atleast aim for one ophthalmologist per 1,00,000 population to begin with while the recommended ratio by VISION is one ophthalmologist per 50,000. This should be ensured despite of factors such as inadequacy of surgeons and additional responsibilities held by DPMs and surgeons at the district level. Possibility of changingg this internally needs to be studied since this is highly prevalent in most of places. The district authorities/personnel should be sensitized on allowing the ophthalmologists doing ophthalmology work. When an ophthalmologist works as medical officer doing family planning, malaria control and others, his ophthalmic skills would get rusty over a period of time. Today, government does not place requirement advertisement specifically mentioning the need for a specialist, usually it is given as general medical practitioners. This should also change. Ophthalmologists should be posted as eye doctors wherever they are posted. Currently this is position is available only at district hospitals. And they should not be posted as medical officers at CSCs and PHCs NPCB in Chattishgarh has created a post, districtt manager but with less salaries retention might be an issue Some districts may have limited assistance from NPCB. Having a data entry operator could address many of the issues that are being raised. Should be able to tap funds available through other means to the district collector such as innovative programme assistance, SSA to cover salary costs for such additional personnel Ensure non-functional eye surgeons in performing surgeries Quality of training including short term training at the institutions like Aravind is very good and the doctors are very well trained to better surgery. And this is not the same across other teaching centres. A mechanism should be put in place to improve surgical skills of the doctors Increasing the availability of ophthalmologists: o In Assam and Tamil Nadu: It is mandatory for MBBS doctors to work in rural areas for five years and as an incentive, seats reserved for their in-service training in the speciality of their choice. It will be good to push ophthalmology for such MS 29

31 programs. And there should be a campaign inviting more doctors to join MS ophthalmology o All medical colleges currently do not offer MS ophthalmology. MCI should work with the medical colleges to offer good residency programme in ophthalmology There is a huge variation in salaries in under the National Health Mission across the States. There is a need to have an uniform structure and more clarity is also needed There are many NGOs having good experience with respect to managing programmes and such organisations should be involved in programme management as a way forward Mechanism of planning: o District level planning understanding the local situation and involving the local stakeholders (both govt. and private) should be in place. This will help to understand reasons for low performance and address those issues rather than implementing one plan across the districtss one size does not fit all. o Indian public healthh standards were developed in the year 2005 which was revised in the year ( nhm/nrhm/ /guidelines/indian-public-health- if there is anything that is missing with respect to eyee care at the district / sub-district / CSC level. For instance, VISION 2020 advocates one secondary eye care centre for standards.html). This also has assessment forms. One can review it and incorporate every 5,00,000 population and this should also be part of Indian public health standard. There is also a need to take into consideration, geographical context and ensure access to rural population. Similarly, at least one primary eye care centre should be made available for every 1,00,000 population (though one for 50,000 population is desirable). Thesee would enable the low performing districts and States to help to increase the outputs without compromising on quality in the long run. o It is important to bring accountability amongst the stakeholders if such standards have to really make a difference. For instance, the District Collector should ensure a minimumm number of facilities are operational as per the required standards. The Collector has to ensure infrastructure and resource needs for eye care is reflected in district action plan which in turn get incorporated into the State annual plan. o Not many are aware of Indian public health standards including the medical officers and this should change. o The first step is to do a micro level planning at the district levels involving concerned district officials, interested INGOs and NGOs such as Aravind, Dr. Shroff s, central government officials, eye care institutions like Aravind or Shroff s to develop an action plan immediately Equipment procurement and maintenance o Utilisation of ophthalmic equipment in most cases is less than 40%. Theree is a need to put in place mechanism of regular maintenance; also the involving local teams in the procurement of equipment. o There should be some amendment in the existing approach to give weightage to the quality of equipment and not just cost of the equipment. There can be a list of standardd list that can include some Indian manufacturers of quality ophthalmic equipment. 30

