India is considered to be one of the hubs of cheap but quality healthcare. This is quite ironic when you consider the decrepit state of government health services that most Indians have to rely upon and the minuscule budget allocation towards it. Fortunately enough, this is where private charity hospitals have been stepping in, especially in eye care. One of the most well-known ones is Dr Shroff’s Charity Eye Hospital (SCEH) in New Delhi. It is currently the only eye and ENT institute in North India with NABH (National Accreditation Board of Hospitals) accreditation.

SCEH’s stated mission is ‘to make a lasting impact on the eradication of blindness and deafness in India by providing quality care to all sections of the society’, and its vision is ‘to be the best tertiary eye care and ENT care institution in North India providing quality services to all economic sections of the society.’ Its main focus areas are comprehensive eye and ENT care, quality consciousness, community impact, research, publication, training, and transparency.

Established in 1914 and founded by Dr SP Shroff, SCEH operates out of various locations in Delhi, Haryana, Rajasthan and Uttar Pradesh. Its core mandate is to provide quality eye and ENT care to people from all sections of society, irrespective of income. SCEH annually sees over 2 million patients in over 18 locations including in economically backward communities in Alwar in Rajasthan, Faridabad, Gurugram and Rewari districts in Haryana, and Bagpat in Uttar Pradesh.

About 50 per cent of all surgeries done in a year are either free or highly subsidised. This is done through community-outreach operations (responsible for identifying and facilitating this) and the delivery of projects that are developed by the clinical departments. The operating principle is to partner with communities to create awareness and develop self-sustainable eye-care models focusing on community-based rehabilitation.

The institute operates on a cross-subsidy principle. In 1996, dwindling support and donations resulted in heavy deficits for the hospital. The board then decided to adopt the cross-subsidy model as per which commercial services would be provided so as to meet the operational and funding needs for the free services given to the poor and the underprivileged. Essentially, fees from those patients who can pay are used to cover the costs for those who can’t. This cross-subsidisation model, pioneered in India, is popular across eye-care institutes.

Within five years, SCEH became a leader in this domain in North India. Now with this funding model and the constant support from patrons, SCEH continues to provide about 60 per cent of its services free of cost to those who can’t access or afford it.

What SCEH does
SCEH provides the following services:

  • Medical & allied services: Eye care includes services such as cataract and corneal surgeries, glaucoma remedies, and lasik. ENT services provided are comprehensive ENT care, endoscopic surgeries, cochlear implants, a ‘Sleep and Snoring Clinic’ to address the needs of sleep apnea patients, a hearing-resource centre, etc.
    The institute also focuses on low vision and rehabilitation. A Low Vision Aids Clinic, also known as Vision Enhancement Clinic, helps children with low vision through a comprehensive evaluation that allows for accurate prescription of optical and non-optical aids. These clinics provide a comprehensive range of low-vision enhancement services, such as assessment, prescription and demonstration. Then there’s the Vision Therapy Clinic that treats children with amblyopia, accommodative problems, reading difficulty, oculomotor problems, etc., through various exercises. The Prism Clinic examines patients with complaints of chronic diplopia (double vision).

SCEH also has an eye bank that was started in 2004. Other ancillary services include ocular microbiology and prosthesis, audiology and speech therapy, and anaesthesia.

  • Education, research, and volunteering: This involves active research, education, and sharing of knowledge and skills in technology and services. Education opportunities are offered in ophthalmology, optometry, para-optometry, ophthalmic nursing, etc. Continuing medical education by experts is offered to the SCEH community, while many of their research projects have been published in several journals.

A key factor in achieving its mission is the creation of highly skilled medical and non-medical personnel across all functions of eye care. Training is divided into medical and non-medical streams. The medical stream works under the Medical Education Department and oversees the development of curriculum and offers various short- and long-term courses for doctors and optometrists that attract both foreign and Indian candidates. Leading eye-care organisations and the government have opted to train their personnel at SCEH.

The organisation offers customised programmes to candidates, including scientists and medical students, to study and volunteer at their locations. Till 2013–14, around 700 national and 65 international students were trained. SCEH has also developed a two-year programme where trainee surgeons spend at least 15 months in semi-urban secondary centres. The institute has been recognised as a Scientific and Industrials Research Organization (SIRO) by the Department of Scientific and Industrial Research (DSIR).

  • Community work and projects: The SCEH network reaches out to poor and disadvantaged communities through its ‘vision centres’. These are regular clinics at permanent locations, not temporary camps, often collaborating with NGOs on multiple projects – examples include Project Prakash, a Diabetic Retinopathy project, Ujagar project, and Seeing is Believing project.

In terms of outreach strategies, SCEH builds expertise and capacities in communities to deliver eye care. This is done by training community resources in paramedical functions (there are vision technician and ophthalmic assistant courses) and building infrastructure and technology, among other things, so that the centre is able to take referrals from the vision centres and send further referrals to a tertiary centre.

Community impact of its work is measured on these parameters: equity in service delivery, cataract surgery coverage and cataract surgery rate, gender equity, comprehensiveness of eye care, visual outcomes, etc.

Other services and key numbers
Super-speciality services at secondary hospitals are provided through weekly visits of specialists from the tertiary unit and through tele-ophthalmology at some of its centres.

