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Impact of systematic capacity building on cataract surgical service development in 25 hospitals Judson, Katherine; Courtright, Paul; Ravilla, Thulsiraj; Khanna, Rohit; Bassett, Ken Jun 19, 2017

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RESEARCH ARTICLE Open AccessImpact of systematic capacity building oncataract surgical service development in 25hospitalsKatherine Judson1* , Paul Courtright2, Thulsiraj Ravilla3, Rohit Khanna4 and Ken Bassett5AbstractBackground: This study measured the effectiveness and cost of a capacity building intervention in 25 eye hospitalsin South Asia, East Africa and Latin America over 4 years. The intervention involved eye care non-governmentalorganizations or high-performing eye hospitals acting as “mentors” to underperforming eye hospitals- “mentees”in 10 countries. Intervention activities included systematic planning and support for training and key equipmentpurchases as well as hospital-specific mentoring which focused on strengthening leadership, increasing the volumeand equity of community outreach, improving surgical quality and volume, strengthening organizational and financialmanagement and streamlining operational processes.Methods: This is a before and after observational study of the impact of this multi-dimensional process on hospitaland individual productivity and financial sustainability after 4 years. Mentee hospitals reported data monthly using astandardized template. Key indicators included cataract surgery volume, cataract operations per surgeon, the proportionof direct paying cataract surgical patients, intervention program costs per additional surgery and cost per mentor.Results: By the end of the study period, the hospitals experienced a 69% average increase (range: −63% to 690%)in cataract surgical volume over baseline with 12 hospitals showing increases over 100%. Twenty-three hospitalsexperienced a 59% average increase in the number of cataract surgeries per surgeon with 10 hospitals showingincreases over 100%. The proportion of paying patients increased in 8 of the 14 hospitals reporting this data. Theaverage mentoring cost per additional surgery for these 25 hospitals was $5.39. An average of $36,489.99 wasspent per mentor per year to support their work with mentees.Conclusions: The intervention resulted in proportionally similar increases in cataract surgical volume and productivityacross diverse settings in three distinct geographic regions. Its wide applicability and moderate cost make it an attractivemeans to rapidly and substantially increase eye care services to meet VISION2020 goals.Keywords: Capacity building, Ophthalmology, Africa, South Asia, Latin AmericaBackgroundThe number of cataract operations in the developingworld is far below the level required to take care of newand existing cases [1]. Using the increased volume andhigh quality approaches initially developed by AravindEye Care System (AECS) and LV Prasad Eye Institute(LVPEI) in India, ophthalmologists, along with a well-managed team, can double or triple their cataract surgi-cal volume [2]. Simply demonstrating or describing howto improve productivity by underperforming institutionsis seldom enough to stimulate and maintain change [3].An engaged process with regionally available coachingand training, termed herein ‘capacity building’ has beenused by 6 mentoring institutions to accelerate change ineye care services in an effort to meet population needand start on a pathway to organizational and financialsustainability [4].Capacity building is defined hereinafter as an interactiveprocess whereby an established institution is invited toutilize its staff to engage with and support the internaldevelopment of other institutions with which it usually* Correspondence: katie.judson@gmail.com1Seva Foundation, 1786 5th St, Berkeley, CA 94710, USAFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Judson et al. BMC Ophthalmology  (2017) 17:96 DOI 10.1186/s12886-017-0492-5has no financial connection. It is a structured, plannedand often altruistic effort to help other institutions wishingto grow and improve productivity and efficiency. Capacitybuilding therefore is distinct from capacity ‘development’which is an internal process not involving explicit externalinvolvement [5].The institutions providing capacity building aretermed “mentors” and hospitals undergoing the capacitybuilding are termed “mentees”.1 In this study 25 menteehospitals located in Asia (16), Africa (7), and LatinAmerica (2), were supported by mentor institutions: LVPrasad Eye Institute (LVPEI), Aravind Eye Care