32 o Most districts (or even some of the States) do not have a bio-medical engineer. A proposal to the government should be made requesting for a bio-medical engineer. This might be a time consuming process. As a stop-gap approach, need to explore the option of engaging bio-medical engineers at a piece rate basis in the context of need. Budget and financial assistance: o Should explore a possibility of making special provisions by the MoH to support some of the short-terand these plans need not be uniform across the districts but based on the initiatives. And State plans are collective of all the district plans real needs of the districts in order to achieve a particular goal without flouting the norms. o Usually for the PIP meetings at the centre, States would be represented by a team and these usually get approved; during the next PIP meeting, we need to ensure officials from thesee nominated districts also accompany this visiting team to discuss the district planning approach and ensuree special package Session IV: (a) Effective Structure for Implementation & Monitoring (b) Next steps ( ) Intervention approach at district level - Plenary: Discussion on steps/support required for pilot - Dr. Bachani, Deputy Commissioner (NCD) Ministry of Health & Family Welfare, Govt. of India Structure to manage district programme Mr. R D Thulasiraj Dr. Bachani, gave a brief account on the approach undertakenn earlier with respect to district planning (version 1.0) in orderr give a better perspective on the efforts taken by the government and other stakeholders. He then discussed with the participants with respect to the intervention approach we need to consider as a way forward. Dr. Bachani was very much part of the implementation of World Bank project and subsequent scaling up of the programme across the country. He compared this remarkable eye care programme expansion between to the green revolution in the 1960s or Prof. Kurien s white revolution (milk procurement and disbursement) that has taken the form of Amul. These initiatives demonstrate the capacity of the country to roll out huge programmes. Initial pilot programme by NPCB with the support DANIDA was successful and government was planning to scale up and needed an outsider to understand and implement this programme in a newer way. That s how Dr. Bachani ended up in NPCB overseeing conceptualisation and implementation of eye care programme across the country. He summarised his experience as described below: 31

33 a. Previous programme was initially considered as a success. It was wonderful that the initial target of one million cataract surgeries were achieved and thereafter the annual targets were revised with five percent increase with higher targets for better performing States and lower targets for poorer low performing States. At that time the incidence of cataract was estimated to be 2.2 million per year. And about 40% of the patients operated were converted into aphakic blind because of the surgical technique which at that time was ICCE. Hence World Bank suggested a technical revolution as well: ICCE to ECCE. b. And this was a game changer - ICCE to ECCE with IOL. This meant new parameters to be considered. NGOs were good planners and organizers. There were also volunteers. The qualifying criteria for NGOs became different only those having fixed facilities for eye care weree considered. NGOs having a potential to set up an eye care facility were also identified and supported. c. For instance, at Chitrakoott in Madhyaa Pradesh, large eye camps were organized every year performing high volume surgeries by the volunteer doctors with so much commitment. And there are all the chances for infection performing surgeries in make-shift operating theatres. It was then a scheme for non-recurring assistance for NGOs was devised to support facility expansion in the NGO sector as well. Later Sightsavers and LCIF SightFirst took up similar path. Technological advancement and expansion of facilities were mooted as part of the programme. d. Introduced the concept of aphakic motivators which made a huge difference to the success of the programme in the early days. Focus was to perform a good cataract surgery on one patient from each village. This led to cascading effect each operated person bringing 10 other persons for cataract surgery e. The programme also included private institutions. In fact, most private practitioners confided that their practice went up after participating in this national programme. f. The idea of decentralised model came up while negotiating with the World Bank that led to setting up District Blindness Control Society (DBCS) to begin with in seven States and this was established without much resource. This programme was later scaled up across the country which enabled India to perform annually 6 million cataract surgeries in 2013 in comparison to 1.2 million surgeries two decades ago. It is important that lessons and practices from the past should be brought into Districtt Planning 2.0. National Health Assurance programme will be in place shortly and it is important to think throughh what aspects pertaining to eye care should be incorporated into this mission. And it is not the averages that should satisfy one self and not even the performance of the whole country rather focus should be on creating access to the population that still remains underserved. That s would help to achieve a meaningful universal coverage. Increased CSR can be achieved by just focusing on urban areas with little effort. But coverage to the remote centre is more important. We should not consider just the numbers, but wheree the numbers come from (reach) is also important. It should also take into consideration of sight restoration rate, complication range - i.e. quantity, quality and coverage (quality begets quantity). This approach is important while planning for the services as part of District Planning 2.0; a situation analysis should be carried out that would include the following parameters: 32

