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Year : 2020  |  Volume : 68  |  Issue : 2  |  Page : 279-280

Community ophthalmology - Can excellence, efficiency, and equity co-exist?

Editor, Indian Journal of Ophthalmology, Centre for Sight, Road No 2, Banjara Hills, Hyderabad - 500 034, Telangana, India

Date of Web Publication20-Jan-2020

Correspondence Address:
Dr. Santosh G Honavar
ditor, Indian Journal of Ophthalmology, Centre for Sight, Road No 2, Banjara Hills, Hyderabad - 500 034, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_84_20

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How to cite this article:
Honavar SG. Community ophthalmology - Can excellence, efficiency, and equity co-exist?. Indian J Ophthalmol 2020;68:279-80

How to cite this URL:
Honavar SG. Community ophthalmology - Can excellence, efficiency, and equity co-exist?. Indian J Ophthalmol [serial online] 2020 [cited 2022 Dec 3];68:279-80. Available from: https://www.ijo.in/text.asp?2020/68/2/279/276164

An ideal healthcare system combines equity with quality (or excellence). Healthcare efficiency, in terms of optimal utilization of infrastructure and time, is a moral responsibility in a resource-starved country. The three E's Excellence, Efficiency and Equity, thus have high ethical relevance in the practice of community-based ophthalmology. Essentially, it translates to the delivery of the highest possible quality of eye care to the spectrum of the society with optimal distributive justice and efficiency.

Equity, however, as expressed elegantly by Rick Riodian in his book The Red Pyramid, does not mean that everyone gets the same, it means everyone gets what they need. In a community ophthalmology situation, using expensive multifocal intraocular lens even in patients who may not have any visual need for it at all, or performing a high-risk penetrating keratoplasty in a patient who has 6/6 vision in the other eye and can function normally, or performing a complex vitreoretinal procedure in a similar situation, do not exemplify equity. Several interventions that are considered “effective” may not be exactly “cost-effective”. Cost per disability-adjusted life year may be more valid criteria to decide on effective intervention for a community.

Performing hundreds of cataract surgeries in a camp in a very short period with minimal utilization of resources, but with a high rate of complications or poor visual outcome does not meet the norm of excellence. Quality standards for cataract surgery seem lax – the World Health Organization (WHO) recommends that 80% of operated patients should have uncorrected visual acuity of 6/18 or better in the operated eye.[1] Would any of us settle for such an outcome for ourselves? Then why do we accept this quality norm for our communities? Thus, a perspectival understanding of and a balance between excellence, efficiency and equity are very critical in the planning and delivery of community-based eye care services.

The Committee on Quality of Health Care in America in its report “Crossing the Quality Chasm” recommends 6 attributes for an ideal healthcare system in the 21st century: “1. Safe: avoiding injuries to patients from the care that is intended to help them; 2. Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively); 3. Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions; 4. Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care; 5. Efficient avoiding waste, including waste of equipment, supplies, ideas, and energy; and 6. Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status.”[2] These attributes should form the backbone of all community-based eye care interventions.

There are several models of community eye care delivery in India today – general eye screening camps, fixed primary eye care facilities (vision centers), mobile primary eye care, risk-stratified screening (school eye examination, diabetic retinopathy screening), teleophthalmology-based screening and diagnosis, cataract surgical camps in make-shift operating facilities, base-hospital approach, hub-and-spoke model, etc. Each of these come with their own advantages and shortcomings. There are several excellent and time-tested models in India which embody the essence of the vital three 'E's'. Invited editorials in this Community Ophthalmology Special Issue of the Indian Journal of Ophthalmology describe some of these successful models.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12]

I believe that our wise opinion leaders and health care policymakers will distill in the concepts of excellence, efficiency and equity while formulating community eye care delivery norms beyond 2020, and help us cross the quality chasm.

  References Top

World Health Organization. Informal Consultation on Analysis of Blindness Prevention Outcomes. Geneva, Switzerland: WHO; 1988:/PBL/98.68.  Back to cited text no. 1
Committee on Quality Health Care in America, Institute of Medicine. Crossing The Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.  Back to cited text no. 2
Rao GN. Universal health care: Can Indian ophthalmologist community set an example? Indian J Ophthalmol 2020;68:281-4.  Back to cited text no. 3
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Namperumalsamy P. Maintaining quality in community eye care – The Aravind model. Indian J Ophthalmol 2020;68:285-7.  Back to cited text no. 4
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Badrinath SS, Narayanan A, Hussaindeen JR, Surendran TS. The Sankara Nethralaya Community model - Technology and evidence based comprehensive quality eye care equally to all. Indian J Ophthalmol 2020;68:288-90.  Back to cited text no. 5
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Kumar A, Vashist P. Indian community eye care in 2020: Achievements and challenges. Indian J Ophthalmol 2020;68:291-3.  Back to cited text no. 6
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Jain BK, Jain E, Kuyyadiyil S, Sen A, Sood D, Bajaj A. High volume and high quality eye care - Bridging the paradox. A unique rural based approach – The Chitrakoot model. Indian J Ophthalmol 2020;68:294-8.  Back to cited text no. 7
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Joshi MM. The MM Joshi model of community eye care- Reaching the unreached. Indian J Ophthalmol 2020;68:299-300.  Back to cited text no. 8
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Shetty B, Shetty R, Jayadev C, Vinekar A. Taking subspecialty pediatric eye care to the community – The Narayana Nethralaya model. Indian J Ophthalmol 2020;68:301-2.  Back to cited text no. 9
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Bhadauria M. Community eye care - The Sitapur model. Indian J Ophthalmol 2020;68:303-4.  Back to cited text no. 10
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Raman R, Krishnan R, Ramasamy K, Natarajan S. Diabetic retinopathy: A right time to intervene. Indian J Ophthalmol 2020;68:305-6.  Back to cited text no. 11
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Samanta SK. Community based eye care in India – Reconciling quality and quantity – The ACOIN prescription. Indian J Ophthalmol 2020;68:307-8.  Back to cited text no. 12
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