India is a country with a huge rural population that has substantial unmet eye care needs. A majority of eye care facilities and eye care professionals are in urban and semi-urban areas. Eye care provisions for the rural populace were and still remain a challenge as there is an unfavorable rural–urban disparity in terms of provision of and access to health-care facilities.[1] The need of the hour, therefore, is to establish several sustainable rural quality eye care facilities to tackle this evergoing disparity.
I was fortunate to be chosen to play a lead role in establishing and running one such state-of-the-art rural eye care facility in Chitrakoot, one of the most backward and remote areas of India. In this article, I would like to share how the Sadguru Team could build a world-class and inspiring eye care service model in a remote and rural area like Chitrakoot and how this development also helped in the overall upliftment of rural society.
Early Days
Gurudev Parampujya Ranchhoddasji Maharaj, the Saint of Chitrakoot, used to organize mega surgical eye camps and relief camps in nearby places, including my hometown Satna. I was blessed to meet Gurudev way back in 1959. Gurudev had organized his first eye camp in 1950 at Jankikund, Chitrakoot, where 950 cataract operations were performed at a place and time when there was no electricity, running water, or road connectivity [Fig. 1]. Inspired by the selfless work of Gurudev, I visited Chitrakoot in 1963 and somehow the place attracted me. By the year 1968, Gurudev had established the Shri Sadguru Seva Sangh Trust to continue his charitable activities.[2]
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Figure 1: Gurudev Parampujya Ranchhoddasji Maharaj interacting with patients during the eye camp organized in the 1950s
I had decided to become a doctor, as against joining our family business, and pursued my MBBS from S. S. Medical College, Rewa, Madhya Pradesh and my postgraduation from the College of Physicians and Surgeons, Mumbai. After completion of the course in the year 1974, I shifted to Chitrakoot as an assistant surgeon. Thus began my tryst with the trust, and Gurudev became the sole inspiration for me and my family in every aspect of our lives.
The Challenges of Quality Rural Eye Care Delivery
Being located in a remote backward region, there were several unique challenges faced by our hospital in the provision of quality eye care to the rural masses. Our base hospital received power from both MP and UP state boards. However, the supply was irregular and erratic. We were forced to install our own backup generators to tackle the problem. Another recurring challenge was to ensure regular supplies for daily needs from the nearby towns. Also, the region lacked even basic educational facilities as there was no school in the nearby areas.
For the first two decades, most of the ophthalmic doctors and nurses were volunteers from Mumbai and Gujarat, who were supported in the operation theater (OT) and elsewhere by locally trained rural manpower ably aided by a large contingent of devotee workers (Gurubhakts). Financial sustainability was our biggest concern. We were completely dependent on donors till as late as 1998. Hence, scaling up both medical and support infrastructure like housing, education, and so on and meeting the growing requirements of our staff were slow to start with. Reduced connectivity and poor supply chain further slowed down the scaling up of quality eye care service delivery. In spite of all these challenges, we were determined to create a high-volume, high-quality, sustainable rural eye facility.
Gurudev’s Core Philosophies
I personally feel that all challenges can only be tackled effectively if we approach them with some established core values and philosophies. I had the good fortune to receive direction and support from Shri Arvind N. Mafatalal, Founder Chairman of the Trust, Shri Keshubhai Sheth, Shri Rambhai Gokani, Dr. C. L. Jobanputra, Dr. Vishnu Jobanputra, Dr. Mukund Joshi, and Dr. Jogalekar, other disciples of Gurudev, my parents, brothers, sisters, wife, children, and members of my Sadguru family who have been there for me all the way through this adventure [Fig. 2]. The key philosophies which I have learned and implemented with the blessings of Gurudev are discussed subsequently.
Figure 2: Dr. B. K. Jain with Arvind N. Mafatlal (Founder Chairman of Shri Sadguru Seva Sangh Trust) and Shri Vishad P. Mafatlal (Current Chairman of Shri Sadguru Seva Sangh Trust) in the early days of his work
Be a role model
As there was no school in the nearby areas, I had to enroll my elder son (Jinesh Jain) in boarding in Panchgani, Maharashtra. Later, I realized that not all my staff would be able to afford this luxury. It was also true that unless we ensure schooling facilities, staff retention would be difficult. In the early 1980s, we commenced in-house education with a primary school. In order to provide credibility to the level of education, I ensured that my younger son, Elesh Jain (pediatric ophthalmologist and trustee today), joined the same Hindi medium school [Fig. 3]. Eventually, the school went on to become our biggest strength in retaining our employees for a long term and the entire region flocked here for its educational needs.
Figure 3: Dr. B. K. Jain with his wife (Smt. Usha B. Jain) and his children (Mr. Jinesh Jain and Dr. Elesh Jain) during early days in the background of the school built by the trust for rural education
Be future ready
Our approach should always be futuristic. Think ahead and plan for future expansion from day one. In the year 1972, there was just a small dispensary in Gurudev’s Ram Mandir across the road from the current campus. By 1974, we established a 25-bedded hospital, remnants of which still stand on the current campus. In 1978, the hospital was upgraded to a full-fledged general hospital and a separate eye care wing was added. It was a small department working mainly during the winter months.