34 a. Socio economic factors and basic health indicators b. Facilities and the capacity government, NGOs and private c. Human resources doctors, nurses and ophthalmic assistants numbers and qualifications; understand local dynamics d. Performance - block wise cataract surgical rate; level of school eye screening e. Identifying constraints specific to the districts considering the both - supply side (issues relating to emergency duties, equipment related issues, absence of dedicatedd OT etc.) and demandd side Understand quality of services offered; outcomes; reasons for patients with mature cataract (unilateral/mature) not accessing eye care. Need to understand the reasons and that should be the priority. And issuess with respect to relationships, participation with NGOs, etc. need to be analysed. f. Partnershipss - Identify resources in the community who could be deployed to identify village level to enumerate patients who are bilateral blind Need to consider the resources required to carry out this situation analysis with the involvement of various stakeholders by forming teams. Potential time period for carrying out the situation analysis was also discussed everyone agreed to have this completed by Dec Dr. Bachani and Mr. Chakrapani suggested that we should go ahead with the planning process with a quick assessment in order to incorporate the plan in next financial year. One can review the existing assessment templates and customize it to district level situation analysis. Sightsavers have used formats based on health systems framework and this could be revised by a small team. Dr. Bachani suggested that plan should apply health systems blocks incorporating both short term (two years) as well as long term (five years) goals. Mr. Chakrapani suggested considering technology as a solution to address many challenges that are faced today - access, resources constraint, etc.; he also suggested exploring potential linkages with other programmes such as school health, geriatrics programme and others. For instance, recently Jharkhand government sanctioned funds bringing together IT and healthh departments for setting up 15 Vision Centres as a pilot. Team from Orissa informed that they would like to pursue the idea of setting up IT enabled Vision Centres in Orissa At this point, Mr. Thulasiraj steered the discussion towards the structure that should be put in place in order to implement the plan effectively. There needs to a higher level of coordination to make things happen at district level and State level. The group agreed that the district planning 2.0 should consider this approach: At district level: A two person committee representing government and NGO/private sector At State level: o One person to serve as anchor and work with the State leadership a person of highh caliber who could effectively liaison with the government and other stakeholders. One option is we consider from the pool of Prime Minister Rural Development Fellows (who were placed directly under the District Collectors during their fellowship to assist them in executing specific programmes o Constituting a core group consisting of State Programme Officer, INGO representatives, and a representative from a resource organization, etc. 33

35 At national level derive policy support thatt could be facilitated by CIPS for linking up with the senior officials Some concerns were also raised by the participants. Prasanna Kumar from Sightsavers shared the bureaucratic difficulties they had experienced while working through public private partnership approach. Mr. Thulasiraj alluded to it and stressed the importance of having a person to coordinate Hence it is crucial to have an anchor person in place who could coordinate and follow up so that planned activities are implemented and move in right direction. Budgetary requirements and stakeholders responsibilities: Who will do what? Plenary facilitated by Mr. Thulasiraj Mr. Thulasiraj along with Dr. Bachani and Mr. Chakrapani facilitated the discussions relating to important component, budgetary considerations for the district planning 2.0 approach. He said there is existing budget that is available for eye care programme and there is also a strong commitment from the government to improve the conditions. It was also discussed that a special package for these districts nominated for pilot should be specifically requested for. And Mr. Chakrapani also suggested that we need not to limit our thinking to NPCB alone but could look beyond that. Mr. Thulasiraj also said we need to also look for funding support for the planning process that includes situation analysis, micro-level district planning involving the stakeholders working in the district, etc. which needs to be supported through other sources in order to make it happen without any further delay; INGOs have already committed to make this happen. One of the doctors from Orissa raised an issue pertaining to the current funding support to perform cataract surgeries which is very low and difficult to manage Rs. 450/- per surgery for the district hospital and this would include procurement of IOLs and all the consumables and other direct expenditure incurred. And there is no proper transport facility available for bringing the patients from the interior parts to the district hospital. It was mentioned that in Rajasthan State, IOLs are supplied by the State and there is no issue of scarcity and they are performing surgeries with foldable IOLs. Whenever complications (cluster complication) occur, the government is not willing to take extend the support to the government surgeons. Participants felt thatt it is important such key issues are addressedd if the surgical volume needed to increase as discussed. Mr. Chakrapani suggested that thesee issues should be raised by the DPMs and SPOs with the NPCB officials and CIPS/INGOs would be glad to facilitate this discussion. It was agreed that a programme plan for the implementation phase needs to be developed taking into consideration all the components that needs to be supported for the pilot initiative (going beyond what is currently being supported by NPCB) with budget requirement and submit a proposal to the government and if required other potential sources too. It was also agreed that the pilot project proposal to be included to the State PIPs in February. Ms. Saraa committed CBM s funding support and work closely with some of the States for the planning phase. Similarly, Dr. Sandeep and Mr. Prasanna too committed their support and they requested inclusionn of Uttar Pradesh as part of this pilot since unmet need is so high in the 34