System(AECS), Sadguru Netra Chikitalaya (SNC), VivekanandaMission Ashram Netra Niramay Niketan (VMANNN) inAsia, Kilimanjaro Centre for Community Ophthalmol-ogy (KCCO) in Africa and Visualiza Clinica de Ojos inLatin America. For the purpose of this study all of thementee hospitals managed by the mentors that hadundergone four or more years of the capacity buildingprocess by 2014 were included.The mentees initiated the capacity building process ina variety of ways. Some mentees had long-standing rela-tionships with mentor institutions through their leadersor through ophthalmology training programs; somementees approached the mentor institution and re-quested the intervention, while others were recom-mended by outside governmental and non-governmentalorganizations.Several key factors typically influenced a mentor’s de-cision whether or not to engage with a mentee: [a] lead-ership capacity or potential [b] willingness/desire tochange, [c] willingness by the hospital to establish a sep-arate bank account for the eye unit, [d] some infrastruc-ture/personnel in place. Both private and governmenthospitals were included.This study measures the cost and impact of the cap-acity building intervention on cataract surgical volume,surgical productivity and demand for services.MethodsFor this research we had three primary questions:1. Did the capacity building intervention result in anincrease in the number of cataract surgical operationsper year?a) by site, compared to baseline averages and provincialor national growth rates?b) by ophthalmologist compared to baseline?2) Does the capacity building intervention result in anincrease in the total number and proportion of payingcataract surgical patients (‘direct’ walk-in patients) com-pared to prior years?3) What are the capacity building costs to increasecataract surgical volume by region?DataMonthly monitoring of surgical activity and program per-formance at the hospital level begins after the vision build-ing workshop in most settings. Hospitals report theirmonthly data to the mentor institution. The monthly datasheet collects four main indicators: patient and surgical vol-ume, cataract surgical outcome, hospital financial viability,and human resources utilized.Mentee reported data were compiled annually. Base-line year was the calendar year prior to active engage-ment in the capacity building program with the needsassessment visit to the mentee hospital.National and state cataract surgical rate data wereobtained from a variety of sources [6–10]. For almost allcountries, data were only available for the four-year timeperiod 2010 to 2013. State-level data provided for Indiais the 2010–2014 timeframe. Some of the African andIndian interventions began in 2009, however the 2010–2014 comparison data were used. All 25 mentee hospitalswere eligible for inclusion of which 23 were included. 2were not included as CSR (cataract surgical rate) data wasnot available during the correct time period for menteesin Bangladesh and China (Sichuan Province).Key program indicators1. Cataract surgical volume: used as an indicator foroverall program growth, reflecting the number ofoutreach and outpatients examined, their interactionswith program staff, and that underwent surgery2. Cataract operations per surgeon: used as an indicatorof program efficiency in managing patient flow,operating room procedures, and ancillary staff3. Percentage of direct (walk-in), cataract surgicalpatients who pay for surgery: used to indicate programacceptance to patients with discretionary income, aswell as a proxy for quality and financial sustainability.Two additional indicators were:1. T1. the total amount of external funding provideddivided by the cumulative amount of additionalsurgeries performed over the 4 year study2. The total amount of external funding provided toeach mentor divided by the total additional surgeriesperformed by it’s mentees over the 4 year study.InterventionThe capacity building intervention was not strictly pre-scribed, nevertheless, all interactions included 4 corecomponents:1) Needs assessment visitJudson et al. BMC Ophthalmology  (2017) 17:96 Page 2 of 82) Vision building workshop resulting in a strategic planand an action plan3) Ongoing consultation on improvement of services andadministration including: training to meet priorityneeds, support for outreach, and advice on strategicpurchases (equipment) and renovations4) Monitoring of key performance indicators (data).Needs assessment visitThe capacity building process begins with the mentorinstitution sending a team (usually made up of at leastone ophthalmologist and management staff) for