A dedicated infrastructure for eye care was established in 2000 with the goal to combat the seasonal imbalance of patient attendance by providing round-the-year quality eye care service delivery. Eventually, we did succeed in reducing the seasonal imbalance significantly. In the year 2015, we came up with a state-of-the-art infrastructure [Fig. 4] with one of the largest operation theater complexes comprising 26 modular operation theaters [Fig. 5] and dedicated facilities for specialty departments in eye care. These planned time-bounded steps have ensured that today, we are the largest eye hospital in India to get full-level National Programme for Control of Blindness & Visual Impairment (NPCB&VI) accreditation.
Figure 4: Images depicting the infrastructural changes from temporarily made barracks for eye operations during the 1960s to the state-of-the-art modern infrastructure of today
Figure 5: Sadguru Netra Chikitsalaya with 26 modular eye OTs, one of the largest eye OT complex in the world. OT = operation theater
Bring compassion and competency together
It is a matter of faith with me that infrastructure and dedicated staff alone are not enough for better patient care – competence must also go hand in hand. During our early decades, we had to largely rely on rural manpower and volunteer Gurubhakts to support our surgical teams. Hence, we ensured that rural talent is identified and groomed as eye care professionals. In 1997, we established the School of Ophthalmic Science, followed by the School of Nursing in 1999 [Fig. 6]. We also run several ongoing structured internal training programs to ensure that care, concern, and compassion are matched by competence at every level of patient care. Today, we are a Govt. of India–recognized postgraduate training center and are recognized by the International Council of Ophthalmology (ICO) where we train ophthalmologists from the world over.
Figure 6: Image from the Sadguru Institute of Paramedical Science, which runs optometry and nursing courses at Chitrakoot
Empower employees
Unlike in cities where one takes many amenities for granted, rural areas have always witnessed challenges in attracting and retaining skilled manpower including ophthalmologists. In the 1980s, we had just one full-time ophthalmologist; today, more than 120 full-time ophthalmologists embellish our staff, with a waiting list of doctors willing to serve even as they learn. We approached the issue of skilled manpower retention with a judicious mix of financial support, academic stimuli, and rest and relaxation facilities. Today, our holistic approach also includes accredited school and college facilities for their offspring. In a limited resource setting, proper advance planning and budgeting go a long way in addressing this issue in an organized manner.
Community engagement
I aver that in every model of eye care delivery, especially in rural-focused models, selfless community engagement is an integral component.[3] What we are today is because of the support we have received from the community [Fig. 7]. With their continued partnership and collaborations, established over the years, we use all models of eye care delivery ranging from the door-to-door approach to tele-ophthalmology. Annually, we conduct about 4000 rural outreach camps across 35 of the most backward districts in MP and UP, and we also ensure continued provision of eye care via more than 100 vision centers.
Figure 7: Dr. B. K. Jain addressing one of the annual community supporters’ meetings at Chitrakoot
Quality assurance
Right through the pre-IOL camp era of the 50s–80s too, our organization had always been conscious of quality in service care delivery. Even during mega surgical camps of that era, the poor unclean patients were given a preop bath and provided new clothes to ensure hygiene. Their feet were washed and wiped again before entry into the OT. In fact, this act of feet washing became a model of humility in service for our volunteer staff. In 2006, we obtained International Organization for Standardization (ISO) certification and in 2021, we became the largest eye care center in India to receive NABH certification.
Financial sustainability
Till 1998, we were completely dependent on donors for revenue and expenses too. In the year 1998, we introduced a segmented pricing model, where irrespective of caste, creed, sex, or religion, the patient was free to choose how much to pay or not to pay at all. Our philosophy never allowed us to deny services due to his or her inability to pay. Today, while a majority of our services are free or subsidized, we also cater to a substantial portion of paid customers. This cross subsidy helped us to achieve operational sustainability and growth, especially in cataract services. In 1998, our total output used to be about 20,000 free surgeries annually, which has increased to over 1,31,000 surgeries [Fig. 8], of which 1,12,000 are free/subsidized.
Figure 8: Ophthalmic surgery graph depicts the growth of Sadguru Netra Chikitsalaya over the years
Innovation
Our service reach was diversely extensive, catering to patients from as far as Chandigarh in the north to Patna in the east. With a belief in continuous innovation and improvement in our practices and models, we conceptualized a focused approach to tackle the cataract backlog. Thus, evolved the concept of cataract blindness backlog-free zone. It was a practical approach to scale up the volume of cataract surgeries and reduce blindness prevalence (geographic) area-wise. With the help of the local authorities, we focused our outreach and operative efforts and were able to declare five contiguous districts as cataract blindness backlog-free zones in a span of 3 years [Fig. 9]. We were fortunate to receive guidance and support from officials of National Programme for Control of Blindness & Visual (NPCB&VI) and the Ministry of Health (both at national and state levels). This success of a unique and path-breaking initiative was appreciated by NPCB officials, and it gladdens our hearts to no end to note that our concept has now been adopted and implemented at a national level. With similar innovations and regular models of eye care delivery, every year, we serve over 10 lakh patients and perform over 1,30,000 ophthalmic surgeries. Till date, we have served more than 22 million patients and performed more than 2.9 million eye surgeries with the support of many similar-minded national and international organizations and individuals.