36 State. Mission for Vision was ready to extend its support in Rajasthan since they are already working in the State. It was suggested that the State programme officer and district programme managers should take the responsibility in bringing he planning phase in to action. The two day workshop, District Planning 2.0 was concluded after agreeing upon clear commitments by the stakeholders and also definitive next steps: Commitment of support by the INGO and the national NGOs to support specificc States State Assam INGO ORBIS/VISION 2020 India National NGO Sankaradeva Nethralaya, Assam Bihar Sightsavers India Netra Niramay Niketan, WB and Akand Jyoti Eye Hospital, Bihar? Chhattisgarh Jharkhand Orissa CBM/Sightsavers India CBM/Sightsavers India CBM/Sightsavers India MGM Eye Hospital, Chhattisgarh Netra Niramay Niketan, WB LV Prasad Eye Institute, Orissa?? Rajasthan Sightsavers India and Mission for Vision Dr. Shroff s Charity Eye Hospital, New Uttar Pradesh Sightsavers India and Delhi Mission for Vision LAICO along with CIPS would carry out overall coordination of the initiative with the support of senior officials, Dr. Bachani from the MoH and Dr. Praveen Vashist, RP Centre, AIIMS, New Delhi An brief introduction about the INGOs and National NGOs to the participating officials from different States for a better understanding about their work Commitment by the stakeholders to the next steps as listed below Activity By whom Submission of the report to the LAICO Ministry through CIPS Directive from the Ministry of Health Draft letter from LAICO and letters to the States (to include From the Ministry to States invitation to invite stakeholders) (through Dr. Bachani and CIPS ) Meeting at State level before carrying out situation analysis through VC/onsite discussion Finalise situation analysis template Sightsavers and LAICO Draft Engaging an anchor at the State level By CIPS By when 8th Nov 14 8 th Nov 15 th Nov 15 th Nov 30 th Nov Situation analysis & district level micro Core group planning (two year plans?) Approval of plans at district level Core group 31 st Dec th Jan 15 35

37 A report on workshop proceedings will be circulated to the government officials and the Secretaries of the respective States by CIPS and LAICO would share the report with the INGOs and the national NGOs. State Programme Officers to finalise and confirm the two districts to be included for pilot project; Sightsavers to consult with the State Programme Officer of Uttar Pradesh to nominate two districtss for the pilot; criteria for selection of the districts are: district population one million+; CSR less than 2000; availability of eye care infrastructure and some resources; it is desired to select atleast one district with NGO eye hospital presence Mr. Chakrapani, Mr. Thulasiraj, Dr. Bachani and few participants gave their concluding remarks. Mr. Chakrapani: He said it is important to integrate the policies and mission of National health mission into this planning framework and we cannot be working independently. It is important to keep up the momentum taking forward the action items after the workshop. He also highlighted the underlying commitmentt of the participants generating so much interaction during the workshop and he once again stressed on making use of technology as one of the solutions to addressing the problems. He also requested the participants to brief their respective nodal officers about the proceedings of the workshop and the resolutions passed in this workshop. He would give his personal commitment to visit every State along with the visiting teams and take efforts for the change to happen. Mr Bachani: He committed his support to (1) Follow up with the Health Secretary, MoH, Govt. of India to send out a letter to the concerned State Secretaries with respect to the resolutions of the workshop and follow up activities; (2) Closely work with this core group in order to make this pilot project a successful one. He felt there is a charisma of Dr. V that attracts him to visit Aravind and it is more of a self-rejuvenation; Dr. Bachani expressed that Dr. V would have been very happy to be present at this workshop since he contributed so much to eye care during this tenure in the government Mr. Thulasiraj: He requested VISION team to extend its support to these districts. He requested the officials from the States to ensure their support in implementing the action plan both during the planning phase and importantly during the pilot project implementation phase. He said the core group will remain in touch in the forthcoming weeks to keep up the momentum. Participants: A) State Programme Officers need to undertakee a lot of advocacy at the State level after their return to their offices. B) Jharkand: Since the State is gearing up for the election scheduledd in December, there might be difficulty; however we can try out best C) Chhattisgarh: Need to overcome all the hurdles to achieve the goal of eliminating needless blindness 36