a multi-dayvisit to the mentee institution designed to understand thecurrent situation and assess the potential for change. Thisvisit includes review of current service delivery and staffing,engagement with community and other stakeholders,organizational and financial systems and observation ofclinical practices and outreach. A senior ophthalmologistfrom the mentor institution spends time with and carefullyevaluates the surgical skills of the ophthalmologists in thementee institutions.The visit usually ends with a review meeting attendedby representatives from all levels of clinical and non-clinical staff of the mentee hospital. The goal is to helpthe staff recognize their growth potential, define limitingissues (bottlenecks) and plan solutions involving cooper-ation and organizational change.Planning and vision building workshopPlanning and Vision Building workshops take a varietyof formats but share a common goal: facilitating thementee institution staff to identify what needs to happen,take ownership of the transformation process and to settargets and create a plan of action that will allow thehospital to reach their targets. Activities in the changeprocess include defining new service delivery models, es-tablishing organizational and financial sustainabilitytargets, and introducing new processes into the hospitaland outreach systems. Staff from multiple departments ofthe mentee hospital are often encouraged to attend thevision building workshop so responsibility for the goals isshared among the entire hospital.Ongoing consultation on improvement of services andadministrationOver the next several years, mentors interact with menteesthrough annual on-site visits and via email and telephone.The ongoing dialogue typically deals with service deliveryissues and improving organizational and financialsustainability through a structured fee system. Mostmentors will on occasion bring mentees together to dealwith common issues and review key performance indicators.The ongoing communications and follow-up visits usuallyinvolve the same mentor personnel in order to maintaincontinuity and built relationships.Capacity building involves additional training of variousclinical and non-clinical eye care personnel. Initial trainingoften focuses on improving cataract surgical skills, eye unitmanagement and hospital administration and developingoutreach program expertise. As the capacity building processmatures, in some settings clinical training expands toinclude subspecialty services and administrative trainingexpands to include auxiliary services such as librariantraining and human resources and financial planning.An integral part of the mentoring process is to supportsome form of regular outreach in order to increase accessto and use of eye care services in the catchment area ofthe mentee institution In some cases (generally not inAfrica), outreach activities are supported by a small seedgrant until the hospital is able to fund it themselvesthrough new revenue generated through the capacitybuilding process. At times, support for an eye unit manageris required.If necessary, plans for hospital equipment purchase andinfrastructure improvements are also developed during theaction planning process and executed during the activephase of mentoring. Mentor institutions may provide fund-ing to purchase equipment, and if necessary will work withmentees to secure funding through outside funders.Monitoring of key performance indicators (KPIs)Each mentee is required to submit hospital-level datato their mentor on a monthly basis. These metrics weredeveloped to determine whether or not the change processwas having a positive effect on different hospital processes.ResultsAll 25 mentee hospitals provided data on cataract surgicalvolume (CSV). The baseline average CSV per year perhospital was 3528 (range: 200–17,897 median: 1432) withsubstantial variation by geographic region (Table 1). Theaverage CSV increased during years 2 through 4 reaching69% above baseline by year 4, with the relative increasegreatest in Africa (164%) and Latin America (136%) com-pared with Asia (66%).Table 1 Cataract surgical volume (CSV) per year by geographicregionGeographic region Baseline CSV Year 4 CSV CSVchangeoverbaseline(%)(N hospitals) N average (range) N average (range)Asia (16) 5294 (248–17,897) 8781 (2010–49,898) 66Africa (7) 340 (200–5560) 899 (561–1525) 164Latin America (2) 556 (456–665) 1311 (305–2318) 136OVERALL 3528 (200–17,897) 5976 (305–49,898) 69Judson et al. BMC Ophthalmology  (2017) 17:96 Page 3 of 8The CSV decreased slightly in year 1, increased steadilyin years 2 and 3 (Fig. 1) and showed