Vision centres have been established across the districts of Alwar, Mewat and Saharanpur, and certain urban slums of Delhi to deliver quality primary eye-care services to the underserved populace. These centres are run by vision technicians who hail from local communities and have been trained in primary eye care at the institute for 18 months.

Those in need of eye surgery are identified through the vision centres and traditional camps. Apart from regular cataract surgeries, all kinds of speciality surgeries and services are offered as well. In 2010, community operations were directly responsible for the identification, counselling and transportation of 85 per cent of the total 5,383 free surgeries, amounting to 4,576 surgeries. That’s almost 15 surgeries per day for 300 working days.

A good example of its many training programmes is the Certified Ophthalmic Personnel (COP), which is dedicated to creating allied health resources. A pilot project of training young women as eye-care paramedics, from rural areas and urban slums, was initiated in the year 2014. Over 400 participants were recruited, resulting in the expansion of eye-care services, improved quality outcomes, better patient satisfaction, and improved efficiency. This programme is now working towards creating critical human resources for various functions within the organisation’s network.

In the last two years, the ratio of paid surgeries to free surgeries was 58 and 51 per cent respectively. The board mandate is to have a minimum of 50 per cent free surgeries.

As per the 2013–14 annual report, the SCEH network – across Delhi, Alwar, Gurugram, Saharanpur, Meerut and Lakhimpur Kheri – saw 245,357 patients with 17,584 sight and hearing restoring surgeries performed. Out of this, 9,681 surgeries were free or highly subsidised, and 4,258 of all surgeries were sub-speciality cases or of tertiary specialisation. On the eye-banking front, 673 corneal tissues were retrieved by the eye-banking team through HCRP (hospital-based cornea-retrieval programme) and direct tissue donations.

Funding comes from three sources: patient revenue, reimbursements from the government under the national programme for control of blindness for free (non-paying) surgeries, and projects with NGOs and corporate CSR programmes. Around 90 per cent of the funds are generated by revenues from patients, as per the organisation.

As per the 2017–18 FCRA report, of the total income of Rs 3.84 crore, Rs 3.69 crore was from grants-in-aid. Donations amounted to Rs 1.3 lakh. In 2013–14, the total amount from hospital receipts was Rs 19 crore. Last December (2018), SCEH was one of the three private hospitals in Delhi that enrolled for the government’s flagship health insurance scheme Ayushman Bharat.

Long-term goals
In terms of its long-term strategic goals, SCEH’s community-outreach operation is committed to developing vision centres across Alwar, Mewat, Saharanpur, and outlying areas of Delhi to ensure quality primary eye-care delivery, as well as creating awareness about eye-care issues by working with various communities. It will also implement field activities of projects developed by clinical departments and provide capacity-building inputs to its partners.

SCEH is currently engaged in developing a long-term strategic plan. Some of the details are given here.

Tertiary level

  • Build a Centre of Excellence in Delhi to increase capacity in order to handle more cases, including complex ones.
  • Enhance capacity to train medical resources, conduct more research, and further advocacy.
  • Expand collaborations with organisations, including in foreign countries (SCEH is already working with LV Prasad Eye Institute, Aravind Eye Care System, Massachusetts Institute of Technology, University of Wisconsin, among others).
  • Build up capability of the quality resource centre to provide hospital quality-systems consultancy (the centre has already worked in Bangladesh, Vietnam and Indonesia).
  • Set up a training school to train approximately 50 women a year at one of its current locations.

Secondary level

  • Enhance the output capacity of the 4 secondary centres to more than 8,000 surgeries per annum per centre in the next 3 years (current capacity is about 4,000).
  • Further geographic expansion for locations in Uttar Pradesh.

Primary level

  • Set up more vision centres.
  • Adopt administrative blocks in its operational areas and make them avoidable blindness-free and set up a sustainable system to ensure they remain so.

As SCEH explains, institutional eye care is like a pyramid – for the tertiary centre to prosper and grow, it is necessary that the primary and secondary bases work efficiently and develop adequately. Otherwise the tertiary centre will get clogged with primary and secondary level of cases, leading to deterioration in quality and bad customer experience.

CB view
There’s little doubt that SCEH is fulfilling its mission of providing quality eye care to those who do not have the economic means of accessing this critical health service. Through the proven cross-subsidy model, the institute is socialising a common good that is healthcare. While operating a charity hospital of this size is no easy task, deeper analysis of its operations, efficiency levels and other measures should be considered to become as financially independent as possible.

Data is a sticking point – right now the latest annual report is for 2013–14, though the FCRA reports are more up-to-date. However, the latter can only provide financial data, not operations or key performance metrics. Voluntarily sharing such information implies that the institute is open and transparent about its practices and workings and has no compunction holding itself accountable—something only done by the best organisations in the world. It will also be interesting to see if SCEH takes up projects on sustainability within its many centres. After all, climate change and environment issues are everyone’s problems; they should not be a cause for concern for only large companies.

That private hospitals like SCEH have to step in to deliver quality service to the country’s poor and needy, instead of merely supplementing the state’s healthcare infrastructure and services, should be a wake-up call to the government to make health a national priority and dedicate resources commensurate with the scale of this basic human right. But with elected representatives obsessed with wasting money on vanity projects such as gigantic statues, there is hardly any reason to be optimistic. Till the time we get our priorities right, institutes like SCEH will continue to thankfully bridge the gap between demand and supply.