38 Government Officials S.No Name Dr. Mohamad Iqbal Bharti Dr. Ravindra Kumar Meena Dr. Nijamuddin Dr. Tara Babu Soni Dr. Mangilal Garg Dr. Nidhi Pandey Dr. Sarita Kumeti Dr. Usha Vindhyaraj Dr. M. Jayalakshmi Dr. Sabyasachi Pattnaik Dr. Sujit Narayan Mahapatra Dr. M. Suresh Kumar Dr. Amrit Gogoi Dr. Partha Sarathi Gayan Dr. Shrawan Kumar Bordoloi Dr. Munindra Narayan Bordoloi Dr. Sumant Mishra Prof. Dr. Sheo Narayan Chaudhary Dr. Raj Mohan Dr. Rajesh Kumar Dr. Naresh Kumar Bhimsaria Dr. Saroj Singh Designation Jt. Director Health Services (NPCB) Assistant Professorr Medical Officer Associate Professor Professor Associate Professor Eye Specialist Eye Specialist Eye Specialist Eye Specialist Eye Specialist Joint Director Registrar Jt. DHS (Ophth) cum State Programme Officer Sr. Medical & Health Officer Director in Chief Director SPO Ophthalmologist Director Additional Chief Medical Officer Participants List Organization Directorate of Health Services & Family Welfare Jhalawar Medical College Medical and Health Department Government of Rajasthan Regional Institute of Ophthalmology Pt. J.N.M. Medical College, Raipur Pt. J.N.M. Medical College, Raipur Komal Dev Hospital, Kanker District Hospital, Kawardha Capital Hospital, Bhubaneswar District Hospital, Balasore District Hospital, Rayagada Health Services (H.Q) Regional Institute of Ophthalmology NPCB Lakhimpur Civil Hospital Health Services RIO, RIMS, Ranchi NPCB Sadar Hospital, Daltonganj Rajendra Nagar Hospital Office of the Civil Surgeon Place Rajasthan Rajasthan Rajasthan Rajasthan Chhattisgarh Chhattisgarh Chhattisgarh Chhattisgarh Odisha Odisha Odisha Odisha Assam Assam Assam Assam Jharkhand Jharkhand Jharkhand Jharkhand Bihar Bihar Id drravindrameena@gmail.com drnizamuddin006@gmail.com drtarababusoni@gmail.comm drgarg2012@gmail.com nidhi_ophth@rediffmail.comm vasudevkumeti20@gmail.com ushavindhyaraj123@gmail.com spatnaik64@yahoo.co.in mahapatradrsujit@rediffmail.com drskmedimi@yahoo.co.in dr.amritgogoi@gmail.com assam.npcb@gmail.com drmunindrabordoloi@gmail.com nrhmjharkhand3@gmail.com drs.n.chaudhary@gmail.comm npcbjharkhand@gmail.com nareshbhimsaria@gmail.com 37