a more marked in-crease in year 4 due to two high-volume centers in Indiamore than doubling their volume. Asia drove the overallincrease in volume accounting for 89,109 (83%) of add-itional surgeries. Four hospitals did not increase their CSVby year 4, while 8 showed an increase of 200% or more.In the African countries, the national CSR (defined asnumber of cataract operations per million people peryear) increased slightly or declined in all but one countrywhere a mentee is present (range: −39% - 42%) while theCSV in all but one of the mentee hospitals in this studymore than doubled (range: 172%–245% increase) by theend of year 4. The hospital in Burundi saw the greatestoverall increase in surgeries of 245% (Table 2).The two Latin American countries saw a decline inCSRs (Honduras −19%, Peru −28%) while the CSV in thePeruvian hospital increased by 254% and the Honduranhospital decreased by 33%. The Honduran hospital didnot continue to grow after the second year of interventiondue a refusal to hire another ophthalmologist.In India, CSR data is available at the state level. Of theeight states where mentee hospitals are located, CSRdecreased in two states by 14%, mildly increased in five(range: 6–28%) and significantly increased in one (93%).Two of the 14 Indian mentees increased their CSV lessthan the CSR of their state. The other 12 hospitals in-creased their CSV at more than double the change inCSR (range of increase: 39–325%) (Table 2).Twenty-three hospitals reported data on the numberof operations per surgeon. The baseline average numberof ophthalmologists per institution ranged from 1 to 7depending on region, with 4 times as many surgeries persurgeon in Asia (average: 1704) compared with LatinAmerica (average: 370) and Africa (average: 340). Allregions increased the number of surgeries per surgeonwith the greatest relative increase in Africa (131%increase) (Table 3). By year four, 4 hospitals (3 India, 1Latin America) did not increase the number of surgeriesper surgeon. Of the 19 hospitals showing an increase,more than half increased 100% or more (5 Africa, 1Latin America, 4 Asia).Fourteen mentees (13 from Asia, 1 from Latin America)reported the number of patients who come directly to thehospital and paid all or a portion of the cataract surgicalfees. Countries in Africa did not provide data on walk-inpaying patients. The number of direct paying patientsshowed an average increase of 61% by year 4 (Table 4).Eight of the 14 hospitals increased the percent of payingpatients (range: 12%–1397%) while 6 decreased (12%–64%) by the end of the fourth year of intervention. Of the8 hospitals that increased the percent of paying patientsby year four, 4 hospitals increased by 200% or more. Thehospital from Latin America saw a decrease in number ofpaying patients.Seva or the Swiss Lions paid an average of $5.39(range: 55¢ - $13.89) per additional surgery (Table 5). Thehighest “return on investment” by mentor was 55¢ peradditional surgery across their 2 mentees. By geographicregion, Asia saw the highest return on investment with$4.16 per additional surgery while Latin America saw thelowest with $13.89 per additional surgery.DiscussionThe capacity building intervention focused on strengthen-ing organizational management, leadership, team building,equitable access and use of services, financial cost-recovery,and quality of care. How this transpired depended upon thelocal context; while general principles were followed in allsettings considerable variation in setting of priority inter-ventions was noted. In most of the South Asian settings thefocus was on providing high quality surgery to all sectors ofthe population, introducing a tiered patient paying systemand reorganizing patient flow for maximum efficiency.In African settings priority interventions focused onstrengthening basic organizational, personnel, and fi-nancial management systems and designing practicaloutreach programs. Because the services were providedequitably and sustainably through service fees, they metmost of the criteria of effective [11] and systematic [12]capacity building.The capacity building intervention itself varied sub-stantially from mentee to mentee and mentor to mentor,depending upon the local context and needs. Some menteefacilities only needed minimal interventions such as re-Year 1 Year 2 Year 3 Year 4Additional Surgeries (2,199) 19,596 28,652 61,207 (10,000) - 10,000 20,000 30,000 40,000 50,000 60,000 70,000Fig. 1 Additional cataract surgeries above baseline over four-year periodJudson et al. BMC Ophthalmology  (2017) 17:96 Page 4 of 8orientation and team building strategies, others