Eyes in the sky: Considerations for a tele-ophthalmology service in South Sudan

Abstract

Telehealth services employ telecommunication technology to provide scarce specialist care to the multitude across the geographical divided and hard to reach areas. The Aravind Eye Care System in India has a successful tele-ophthalmology model that services poor households and could be adopted in impoverished settings such as South Sudan. Evolving technological changes in South Sudan, including provisional approval of Starlink, improve the feasibility of telehealth services. However, realizing intended benefits at minimal cost require careful consideration of multiple factors across demography, infrastructure, and governance. This article reflects on a previous evaluation project aimed at extending this model to other settings and makes recommendations for South Sudan.

Keywords: telehealth, eyecare, healthcare innovation, digital health, South Sudan

Introduction

Wholesale adoption of healthcare models is uncommon. Yet, nascent health systems like South Sudan’s could benefit from proven models. The Aravind Eye Care System’s (AECS) tele-ophthalmology model helped curb blindness in India ^[1,2] and could help other poor settings. In South Sudan, 1.5%^[3] to 7.7%^[4] of the population is blind or visually impaired, mainly due to cataract (30-50%), trachoma (35.3-58.1%), onchocerciasis (35%), and refractive errors.^[3-5] These are exacerbated by poor socioeconomic conditions^[5] and poor access to eyecare.^[3]

South Sudan’s strategy for self-sufficiency in eyecare is constrained by infrastructure and workforce.^[3] It could benefit from Aravind’s innovations, including the use of Wi-Fi technology, cheap intraocular lenses, a paraprofessional workforce, standard management systems and processes, and outreach programmes.^[6] These approaches circumvent constraints. However, wholesale domestication has yet to be explored.

Evolving technological changes, including approval of Starlink in South Sudan,^[7] improve feasibility of telehealth services. Telehealth avails scarce specialist care to many across geographical divide. However, reproducing outcomes from proven models requires contextual considerations.

This article reflects on an evaluation project completed at Lions Aravind Institute of Community Ophthalmology (LAICO) in Madurai, India, between 2017 and 2018. The project examined the effectiveness of Aravind’s eyecare model with a view to scaling it. The article uses insights from fieldwork and administrative data to demonstrate key elements of the model and inform considerations for South Sudan. First, it delineates Aravind’s approach to the global scourge of needless blindness and expounds on its elements of sustainability and quality assurance. Second, it considers constraints and opportunities for scaling the model to South Sudan. The article then concludes with recommendations.

The Aravind Eye Care System

The AECS is a primary eyecare service that operates across over 100 sites that are digitally connected to a base hospital in Madurai. Its critical elements include training of clinical staff, acquiring staff, eye camps, vision centres (VCs) and community clinics (CCs), telehealth specialist reviews, standardized and high-throughput surgical care processes, and tiered pricing for equitable access (Diagram 1). VCs are community-based eyecare units staffed with skilled eyecare service providers. These offer comprehensive eye examinations, refraction, blood sugar test, blood pressure monitoring, a teleconsultation with an ophthalmologist, eye health education, and glasses and medicines dispensing services.^[2] 

Figure 1. The Aravind Eye Care System’s business model

Although VCs are low-cost and critical to the Aravind’s model, they incur set-up costs and overheads, basic necessary investments, and recurring expenditure (Table 1).

Table 1. Investments per vision centre

The AECS uses high-throughput surgery with a large volume of patients to generate sufficient revenue to offset operating and establishment costs at VCs and community clinics (Table 2).

Table 2. Economic profile of vision centre and community clinic

Note: INR: Indian Rupee.

The AECS’s sustainability and brand recognition hinge on multiple approaches, encompassing a business model which is tailored to the poor, standardized processes for cost containment and quality assurance, volume-driven growth, emphasizing organizational culture when recruiting, and locally-embedded management practices and technological innovation (Table 3).

Table 3. Key tenets of the Aravind Eye Care System (AECS)

Considerations for South Sudan

Resistance to innovation

Healthcare innovation is fraught with risk-aversion: the health sector prizes evidence over logical argumentation, which results in a long lead time for translation.^[8] Technology transfer often induces the fear of change and threat to vested interests.^[9] Factors which are critical to technology transfer include favourable governance and business conditions, supportive financial ecosystem and technological literacy.^[10] Nonetheless, even after the adoption, many innovations in healthcare fail for reasons including organizational, technological, and political complexities.^[11] 

The Aravind’s model has been externally inspired but locally championed.^[2] Leadership is essential for demystifying innovation and its mainstreaming.^[9] Regulatory hurdles and competition against existing products are potential barriers that require experienced entrepreneurs to scout innovations and invest for production.^[12,13]

Politics of metrics

The burden of eye diseases should be a political priority. Policy designers need to translate epidemiological evidence into political priorities. For India, ‘Vision 2020: The Right to Sight’ helped to target funding to eye health services.^[6,14,15] 

Eye health metrics also need to track quality of care. In Aravind’s practice, this includes supply chain management, evaluation of care processes, and clinical outcomes. This also evaluates satisfaction rates and assesses care effectiveness.

