“I looked after grandchildren and cooked, and my son and daughter-in-law worked in the farm,” 75- year-old Mangari Majhi from Rautahat said, her eyes roving aimlessly about the floor.
Her sockless, wrinkled feet pushed into worn out slippers, she crouched on a bench in the lobby of the Hetauda Community Eye Hospital, wearing a thin, dirty white sari, and a tattered brown shawl over it, as temperature dipped in the chilly evening of mid-December.
Cataracts developed in her eyes years ago, slowly clouding her vision deeper, until, two years ago, all that lay before her eyes was darkness. For the woman who had toiled all her life to make ends meet, loss of eyesight not only stole little delights of her old age, but struck harshly on her poverty-stricken family. Even for small personal routines, she became dependent on family members. Her daughter-in-law had to cut her work in the farm to attend to chores.
“I’ve become a burden on the family,” she said, as she waited for surgery to remove cataracts, completely unaware that she would be magically freed of these thoughts the next morning.
The sun shone warm and bright the next day, and what Majhi saw when the patches that covered her eyes after the surgery were taken off, allowing her to see for the first time in two years, was a clear, beautiful day.
Able to see again, her life was suddenly transformed.
She was one of 1,030 patients from poor, rural households who underwent cataract surgery to regain their eyesight, and with that, joy and prospects, in the free eye camp organized by the Hetauda Community Eye Hospital in mid-December. 65 percent of blindness in Nepal is caused by cataract, said a 2012 survey.
While this was a mass camp where the hospital reached out to a large number of people in a few days, tens of thousands of poor Nepalis have benefitted from the hospital’s services since its establishment in 2008. With exemplary outreach and in-hospital services, the hospital, a non-profit community-based institution that operates under Tilganga Institute of Opthalmology (TIO), has evolved into a model of community-driven hospital restoring sight to tens of thousands of neediest Nepalis. As the country enters the federal model with the hopes of equally distributing opportunities and services to all, the hospital provides a unique model of how healthcare can be taken to the poorest Nepalis in rural areas.
Reviving livelihood, mending relationships
When someone from a poor household, like Majhi, loses eyesight, its socio-economic consequence can be as devastating as severed livelihood and survival.
Shankar Paswan’s story is no different from hers. Hailing from a remote Badafar village in Bara, the 40-year-old, who lives at his sister’s house was consumed by the self-deprecating thought that at the prime of life, he was capable of doing nothing. He grappled with the thought of being a burden on his sister’s family that itself struggled financially.
The social impact of going blind in poor household is so intense that it often creates tension in relationships. Majhi’s inability to work inflicted financial burden on her family, souring relationship between her and her son and his wife. And, Paswan’s sister, who accompanied him to the camp, said without hesitation that he is a financial burden on their family. Both she and her husband are daily wage laborers.
“He just sits and eats,” she said. “We need to cut our working hours to care for him.”
Mass camps like this are among the hospital’s core programs targeting poor communities that otherwise have no means to access these services.
“We organize three to five such camps each year,” said Sudhir Bhadra Shrestha, hospital’s senior administrative officer. “Each camp restores sight of at least 300 people.”
The hospital’s medical assistants travel to poor, remote localities in the surrounding districts to organize screening camps for cataracts. They then transport the patients to the hospital where they get surgery, food and lodging all free of cost before they can leave after receiving post-operation counseling.
Devolution of healthcare
In a country where all infrastructures and facilities are centralized in Capital Kathmandu, the hospital takes quality eye care to Nepalis who are geographically, economically and socio-culturally distant from Kathmandu.
Thanks to the hospital, patients from Makwanpur and districts surrounding it have been spared tedious, expensive journey to Capital to access quality eye care.
“Taking my father to Kathmandu for surgery would cost me at least double the money and much more time than I’d spend coming here,” said 50-year-old Rukma Adhikari, who had brought his 90-year-old father for surgery. He had travelled from Nijgadh in Bara, an hour and a half away in bus from Hetauda.
The hospital is a successful example of constructive collaboration with larger institution to provide quality healthcare, an approach that smaller health institutions outside Kathmandu can emulate to maximize their quality and reach of their services to remote communities. The hospital’s two permanent surgeons get additional support from regular visits by three others from TIO. TIO’s technical team also conducts regular preventive maintenance works to ensure the machineries are in their optimum state at all times.
Such regular guidance and support is certainly one reason that has ensured hospital’s quality service. And this quality, and proximity are what have made this hospital the first choice for eye health for the people of Sarlahi, Bara, Parsa, Rautahat, Makwanpur, and parts of Chitwan, Sindhupalchowk, Lalitpur, Sindhuli and Dolakha.