requiredphysical renovations and equipment, while most requiredoutreach programs and clinical and management training.Nevertheless, in all settings, raising production targets andchanging institutional attitudes to growth was a big part ofthe capacity building program. However, target setting forgrowth was more of an internal exercise to increase sup-plies, training, and efficiency, not an explicit attempt tomeet population need. In all of the settings the need forlarge increases in eye care services, including cataract sur-gery, was simply accepted as a background reality in theplanning process.Hospitals and eye units worldwide use cataract surgicalvolume (CSV) as an indicator of overall eye care activitylevel. It reflects hospital performance and efficiency includ-ing patient choice and acceptance of surgery as well as thequality of ophthalmic professionals, patient experience,equipment and supplies. CSV directly depends on the num-ber of patients attending hospital outpatient departmentsand community outreach activities, often termed diagnostic/screening ‘camps’. Attendance at outpatient and outreach, inturn, reflects interaction with the service population regard-ing eye diseases and their awareness of treatment options.While mentee hospitals and eye units gathered and usedthese statistics for their own improvement, the complexityand variability was too great to include in this initial, broadlevel, assessment study.The capacity building intervention was systematic [12]it resulted in an initial decrease in cataract surgical vol-ume in 11 of 25 institutions due to key clinical staffundergoing training off site, physical alterations to thehospital building and installation and training on newequipment, as well as service populations learning toaccept paying fees for previously free services (thoughfree services were still provided for patients too poor topay). Despite widely diverse population density, diseaseprevalence, and eye care infrastructure [13, 14] the cap-acity building intervention show a substantial increase inTable 2 National and state cataract surgical rate (CSR) change versus cataract surgical volume (CSV) change at 4 yearsCountries CSR 2010 CSR 2014 [2013] Change 2010–14/[13] (%) # of menteeHospitalsper countryBaseline cataractsurgical volumeYear 4 cataractsurgical volumeChangebaseline-year 4 (%)Madagascar 312 373 20 3 1355 3096 128Ethiopia 468 [480] [3] 1 236 685 190Burundi 135 [192] [42] 1 342 1181 245Uganda 331 [203] [−39] 1 250 681 172Tanzania 543 [562] [3] 1 200 648 224Peru 1572 [1130] [−28] 1 655 2318 254Honduras 800 [650] [−19] 1 456 305 −33Indian States CSR 2010 CSR 2014 Change 2010–14 (%) # of menteehospitalsper stateBaseline cataractsurgical volumeYear 4 cataractsurgical volumeChangebaseline-year 4 (%)Andra Pradesh 6782 5805 −14 1 1446 2658 84Gujarat 12,163 12,920 6 1 5555 7738 39Haryana 5411 10,467 93 1 5652 5971 6Odisha 3064 2630 −14 4 32,649 32,078 −2Madhya Pradesh 5627 6310 12 1 17,897 49,898 179Uttar Pradesh 3667 3971 8 3 5126 21,772 325West Bengal 3433 3815 11 1 6025 4816 −20Assam 1618 2075 28 2 2267 5741 153Table 3 Cataract surgeries per ophthalmologist per year over 4 years, by geographic regionGeographicregionBaseline Surgeons Baseline cataractsurgeries per surgeonYear 4 surgeons Year 4 cataractsurgeries per surgeonChange insurgeries persurgeon (%)N average (range) N average (range) N average (range) N average (range)Asia (14) 3 (1–7) 1704 (248–8222) 3 (1–7) 2602 (402–7128) 53Africa (7) 1 (1–1) 340 (200–566) 1 (1–1) 786 (561–1181) 131Latin America (2) 1 (1–2) 370 (327–456) 2 (1–2) 580 (305–772) 56OVERALL 2 (1–7) 1444 (200–8222) 2.5 (1–7) 2217 (305–7128) 54Judson et al. BMC Ophthalmology  (2017) 17:96 Page 5 of 8cataract surgical volume by year 4 in Africa (164%) Asia(66%) and Latin America (136%).The proportional increase in CSV observed exceededthe change in cataract surgical rate (CSR) over the sametime period in all but three jurisdictions [6–10]. CSR is awidely used, population-based measure, while CSV issimply the number of operations per year in an institution,without the population denominator. Nevertheless, thecomparison provides a reasonable way to assess menteegrowth rate to background eye care system growth in thesame geographical area, thereby controlling for broadpolitical and economic changes during the study period.CSR remains unchanged or declines in settings such asMadagascar and Tanzania where most eye care servicesare part of government hospitals where eye care is a lowpriority, equipment is not affordable, and active outreachdoes not occur. In settings such as India, CSR is steadilyrising, albeit much