Governance

Governance is an important factor in scaling social impact.^[16] Autonomous decision-making is essential for low-resourced contexts, and governance determines organizational values which are difficult to replicate. Moreover, taxation, trade, and technology policies impact technology transfer.^[17] While the requisite set of policies are contested,^[18,19] technology policies are often considered within other priorities, including implications for national security, economic benefits, and rarely, health implications. Aravind’s eyecare model thrives on cheap technology which resulted from favourable governance frameworks. These include the decision to despatch and repatriate engineers after training in USA, the choice of procured technology and its indigenization, subsidies which make technology affordable, establishment of local training institutes for a tailored skilled workforce, development of factories for consumables, and promotion of customised adoption of existing technologies. Similarly, its domestication of manufacturing capabilities benefited from trade, taxation, and technology policies within India’s overarching foreign policy. 

In addition, India’s populous jurisdictions are consequential for the economies of scale realized at Aravind. Success elsewhere would depend on governance frameworks which pool a critical mass under a policy jurisdiction. By contrast, decentralization may limit economies of scale where jurisdictions are small and the adopting organization is compelled to engage policymakers across multiple jurisdictions. Calls for federalism in South Sudan are requests for further devolution, despite current incapacitation.^[20] While this could promote innovation, it may deprive volume-dependent services of requisite scale. 

Furthermore, the financial ecosystem and government capabilities are consequential. Restricted fiscal space necessitates public-private partnerships as the most viable vehicle for technology transfer. In this respect, government guarantees for private investors are instrumental for de-risking innovation. Preservation of public value in such partnerships also depends on capabilities in government and these are relevant for healthcare technology. 

Technology

Cheap and accessible technology is essential for telehealth. The AECS uses Wi-Fi across its network,^[1,6] which enables real-time specialist input. This inspires confidence in quality of service while also acting as force-multiplier. The increasing affordability of Internet, computers, and mobile phone-supported fundoscopy, improve global feasibility of telehealth services. Nonetheless, local policies will be consequential. Policies aimed at cybersecurity or social moderation over the Internet, for instance, may constrain telehealth. 

Furthermore, managerial practices and operations need to be adapted to local realities. The AECS invests in feedback systems, learns from its operations, and manufactures such as to contain costs and customise technology. Tailored approaches are pertinent, because technologies built for rich economies increasingly adopt razor-and-blade model. These target consumers with high purchasing power and aim to profit from consumables or the ‘blades,’ rather than the often-donated implement or the ‘razor.’ So, their maintenance costs are often prohibitive, requiring consumables which are either expensive or difficult to procure.

Ethics

Optimization of operations at the AECS resolves backlog in outpatient reviews, minimizes unnecessary transfers, lowers labour cost, and minimizes downtime for surgeons and operating theatres. The latter involves task-shifting, with paraprofessional staff assessing patients and supporting perioperative care, including preparing the next patient on adjacent operating table while the surgeon is operating. This allows the surgeon to simply rotate around the operating microscope and minimise time between cases.^[21] Although the AECS monitors and witnesses high quality outcomes and low complication rates, replicating its theatre processes would be subject to standards in other jurisdictions and cultures.

Conclusion

The AECS is a successful social enterprise. It operates a high-volume telehealth model which could be adopted for other impoverished settings. However, it is important that critical aspects of its operation are understood such as the associated benefits to be achieved at minimal cost. The foregoing analysis underscores the significance of systemic analysis when scaling care models. It demonstrates that factors particular to settings, including population, infrastructure and governance frameworks, are consequential. Tele-ophthalmology models such as Aravind’s could improve eye health in South Sudan. But wholesale adoption requires all the foregoing considerations.

Declarations

Ethics approval and consent to participate: Not relevant.

Competing interests: None.

Funding: None.

Acknowledgements: The author thanks Harvard University and the management of Aravind Eye Care System (AECS) and Lions Aravind Institute of Community Ophthalmology (LAICO) for approving the project which informed this article and facilitating fieldwork and access to sites and internal operations. The management of AECS & LAICO supplied administrative documents and cleared publication of insights which have been developed from records and fieldwork. A version of this work was presented to the management of AECS and, in collaboration with Dr James Little and Ryan Frisbie, at a 2018 poster conference at Harvard University’s T.H. Chan School of Public Health in Boston, MA.