Figure 9: Dr BK Jain, during the occasion of Declaring Chitrakoot as India’s First Cataract blindness backlog-free District in 2014
Holistic Approach
The success of our model was largely due to the holistic approach we took towards catering to societal needs other than eye care. We focused on the development and support of rural education, general health infrastructure, women empowerment, rural employment and other social reforms, which had a tremendous impact on raising household incomes, thus helping not just individual families but uplifting the entire region in the long run.
Quality education in a rural setting
The initial campus-based schools we commissioned were mainly for our doctors and staff to start with. However, over the years they expanded to benefit the entire region. Today the Trust runs both CBSE-affiliated English and Hindi medium schools from pre-primary to higher secondary and professional levels, where close to 4,000 students enroll annually.[3] [Fig. 10]
Figure 10: Table illustrates Sadguru educational institutions’ student strength for the year 2022–2023
Health facility for the rural community
Along with the eye hospital, we developed a general hospital too. Challenges in attracting and retaining doctors were greatly eased by the attraction of working at Chitrakoot. Many nonophthalmic doctor spouses chose to work in the general hospital as their counterparts served in the eye hospital. With this continued direct and indirect support from eye care, today, the general hospital offers services even in specialty departments like general surgery, urology, gastroenterology, obstetrics and gynecology, orthopedics, pediatrics, ENT, homeopathy, ayurveda, naturopathy, physiotherapy, dentistry, pathology and diagnostics like computed tomography (CT) scan, blood bank, polymerase chain reaction (PCR) lab, and others, thus offering comprehensive healthcare to the rural community.
Women empowerment
Inspired by the teachings of Gurudev, my wife, Smt. Usha B. Jain, plunged into the domain of rural upliftment through seva along with other hospital staff wives. Their achievements over time serve as a great inspirational story of rural women empowerment.[4] Today, our women empowerment wing “Sadguru Mahila Bahu. Uddeshiya Samiti Maryadit” is an established entity with an annual turnover of more than 5 crores. Apart from producing local household products and selling them through its stores, the Samiti has also initiated programs to provide skill-based vocational training and employment for rural women in sewing and stitching, beautician courses, food processing, household product manufacturing, and toy making. Today, even the eye hospital also uses masks, drapes, and other items manufactured by these women empowerment groups [Fig. 11].
Figure 11: Smt. Usha B. Jain with women empowerment wing’s key members at Chitrakoot
Employment to rural youth
With the establishment of several professional educational institutes at Chitrakoot (initially needed for our eye care services), the rural youth from beyond our campus also received an opportunity to upskill and seek better-quality employment. So far, more than 4000 rural youth have received professional education, both in medical and nonmedical fields, rendering them employable in various parts of India in both government and nongovernment organizations. That the opportunity was equitable is shown by the fact that more than 50% of these beneficiaries were females [Fig. 12].
Figure 12: Image from the Sadguru Institute of Computer Science which runs master’s level programs in computer application and other related divisions at Chitrakoot
Involvement in other social fronts
The trust has also established a Gauseva Kendra which provides shelter, food, and medical attention to more than 1200 abandoned and non-milking cows annually. Earth care initiatives like solar power production, organic agriculture, tree plantation, and rainwater harvesting are a few of our activities that directly or indirectly impact the community, both in terms of job opportunities and family well-being.
Conclusion
For the last 50 years, we have been relentlessly working toward rural development and upliftment in Chitrakoot and nearby regions. The scope of our activities ranges from healthcare to education, from women’s empowerment to cattle care, and from dairy development to agriculture. While more than 1400 rural individuals are directly employed, manifold job opportunities are created indirectly as well.
Thus, the trust works like a social industry and shows how rural development can happen through eye care. The Father of our Nation, Shri Mahatma Gandhiji, and the current prime minister, Shri Narendra Modiji, have envisioned the empowerment of rural India to such an extent that no rural youth would feel the need to migrate to urban areas. Our eye care seva is a means toward that goal!
About the Co-author
Dr. Elesh Jain
Dr Jain is a young, accomplished and an empowered ophthalmologist with a dream and a passion - to provide affordable and quality eye care for everyone. He is the board member of Shri Sadguru Seva Sangh Trust and the Chief Administrator of Sadguru Netra Chikitsalaya (SNC). After his postgraduation in ophthalmology, he has been fellowship-trained in comprehensive ophthalmology and pediatric ophthalmology. He has performed over 18000 eye surgeries, including cataracts and other pediatric surgeries. Elesh also leads the Center for Community Ophthalmology at SNC. Under his leadership, the Center runs over 100 vision centers and extensive outreach programs in over 25 backward districts of India. He also takes the lead in quality assurance initiatives in the organization and research, and has more than 45+ research papers published in peer-reviewed journals.