slower than the mentee institutionsstudied here, because of substantial government andprivate investment in establishing high quality eye careservices and broad distribution of eye care services tothe primary health care level.Surgical productivity (defined herein as cataract opera-tions per ophthalmologist or cataract surgeon) also in-creased in all regions by year 4. This reflects improvementin a range of internal hospital features including training,clinical protocols, patient flow within the hospital and op-erating room, and reallocating less-skilled tasks from theophthalmologist to the rest of the eye care team [15]. Sur-gical productivity is also dependent upon the burden ofdisease in the population and there is strong evidence thatthe incidence of cataract (age and sex adjusted) in manyAfrican populations is two to four times lower than inother populations [14].Direct, walk-in patients who pay for some or all oftheir care reflect a number of different conditions, somehospital related and some related to the local context.Where transport systems are efficient and effective “direct-paying patients” or their family members have chosen toseek care at the mentee facility over other local and distanttreatment options and to use their own money to pay forservices. This choice indicates good hospital reputation re-garding quality, cost and efficiency of services. Eye care in-stitutions such as AECS in India achieve a cash surpluswith only 30–40% of their cataract patients as direct payingpatients [16]. As has been shown in different settings in Af-rica, direct paying patients are generally fewer in number ascompared to South Asia. Poor transport systems, long dis-tances, advanced age at development of cataract, and inad-equate social support all contribute to a relatively lowproportion of direct paying patients [17–19].Of the 14 hospitals that reported direct paying patientinformation, more than half reported that paying pa-tients made up 15% or less of total cataract surgical pa-tients prior to the capacity building intervention. Manyof these hospitals were founded as charity hospitals thatprovided services to the poor and therefore did not seekpayment from patients leaving the hospitals vulnerableto changes in external funding. In the African countries,government hospitals (4 of the 7) had minimal fundingfor eye care, mostly consisting of covering salaries. Inmost instances, early discussions between mentors andmentees included conversations regarding implementa-tion of fee structures and payment options suitable tothe hospital context and fiscal demographics of theircatchment area. Restructuring patient fees to provide atiered payment system (particularly in South Asia andLatin America) includes taking into account what top,middle and low income earners would be able to pay forsurgical intervention based on the most up-to-datedemographic information available for the hospitalcatchment area and building pricing structures on thatwhile still providing an option for free surgery for thosewho cannot afford the least expensive option.The assessment of the return on investment of thiscapacity building process would suggest that the SouthAsian sites had the best value-for-money. As noted byLewallen and Thulsiraj [13] there are a considerablenumber of factors that limit the ability of directly applyTable 4 Proportion of paying cataract patients over 4 years by geographic regionGeographic region(N hospitals)Baseline paying cataractpatients N average (range)Proportion ofcataract patients (%)Year 4 paying cataractpatients N average (range)Year 4 proportion ofcataract patients (%)Change in proportionof cataract patients (%)Asia (13) 675 (112–1457) 12 1870 (308–3857) 21 66Latin America (1) 352 (n/a) 54 546 (n/a) 24 −56OVERALL (14) 652 (112–1457) 13 1775 (308–3857) 21 61Table 5 Funding per cumulative additional cataract surgeriesover 4 years by geographic regionGeographicregion(N mentors)Amountspent inUSDCumulative additionalsurgeries over 4 yearsAmount spentper additionalsurgery in USDAsia (4) $ 570,492.99 137,085 $ 4.16Africa (1) $ 229,562.39 20,060 $ 11.44Latin America (1) $ 75,704.43 5451 $ 13.89OVERALL $ 875,759.81 162,596 $ 5.39Judson et al. BMC Ophthalmology  (2017) 17:96 Page 6 of 8practices from India to different settings in Africa. Com-parisons within similar settings may be a more valuableapproach to assessing value-for-money. Nevertheless, inall of these settings capacity building proved to be a rela-tively inexpensive form of increasing the number ofpeople who received cataract surgery.LimitationsThe capacity building intervention was associated withincreased