From general eye check-ups to cataract and other surgeries, services patients get are identical in quality provided by TIO. Shrestha informed that they need to refer patients to Kathmandu for very rare and complex cases only.
He said 200 patients on average visit the hospital daily. Surgeries are carried out Mondays and Thursdays, and 4,000 patients get the surgeries annually.
The hospital also focuses equally on preventive measures. Trainings on eye care to health professionals, women health volunteers, teachers and traditional healers like dhami and jhankris as well as awareness campaigns are organized with the aim to take eye care education to the grassroots of deprived communities in the surrounding territories.
A community effort
The role of the local community is exemplary in achieving the successes that any visitor can see in the large volume of patients it serves, the hospital’s cleanliness, dedication of the staffs and the camp’s success. In other words, the hospital is a good case of community engagement, and a testimony that community ownership is essential for successful outcomes.
A team led by Dr. Sanduk Ruit, Nepal’s internationally acclaimed ophthalmologist and medical director at TIO, started organizing annual cataract surgery camps targeting the extremely remote villages of Makwanpur in collaboration with the Rotary Club of Hetauda in 1996. To their amazement, the number of patients and their enthusiasm at regaining eyesight were overwhelming.
“Dr Ruit shared that a permanent facility was indispensable to address problems of eye health in the region, and we couldn’t agree more,” said Siddhilal Shrestha, the hospital’s patron, who assisted in organizing the camp then as a Rotary member.
He remembers that a section of the local community opposed the idea, voicing that an eye hospital would not be financially viable in a small place like Hetauda. The Rotary Club members and other locals, who saw the value of a hospital there, convinced this group, bringing them on board the collective endeavor of building the hospital. And, despite all odds, the Rotary Club worked hard to acquire land, and the hospital was built with the support of TIO, its partner, the Himalayan Cataract Project, and other international organizations.
Once established, Hetauda locals have constantly engaged in the hospital affairs with a strong sense of ownership. Members of the Rotary Club of Hetauda closely work with the hospital in all its activities, including organizing eye camps, awareness activities and trainings. And there are locals who volunteer in hospital every week, like the members of the local Satya Sai community, who have continuously volunteered in the hospital every week since 2011.
A sustainable model
Although the Himalayan Cataract Project supported the hospital financially in its formative years, attaining a financially sustainable model was an important challenge.
Sudhir Shrestha said that over the years, the hospital has achieved a state self-sustenance of its internal costs from its services, while external financial support is needed for bigger outreach programs like free eye camps.
He admits that the cost for surgery in the hospital is a little more expensive than eye hospitals in Bharatpur and Birgunj. But the hospital justifies the cost, he says, because they use Fred Hollows intraocular lens manufactured by Nepal’s own TIO and that is both affordable and higher quality.
“Fees charged to patients who can pay are used to provide free treatment for poor patients,” he explained the model of cross subsidy.
The hospital’s success in reaching out to thousands of poor patients on minimum resources has, in fact, made it a model eye hospital that can be emulated in the resource-scarce developing world. Supported by a small administrative team, the hospital’s two full-time ophthalmologists and a handful of ophthalmic assistants operate on an average of 4,000 patients annually, and provide 75 OPD services. So successful has this hospital been that two hospitals – one in Bhaktapur and another in Thimpu, Bhutan – are being built following this model.
Community in the center
The hospital’s focus on reaching out to the poor and remote communities is what makes it a model best suited to distribute healthcare to Nepalis. This focus on the patients’ needs that have guided the hospital’s initiatives is what Dr. Ruit stressed during the eye camp.
“It’s all about putting patients at the center and providing the best care that they deserve,” he said after taking the patches off Paswan’s eyes, which he had operated the day before.
The delight in the eyes of the patients who regain their eyesight is the strongest testimony that patients’ needs are indeed in the heart of Hetauda Community Eye Hospital’s work, and that it is dedicated to opening up prospects for thousands of poor Nepalis like Majhi and Paswan.
Majhi was not only happy that she would see her grandchildren, but that she could also help her son and daughter-in-law in the field.
Paswan, who seemed puzzled for a moment when his patches came off, needed some prodding from hospital staff to smile. But once he smiled, the joy of seeing again became clearly reflected in his face, and he carried that with him to home.
“I’ll work now,” he said as his sister prepared to put medication on his eyes after the post-operation counseling.
“And marriage?” I asked, “What have you thought about that?”
And, for the first time in two days since I saw him, Paswan laughed, and said, “If I find someone who gets along with me, of course I will.”