Present scenario
According to statistics published by the World Health Organization (WHO) in 2012, India has an estimated 12 million blind people and additional 456 million people who require vision correction. WHO also reports that 80 per cent of blindness in India is avoidable, yet visual impairities and blindness remain significant problems. “The most prevalent ailments leading to blindness or low vision are – cataract (62.6 per cent) refractive errors (19.70 per cent) corneal blindness (0.90 per cent), glaucoma (5.80 per cent), surgical complications (1.20 per cent), posterior capsular opacification (0.90 per cent), posterior segment disorder (4.70 per cent) and others (4.19 per cent),” informs Dr Mahipal Sachdev, Chairman and Medical Director, Centre for Sight Eye Hospitals. “Estimated national prevalence of childhood blindness/ low vision is 0.80 per thousand,” he adds. In addition to this, WHO’s report also reveals a growing burden of diabetes retinopathy, glucoma and retinopathy of prematurity (ROP) cases in India. Blindness and visual impairment is not just India’s problem. According to WHO global statistics, around 39 million worldwide are blind. In the wake of reducing the worldwide burden of blindness and visual impairment, WHO along with the International Agency for the Prevention of Blindness (IAPB) initiated the Vision 2020. The ‘Right to Sight’ programme that constitutes 120 member NGO groups who work towards eliminating avoidable blindness. This has been achieved through a unique, cross-sector collaboration, which enables public, private and non-profit interests to work together, helping people to see, all over the world. In India, the Vision 2020 works with a strong partnership between Ministry of Health, national and international NGOs, private hospitals groups, and civil society groups who together facilitate the development and implementation of effective and sustainable national eye care plans.
Industry watch
Giving an industry perspective on the eye care sector in India, Professor Hugh Taylor, Vice President, International Agency of Prevention of Blindness (IAPB) opines, “Today, India is one of the leading countries in the world for eye care services.” “Over the past few decades there has been a significant reduction in the burden of blindness. India was the first country in the world to adopt the National Programme for Control of Blindness in 1976. We have seen a significant reduction in cataract blindness. With over six million surgeries performed, not only have the numbers increased, but also the quality. The number of Intraocular lens (IOL) implants has increased from four per cent in 1995 to over 95 per cent in 2011,” reveals Dr Murali Kaushik, Paediatric Ophthalmologist, Sankara Eye Hospital. Adding to this, Dr GV Rao, President, Vision 2020, India informs, “The industry, which comprises the eye hospitals, national and international NGO group institutes, opticals chains, contact lens manufacturers and pharmaceuticals, and device manufacturers, is advancing at a faster pace. In the previous year, out of the six million eye surgeries we conducted, five million were cataract surgeries.” He says that the increased burden of blindness in India and the adoption of newer technologies by the sector has been the key driver for growth of the eye care sector in India.
In the last 15 years, the industry has been doing a good job in not only increasing the volumes of patients that they cater to but also in enhancing the quality of care they provide.
According to an ASSOCHAM study titled ‘Indian Optical Sector’, the eye care hospital sector is growing at a rate of around 15 per cent year on year. Moreover, the ASSOCHAM study also states that the Indian eyewear market is growing at around 30 per cent CAGR and the contact lenses market in India is growing at a CAGR of about 25 per cent. About 40 lakh pairs of contact lens are sold annually and the market is estimated at about Rs 700 crore. This growth is led by a growing demand for daily disposables and frequent replacement contacts, including coloured contacts.
“Most eye care in India is geography bound. You would still find thriving single practice ophthalmologists across the country. Optical stores are transitioning from family run businesses to multi store retail chains. The organised sector barely accounts for 20 per cent of the market,” feels Dr Kaushik.
He further goes on to say, “Investment in research and realisation by MNCs of the potential in India, fueled by patient awareness has ensured the application of latest equipment and techniques in managing eye diseases. This has led to improved outcomes and reduced patient stay in the hospital. Today, a large number of procedures are performed as day care surgeries. There is corporatisation of the eye care industry. Multinational chains today manage a multitude of optical outlets across India. This has led to a moderation of the costs and an overall improvement in the awareness on the need for eye care as the marketing thrust towards eye care has increased. There has been a large venture capital inflow in some hospital chains in eye care. A majority of patients in tier I and tier II cities today, are availing insurance for their surgical care. The government run schemes in Andhra Pradesh and Tamil Nadu have helped thousands to access tertiary facilities for their eye diseases at no cost”.
Major players
In India, eye care services are extensively provided by private NGO eye care institutes and the government. The government sector provides care through their own network of government run eye hospitals such as the RP Centre of Opthalmic Sciences attached to the All India Institute of Medical Science (AIIMS) and Guru Nanak Eye Centre. Eye care services are also offered through the National Programme for Control of Blindness which is probably the most successful public private partnership (PPP) programme in healthcare. This successful PPP model has been an exemplar for all international healthcare organisations.
Under the NPCB programme the government has established a MIS for data entry of cataract surgeries done. The programme provides eye care education and services through telemedicine. The NPCB also looks after construction of eye wards in govt sector and setting up of vision centres. Furthermore, the government has also come up with initiatives such as the Motiyabind Mukti Abhiyan programme in order to clear the backlog of cataract cases.
The government has also instituted the National Eye Bank situated in AIIMS, Delhi, a non-profitable charitable organisation dedicated to the procurement and distribution of corneal tissue for transplantation. It is one of the oldest eye banks in India and has helped to bring the “Gift of Sight” to over 20,000 men, women and children.