39 INGOs Dr. Sara Varughese Dr. Phanindra Babu Nukella Regional Director Chief Executive Officer CBM VISION 2020: The Right to Sight INDIA Bangalore Haryana @vision2020india.org 25 Mr. Mrinal Ray Madhaw Program Manager VISION 2020: The Right to Sight INDIA Haryana Mr. Selvendran Chelliah National NGOs Mr. A. K. Arora 34 Mr. Mukesh Tiwary 35 Dr. Deepshikha Agrawal Resource Persons CIPS Mr. Rishi Raj Borah Mr. Jamal Siddiqui Dr. Sandeep Buttan Mr. Prasanna Kumar Mr. Vasant Shendye Dr. Asim Kumar Sil Dr. Damodar Bachani Dr. Praveen Vashist 38 Shri D. Chakrapani 39 Mr. Avik Chakraborty LAICO 40 Mr. R.D. Thulasiraj 41 Dr. Dipankar Datta 42 Ms. K.M. Sasipriya 43 Mr. Suresh Kumar Assistant Director Program ORBIS Sr. Program Manager ORBIS Programme Development Sightsavers Advisor Director Programme Sightsavers Operations Programme Officer Sightsavers Zonal Coordinator Mission for Vision Medical Director Netra Niramay Niketan Vivekananda Mission Ashram Chief Executive Officer Dr. Shroffs Charity Eye Hospital Sr.Administrator Akhand Jyoti Eye Hospital Director MGMM Eye Institute Deputy Commissioner (NCD) Ministry of Health & Family Welfare Government of India Additional Professor & Head Dr. R. P. Centre for Ophthalmic Sciences Director CIPS Project Research Associate CIPS Executive Director LAICO Chief Medical Officer Aravind Eye Hospital Senior Faculty LAICO Faculty LAICO Delhi Delhi New Delhi New Delhi Madhya Pradesh Chennai West Bengal Delhi Bihar Chhattisgarh New Delhi New Delhi Hyderabadd Hyderabadd Madurai Theni Madurai Madurai @sightsavers.org @gmail.com 38

40 Time Programme Resource Person Day 1 Friday, October 31, 2014 Gap analysis and what needs to be done to address the backlog WORKSHOP INAUGURATION - Invocation to the Almighty - Sanil Joseph - Welcome address Dr. R. D. Ravindran, Chairman, AECS and Mr. Chakrapani IAS, Director CIPS - Participants self-introductionn - Keynote addresss and workshop overview R.D. Thulasiraj, Executive Director, LAICO - AECS : Group photo & coffee Session I: Gap analysis and understanding unmet need Understanding the districts Presentationn on current situation from Six States K M Sasipriya Theni district model A case study presentation Dr. Dipankar Datta, Chief Medical Officer Aravind Theni Briefing about the group work I Group work I - Distilling the gaps at district level Each state as a group LAICO Faculty as a rapporteurr Desired cataract surgical rate at district levels R. D. Thulasiraj - Estimating cataract surgical need & HR requirements - Agreeing upon the target CSR for each district : Lunch Session II : Theme Case presentation on few Interventionn Models Creating access through Vision Centres in Tripura: Dr. Sukumar Deb, Nodal Officer, Vision Centres, IGM Hospital, Agartala - Public private partnership: Kishanganj experience: Prasanna Kumar, Sightsaverss India - Surgical eye camps as short term intervention in Northeast States: R D Thulasiraj - Situation analysiss in North East States: Dr. Praveen Vashist, RP Centre, AIIMS Briefing about the group work II : Tea Session III : Theme Enhancing services in the districts Group work II Enhancing the services Each State as a group - What is possible with the existing resources? LAICO Faculty as a rapporteurr - What more is needed to achieve the desired Performance by Dr. Jayanti S Ravi IAS, Labour Commissioner, Govt. of Gujarat 39

41 Venue: First Floor, Dr. GVERI building Special Dinner at LAICO Dining Hall Day 2 Saturday, November 1, 2014 Intervention plan and way forward Consolidated presentation of group work II : Tea K M Sasipriyaa Session IV : Theme Effective Structure for Implementationn & Monitoring Intervention approach at district level - Plenary: Discussion on steps/support required for pilot Implementation Dr. Bachani Structure to manage district programme Facilitated by Plenary R.D. Thulasiraj / Dr. Bachani : Lunch Budgetary requirements: Plenary - Stakeholders responsibilities: Who will do what Plenary Facilitated by R.D. Thulasiraj / Dr. Bachani Immediate next steps Valedictory function 16.30: Refreshments 40