References

1. Ravilla T, Ramaswamy D. Efficient high-volume cataract services: the Aravind model. Community Eye Health. 2014;27(85):7-8. https://pmc.ncbi.nlm.nih.gov/articles/PMC4069777/.
2. Mehta PK, Shenoy S. Infinite vision: how Aravind became the world’s greatest business case for compassion. 2013, India: HarperCollins. 
3. Mena W. Tackling the high burden of blindness. SSMJ. 2016 Feb;9(1):3. https://www.southsudanmedicaljournal.com/archive/february-2016/tackling-the-high-burden-of-blindness.html.
4. Ngondi J, Ole-Sempele F, Onsarigo A, Matende I, Baba S, Reacher M, Matthews F, Brayne C, Emerson PM. Prevalence and causes of blindness and low vision in southern Sudan. PLoS Med. 2006 Dec;3(12):e477. DOI: https://doi.org/10.1371/journal.pmed.0030477. 
5. Tizazu T, Mburu FM. Prevalence and causes of vision loss in Southern Sudan. Soc Sci Med. 1983;17(22):1785-8. DOI: https://doi.org/10.1016/0277-9536(83)90392-1. 
6. Bhandari A, Dratler S, Raube K, Thulasiraj RD. Specialty care systems: a pioneering vision for global health. Health Affairs. 2008; 27(4): 964 – 76. DOI: https://doi.org/10.1377/hlthaff.27.4.964.
7. Ninrew C. South Sudan inks satellite internet deal with Elon Musk’s Starlink. Updated 27 July 2024, Juba: Eye Radio. https://www.eyeradio.org/south-sudan-inks-satellite-internet-deal-with-elon-musks-starlink/.
8. Kelly CJ, Young AJ. Promoting innovation in healthcare. Future Healthcare Journal. 2017; 4 (2): 121-5. DOI: https://doi.org/10.7861/futurehosp.4-2-121.
9. Juma C. Innovation and its enemies: why people resist new technologies. 2016, Oxford, England: Oxford University Press.
10. World Bank. Global economic prospects 2008: technology diffusion in the developing world. 2008, Washington DC: USA. https://openknowledge.worldbank.org/bitstream/handle/10986/6335/Global-Economic-Prospects-2008-Technology-diffusion-in-the-developing-world.pdf?sequence=5&isAllowed=y (viewed Jan 27, 2021).
11. Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A’Court C, Hinder S, Fahy N, Procter R, Shaw S. Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. J Med Internet Res. 2017; 19 (11): e367. http://www.jmir.org/2017/11/e367/.
12. Mas J-P, Hsueh B. An investor perspective on forming and funding medical device start-up. Tech Vasc Interventional Rad. 2017; 20: 101-8. DOI: https://doi.org/10.1053/j.tvir.2017.04.003. 
13. Le Roy F, Robert M, Lasch F. Choosing the best partner for product innovation: talking to the enemy or to a friend? International Studies of Management & Organization. 2016; 46: 136-58. DOI: https://www.tandfonline.com/doi/abs/10.1080/00208825.2016.1112148.
14. Finger RP, Kupitz DG, Fenwick E, Balasubramaniam B, Ramani RV, Holz FG, Gilbert CE. The impact of successful cataract surgery on quality of life, household income and social status in South Asia. PLoS One. 2012; 7 (8): e44268. DOI: https://doi.org/10.1371/journal.pone.0044268.
15. Murthy G, Gupta SK, John N, Vashist P. Current status of cataract blindness and Vision 2020: the Right to Sight initiative in India. Indian J Ophthalmol. 2008; 56(6): 489-94. DOI: https://pmc.ncbi.nlm.nih.gov/articles/PMC2612994/. 
16. Lehmann T. Scaling social impact: the case of Aravind Eye Hospitals. Master thesis, Business Faculty. 2009, Witten, Germany: Herdecke University.
17. Mazzucato M. The entrepreneurial state: debunking public vs private sector myths. 2013, London, England: Anthem Press. 
18. Bartokas A, Teubal M. A framework for policy oriented innovation studies in industrial countries. Economics of Innov New Techn. 2002; 11(4-5): 477-496. DOI: https://doi.org/10.1080/10438590200000009. 
19. Chang H-J, Cheema A, Mises L. Conditions for successful technology policy in developing countries – learning rents, state structures, and institutions. Economics of Innov New Techn. 2002;11(4-5): 369-398. DOI: https://doi.org/10.1080/10438590200000005. 

Johnson DH. Federalism in the history of South Sudanese political thought. 2014, London, UK: Rift Valley Institute (RVI). DOI: https://riftvalley.net/publication/federalism-history-south-sudanese-political-thought/. 

Le H-G, Ehrlich JR, Venkatesh R, Srinivasan A, Kolli A, Haripriya A, Ravindra RD, Thulasiraj RD. A sustainable model for delivering high-quality, efficient cataract surgery in southern India. Health Affairs. 2016;10:1783-90. DOI: https://doi.org/10.1377/hlthaff.2016.0562.

More from the August 2025 issue