Amongst the private players there are around 1000 eye hospitals and 300 medical colleges spread across India. Some of the premuim ones are Aravind Eye Care System, LV Prasad Eye Institute, Sankara Nethralaya, Sankara Eye Care Institutions, Centre for Sight etc. that function on the basis of different models based on their focus areas. These premium institutes are also a part of the Vision 2020 to reduce the burden of blindness in the country. In collaboration with the Vision 2020 programme the private institutes have established primary eye care centres in the rural areas of our country. Apart from these, large private chains are also now established across the country. The Vasan Hospitals, with funding through venture capital, are now established in over 100 centres across India. Dr. Agarwal Eye Hospitals are predominant in the South. Medfort Hospital is trying to foray into South India but as of now they are localised in Andhra Pradesh. As far as North India is concerned institutes such as Centre for Sight have been fore-runners in this field. “About 60 per cent of most eye care establishments’ revenue comes from cataract operations. This is the sector’s main growth driver with a population of 1.2 billion people that will need cataract operations once they cross the age of 60. And technology has enabled this by simplifying the procedure,” chips in Dr Kaushik.
Within the eye care equipment sector, domestic players are taking the lead. Dr GV Rao says that eye care institutes are slowly adopting domestic equipment over foreign products. Today, around 80 per cent of equipment used in hospitals are domestic ones and this is definitely a good sign.
“In the eye wear and contact lens segment, the major players are Bausch & Lomb, Johnson & Johnson (Acuvue) and Ciba, with B&L accounting for a larger share (60 per cent) of the conventional contact lens market. Among these biggies, Lawrence and Mayo is known to be an early mover. Titan through their Titan Eye franchise outlets and Vision Express has entered the tier II and tier III towns across the country. Ben Franklin Opticals works on different models of offering their services to hospitals and practitioners to run their opticals on their behalf. Today, they manage over 130 counters across the country,” he adds.
Attracting the investors’ eye
As the eye care sector is poised to grow at a double digit rate in the coming years, the industry has attracted the investors’ interest. Industry analysts see increasing number of PE deals in this segment. One of the most talked about deal in this segment this year is the Government of Singapore Investment Corporation’s (GIC) investment of Rs 500 crore ($100 million) in Vasan Healthcare. This eye care hospital group will use these funds to expand its network of eye hospitals from its current 102 hospitals and its dental hospitals from the present network of 14 centres. The company is also looking to expand by acquiring hospital chains that fit into its day-care model that doesn’t involve overnight stays.
Seeing the growing interest of the PE investors in the eye care segment Dr Kaushik says, “The low capital expenditure, faster gestation period (turning profits within a year) and financial operating efficiency make it worthwhile for private equity firms to invest in the eye care sector”.
Challenges and road blocks
Although India, to a certain extent, has achieved its Vision 2020 goals, there is a still a lot more that needs to be accomplished. Availability of service, affordability and awareness are the major road blocks; especially in the hinterlands of our country. Uncorrected refractive errors and cataract are most commonly found in these rural and underdeveloped areas. Here, the other challenge is the low acceptance level from the patients’ side. The reasons being traditional practices, beliefs, fatalistic attitudes towards blindness, fear of treatment, lack of faith in the intervention, and fear about the surgical procedure. “There is a huge gap between the services provided in the urban and rural areas. Rural eye clinics often lack the basic equipment to diagnose or treat eye ailments,” laments Dr Sachdev. Dr Gullapalli N Rao, Chairman, LV Prasad Eye Institute points out that lack of professionals in this field and lack of models to increase accessibility are major challenges.
Pre requisites for improvement
“To improve the current state of eye care in India it is important that the industry learns to strike a balance between demand and supply of service,” believes Professor Kovin Naidoo, Global Programmes Director at the Brien Holden Vision Institute and Chair, IAPB Africa Region. “Financing for eye care and creating a national fund supported by the government is one of the major factors that can solve the problem of affordability in the country. What India needs is Government intervention in this field,” he adds. Furthering on the same Dr Rao expresses, “The prerequisites for our country is that we need to scale up eye care services across India. In that regard, the government has already invested around Rs 13 crore in the last five year plan. Yet we need more support from the government”.
Some of the pre-resquisites listed by industry experts are as follows:
Awareness: Preventing eye diseases and promoting eye health is essential. This would reduce the burden on the healthcare system and also reduce the economic impact due to reduced productivity from blindness, but this goal can be realised only by spreading awareness among the masses. People need to be made aware about eye ailments as they usually go unrecognised for long time leading to irreparable damage.
Capacity building: Creating infrastructure and human resource for eye care services is also important. It is essential to strengthen the eye care infrastructure at the district and village level. This could be done through the vision centre model or through outreach screening vehicles. Although, we have few vision centres across few states, established by leading eye care groups, we need many more of them. Further, district level centres should be able to handle most surgical eye diseases with only those requiring tertiary care being referred to larger cities.
Skill deficits need to be identified and accordingly training should be imparted.
Reducing import duty on certain eye care equipment: Governmental regulations on import of certain devices – low vision (assistive) devices need to be made easy. With a majority of these being developed in China there is a need to create a national distribution hub which could in turn stick these devices from within the country and elsewhere and provide ease of access to practitioners in the country. This would reduce the lead time of importing these devices and also the paperwork needed by individual entities to do so.
Marching forward
Opportunities are galore, all we need is the right direction. The eye care sector currently focuses on the delivery of curative services, but for an effective healthcare system the country requires more emphasis on preventive and promotional strategies, and thus a more convergent approach with the active participation of all stakeholder as well as ‘non-health’ sectors who can and are willing to fund this cause.
On the anvil In a bid to voice the opinion of the industry and to come up with productive strategies, the All India Ophthalmological Society will be organising a national workshop at Dr RP Centre, AIIMS, Delhi in February 2013.