cataract surgical volume and productivity indiverse settings. However, prospective controlled studiesare needed to prove the impact on individual institutionsin each region. State and national CSR data were used forhistorical comparison. Although crude indicators, theyprovide the best available way to capture broad trends innational and state eye health system developmentA much better assessment of mentee impact would becaptured by measuring cataract surgical coverage (oper-ated cataract as a proportion of operable plus operatedcataract) and the more recent ‘effective’ cataract surgicalcoverage (operated cataract and a good outcome as a pro-portion of operable cataract plus operated cataract) asapplied in Ramke, et al. [20]. While not possible hereinwith these early mentees, this approach is becoming moreand more feasible with the increasing number of RapidAssessment of Avoidable Blindness survey studies in all ofthese settings.Data on the quality of cataract surgery, although gatheredby all the mentee hospitals, were not reported in this study.In this program evaluation, high quality surgery was consid-ered a necessary variable in higher level indicators such asthe number of services provided and the number and pro-portion of patients willing to pay for services.ConclusionsIn summary, the capacity building interventions resultedin a proportionally similar increase in cataract surgicalvolume and productivity across diverse settings in threedistinct geographic regions. Its wide applicability, andmoderate cost make it an attractive means to rapidly andsubstantially increase eye care services to meet VISION2020 goals.Endnotes1Please see annex 1 for a complete list of “mentor” andlocations of “mentee” institutions involved in this studyAnnex 1: List of Mentor and Location of MenteeInstitutions Involved in this StudyKilimanjaro Center for Community Ophthalmology(KCCO), TanzaniaMadagascar [3]Ethiopia [1]Burundi [1]Tanzania [1]Uganda [1]Lions Aravind Institute for Community Ophthalmology(LAICO), IndiaIndia [5]China [1]LV Prasad Eye Institute (LVPEI), IndiaIndia [4]Sadguru Netra Chikitalaya (SNC), IndiaIndia [2]Visualiza Eye Care System, GuatemalaPeru [1]Honduras [1]Vivekananda Mission Ashram Netra Niramay Niketan(VMANNN), IndiaIndia [3]Bangladesh [1]AbbreviationsAECS: Aravind Eye Care System; CSR: Cataract surgical rate; CSV: Cataract surgicalvolume; KCCO: Kilimanjaro Centre for Community Ophthalmology; KPI: Keyperformance indicator; LVPEI: LV Prasad Eye Institute; SNC: Sadguru NetraChikitalaya; VMANNN: Vivekananda Mission Ashram Netra Niramay NiketanAcknowledgementsThe work reported in this manuscript was supported by funders of the SevaFoundation and the Swiss Lions MD 102.FundingFunding for interventions and mentorship were provided by donors to theSeva Foundation, the Swiss Lions MD 102 (to the KCCO for work in Africa) andthe International Eye Foundation. Funds primarily supported eye programtraining and salaries, mentor and mentee travel, key equipment purchases,outreach activities, minor building renovations and surgical supplies.Availability of data and materialsThe datasets used and/or analyzed during the current study available fromthe corresponding author on reasonable request.Authors’ contributionsKJ, KB, PC, TR, and RK designed the project and helped to analyze and reportfindings. KJ and KB gathered, entered and analyzed the data. KJ, KB and PCall provided major contributions in writing the manuscript. All authors readand approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable for this publication.Ethics approval and consent to participateThis study was approved by the University of Cape Town Ethical committee(HREC REF 848/2015). Individual mentee hospitals provided consent for theuse of their data.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Seva Foundation, 1786 5th St, Berkeley, CA 94710, USA. 2Kilimanjaro Centrefor Community Ophthalmology, Division of Ophthalmology, University ofCape Town, Cape Town, South Africa. 3Aravind Eye Care System, Madurai,Judson et al. BMC Ophthalmology  (2017) 17:96 Page 7 of 8India. 4LV Prasad Eye Institute, Hyderabad, India. 5University of BritishColumbia, Vancouver, Canada.Received: 12 January 2017 Accepted: 8 June 2017References1. Gretchen A Stevens, Richard A White, Seth R Flaxman, Holly Price, Jost BJonas, Jill Keeffe, Janet Leasher, Kovin Naidoo, Konrad Pesudovs, SergeResnikoff, Hugh Taylor, Rupert R A Bourne, on behalf of the vision lossexpert group. Global prevalence of vision impairment and blindness:magnitude and temporal trends, 1990–2010. 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