Between July 2014 and June 2018, the Combatting Blindness in Peru project engaged six partner health clinics working across 13 regions, with support from the Seeing is Believing initiative, funded by Standard Chartered and CBM. As well as providing high quality cataract surgery, and patient care to 250,000 patients, a key achievement of the project was setting up counselling services in partner clinics to address some of the barriers patients were experiencing in coming forward for cataract surgery, such as fear and a lack of understanding about cataracts. This article aims to share some of the learning from the project related to counselling.
Several partners were already carrying out counselling and community activities at the start of the programme, whilst the programme helped to establish counselling departments in four of the six clinics. Twenty health care professionals were trained in counselling activities, and eleven in community promotion. A workshop was held in April 2017 for sharing experience and best practices in counselling. Partner staff shared useful techniques to help typical patients to overcome barriers which prevent them going ahead with surgery when referred. The partners also learned from one another about how to strengthen their administrative processes, facilitating a more joined up way of working between medical, counselling and community work departments.
As a result of support from the project, there are now full time counselling services at all partner clinics and at community level. 39,544 people with eye health problems were given health information through face-to-face talks and counselling about surgery.
The training and workshops provided by the project to tackle barriers to eye care and surgery have helped Ministry of Health nurses to perform more effective screening, counselling and patient referral. The training promoted honest and effective communication with the patient and their relatives by the medical, counselling and community work teams, with the effect of improving patient care. When users were assisted with understanding their condition and how to treat it, they became more compliant with the treatment prescribed.
Also important to make counselling more effective was hiring counselling staff who could speak local languages and understand the community context well, or who had experience in other relevant areas – such as patient preparation, screening, community outreach work or operating theatre management procedures. The improvement in the quality of counselling provided is shown in changes in the conversion rate from counselling to surgery, which increased over the course of the project from 72% to 85%.
The final evaluation of the project found that the training in administrative processes and counselling had supported the development and expansion of activities carried out by each of the partner clinics, giving rise to an important reordering of processes and an improved information base. For example, one partner developed its database so it can now monitor the number of patients receiving counselling and surgery, allowing the effectiveness of counselling to be monitored through conversion rates and other relevant metrics. This process was facilitated by a willingness amongst partners to work collaboratively to solve problems and share data and ways of working; this was supported by high levels of trust developed through working together during and before the Seeing is Believing project.
The establishment of counselling along with community outreach activities has been central to institutional growth for partners. The counselling and community outreach work in each centre over the past two years has resulted in an increase in the volume of patients turning up for appointments and going ahead with surgery thanks to reduced cultural and psychological barriers towards cataract surgery within communities. This increased volume of surgeries has strengthened the skills of trained professionals, facilitating an improvement in the quality of surgeries. The quality of life of many patients has improved as a result of receiving high quality surgery. This has resulted in a virtuous cycle: staff are more motivated and patients encouraged to undergo surgery due to the expectation of good outcomes.
In addition, to improve efficiency in allocating subsidies to patients, counselling departments have worked more closely with community work departments, whose knowledge of communities assisted partners to more accurately assess patients’ ability to pay, through knowledge of their communities.
However, despite counselling work tackling barriers to cataract surgery by addressing myths, men have remained less likely to access surgery. Machismo cultural attitudes remain a barrier that counselling departments are working to overcome.
In the long term, partners are expected to sustain strong counselling services; trained staff can cascade training to newly recruited staff to maintain skill levels. Through the project, partners have adopted new management indicators such as conversion rates (from counselling to surgery), monitoring the ratio of old and new patients, and the ratio of gross income and expenditure. It is anticipated that partners will continue to collect this information and sustain their use of data for improved planning and monitoring, providing evidence about the value of investing in counselling.
Below is a summary of some of the key learnings from the project relating to counselling:
- Clinics highlighted the importance of honest and effective communication with the patient and their relatives by medical, counselling and community work teams.
- When users were assisted with understanding their condition and how to treat it, they became more compliant with the treatment prescribed.
- Engaging staff who could speak local languages and understand the community context well, or who had experience in other relevant areas of the clinic, increased the effectiveness of counselling.
- A joined up way of working between medical, counselling and community work departments was valuable to maximise the impact of counselling, including helping to identify patients needing subsidised care.
- Improving administrative systems provided the data needed to monitor the effectiveness of counselling services.
Programme Manager- West and Central Africa