 Thank you very much for having a shared experience from Nigeria in a developing country setting. Nigeria has a population of about 178 million people. About 94 million of these people live in rural areas. And there are about 3 of themologies that serve 1 million Nigerians. These of themologies perform an average of 100 Khatrak surgeries each year. Khatrak services are therefore not readily available because the few services are mainly located in the major cities. Therefore the rural areas remain unsaved. And the effect of this is that the services are underutilized since they are located far away from the people that need these services most. Therefore in rural settings, traditional healers have come in to fill the gap because these traditional healers are readily available in the rural communities. They perform couching on Khatraks, leaving patients with unpleasant outcomes like blindness and sometimes painful blind eyes. To create a demand for Khatrak surgical services is a challenge for most Niger providers in this setting. Because in the first place, most patients do not have enough information about what Khatrak is, about what can be done for Khatrak and where such services can be obtained. This is in contrast to traditional healers who are available in the rural communities and therefore can readily provide the services to these people that reside in rural communities. When patients eventually get information and decide to go to the cities to get treated for Khatrak, they are faced with very difficult road networks and poor transport services. Also the appointment system in many high hospitals and clinics means that many patients have to present several times before they eventually get scheduled for surgery. The result of this is an increase in the indirect costs which is often a major deciding factor on the uptake of Khatrak surgery. There is also a long waiting list which adds to the patient's anxiety by the time they eventually come to the operating theatre. In developing countries, it is required that the Khatrak surgical rate should be about 2000 per year. However, the Khatrak surgical rate is only about 300. Now this low Khatrak surgical rate is often linked with in-efficiency at the hospital level. Getting on the list for surgery does not automatically guarantee that surgery will be done. So there are usually delays and cancellations for various reasons and these reasons can include power failure, absence of the surgeon who may turn up sick and then there is also the lack of efficient use of allocated theatre time. Surgeons also have great difficulties with the equipment which are in short supply very often. Many of these factors are up to make Khatrak surgery inaccessible to many patients. To overcome these barriers, one of the first steps that need to be taken is the need for us to demystify Khatrak surgery. This means that we need to provide patients with essential information so that they are able to make decisions on Khatrak surgery. This information can be provided either by eye care workers or patients, satisfied patients who have undergone Khatrak surgery before. If we are able to provide this at a local level, it is usually easy to convince and cancel elderly patients to accept Khatrak surgery. Another thing we need to also do is to develop referral systems and modify the appointment systems in most of our eye clinics. This means linking health workers in rural settings with eye hospitals as part of a team. Eye clinics that are located in cities need to have primary eye care clinics in rural communities that refer patients to them directly. This can be done as a group referral so that patients that are coming from the village come as a group. They know who they are going to see and they are sure also that they are going to be seen on that day. This makes it less daunting for patients in major cities and in big hospitals. We also need to have eye care workers or general health workers change their attitude about blindness from Khatrak. Such that any patient that is Khatrak blind can or should be treated as an emergency in our eye clinics. This means that the patient that shows up to the clinic should be evaluated same day and accept unless there are absolute contraindications such a patient should be able to get onto the surgery table the very next day. This will reduce multiple visits and indirect cost of surgery. The first step to manage efficiency that we took in our hospital was to manage theatre time by providing more surgical instrument sets, more operating tables and having the right mix of theatre time. We took this step when we discovered that less than 50% of the allocated theatre time was spent on actual surgery. Improving patient turnover means more surgeries can be done within the allocated theatre time. Efficiency will be increased and this will result in a reduction in the waiting time for surgery and also reduce both the direct and indirect cost of surgery to the patient. Staff motivation is also closely linked with satisfaction with their work and this means we need to provide staff with good working conditions, adequate and functional equipment and help them to have a team approach on all aspects of patient management from the referral and from primary eye care centres to managing the outcomes of Khatrak surgery. I would want to leave us with three take home messages. The first is that we need to provide simple information to patients about what Khatrak is, how Khatrak can be managed and where such treatment can be obtained. The second thing we need to do is to develop linkages between primary eye care centres and eye hospitals for a seamless referral system. And lastly we need to ensure Khatrak surgery programmes are efficient so that patient turnover is increased. This will reduce the waiting time and the cost of surgery to patients. Thank you very much.