“restoring vision to millions”Aravind

What does it mean to be blind?

Loss of Vision deprives one of the livelihood, economic independence, self-

esteem & status in the community

Kuppammal is one of the…

• 45 million blind, worldwide• 12 million blind in India

80% of this is preventable or curable• Cataract Surgery – a simple procedure – will

give sight to 7.5 million• A pair of spectacles will make another 2.4

million see

200 million need eye care in IndiaLess than 10% have been reached

GenesisIn a developing country with competing demands on limited resources, government alone cannot meet health needs of all the poor.

In 1976 …Dr.V, feeling the urgent need, started an eye clinic with 11 beds, to create an alternate, sustainable eye care system to supplement the government’s efforts

“… Spirituality allows the divine force to work through each of us for a greater good.

If work is approached from a spiritual perspective, then it becomes divine work. If in your actions, you allow the divine force to flow through you, you will accomplish things far greater than you might have imagined.” - Sri Aurobindo

Aravind’s Guiding Values: Compassion/Dignity Equity Transparency Sharing

Guiding PhilosophyHow Dr. V built the Organization

Translated to action: Eye care to all - Equity Standardization - Transparency Affordability Accountability

Aravind’s Vision

“To eliminate needless blindness by providing high quality, high volume,

compassionate eye care to all”

Aravind Eye Clinic, 1976

11-bed clinicPost-retirement project of Dr. V

Aravind Eye Care System, 2009

Eye Bank

Hospitals(5) Aurolab

Out ReachResearch

“Aravind Eye Care System”

LAICOIT

Training

AMECS4

Hospitals

Aravind Eye Hospitals

4000 beds in5 eye hospitals

Tamil Nadu

A m e t h iL u c k n o w

A m r e l i

K o l k a t a

C o i m b a t o r e

M a d u ra i

Po n d i c h e r r y

T i r u n e l v e l i4 managed eye hospitals33 primary eye care centres

T h e n i

Total Surgeries & Lasers till March 2009: 3,400,632

19781980

19821984

19861988

19901992

19941996

19982000

20022004

2006 - 07

2008 - 09

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

Paying Free

40% 60%

A day at Aravind...

• 850 – 1000 surgeries• 6,000 Outpatients in hospitals • 5-6 outreach camps

– 1500 examined– 300 transported to base for surgery

• 500 – 600 Telemedicine Consultations• Classes for 100 Residents/Fellows & 300 technicians and

administratorsMaking Aravind the largest provider of eye care services

and trainer of eye care personnel in the world

Building Blocks of Aravind

Value System Delivery System

Innovation Dr. G. Venkataswamy

The need to innovateMarket conditions at the ‘bottom of the pyramid’:• Large underserved population • Resource scarcity (Capital and HR)• Dispersed population• Low affordability• Poor logistics

(Based on analysis by Prof. C K Prahalad)

Breaking the access barriers

2008-09:• 2131 screening eye camps• 676,281 patients examined• 61,021 spectacles dispensed• 70,798 surgeries performed

Effectiveness of screening camps?

• We reached only 7% of those in need of eye care1

• Those with rarer eye conditions were not addressed 1 “Low uptake of eye services in rural India”; Astrid E. Fletcher et al; Archives of Ophthalmology Vol 117, Oct 1999

Solution 1: Primary eye care centers• 33 centers covering a

population of 2 million• 215,431 patients seen so far• 40% penetration within the

first year• Everyone receives

telemedicine consultation • Online health records• 91% of them received full

care at the center

Solution 2:Taking super-specialty care to villages

Impact – reaching the unreached• Increased awareness• Influencing health-seeking behaviour• Creating access• Community participation• Growing the market (reaching the unreached)

ARAVIND EYE CARE SYSTEM

Efficiency

Scenario A B

Surgeon 1 1

Tables 1 2Scrub nurse 1 2

Instrument sets 1 6Surgeries/hour 1 6 - 8

Surgical Productivity

Aravind (Wo)manpower

• 300+ village high school girls selected each year• Value fit over skill fit

60% of Aravind’s workforce• Perform most of the routine

clinical tasks• Thus allowing doctors do

what they are best at - diagnosis & surgery

• Results in higher quality, productivity and lowers cost

• The life of these young women are vastly improved

Surgeon Productivity: A comparison

India

Aravind

Bangladesh

Thailand

Indonesia

0 500 1000 1500 2000 2500

Surgical Quality2

Adverse Events During SurgeryAravind, Coimbatore

N=22,912UK National Survey

N=18,472

Capsule rupture and vitreous loss 2.0% 4.4%

Incomplete Cortical Clean up 0.75% 1.00%

Iris Trauma 0.3% 0.7%

Persistent Iris Prolapse 0.01% 0.07%

Anterior Chamber Collapse 0.3% 0.5%

Loss of nuclear fragment into vitreous 0.2% 0.3%

Choroidal Haemorrhage ------ 0.07%

Loss of intra Ocular lens into vitreous 0.01% 0.16%Aravind’s complications are less than half of those in UK

2 “Fortune at the Bottom of the Pyramid” by C. K. Prahalad

Making it affordable• For the patient & the community• For Aravind (to be sustainable)• When most can’t pay

ARAVIND EYE CARE SYSTEM

What we did

• Gave away a lot of it free• Charged market rates for those who can pay• Were helped by market inefficiency• Had the MINDSET

Financial Results

80-81

81-82

82-83

83-84

84-85

85-86

86-87

87-88

88-89

89-90

90-91

91-92

92-93

93-94

94-95

95-96

96-97

97-98

98-99

99-00

00-01

01-02

02-03

03-04

04-05

'05-06

'06-07

07-08

08-09

0

5

10

15

20

25

30

ExpenseRevenue

Free (Camp) 33%Paying 45%

Free (Direct) 22%

Surgery mix in 2008 -09Year: 2008-09

Income: US$ 22 Million

Expenses & Depreciation: US$ 13 Million

EBITA: 39%

Through a unique fee system & effective management, Aravind provides free eye care to 60% of its patients

“Eliminating needless blindness” requires going beyond Aravind

Creating competitionMaking eye care affordable worldwide

Creating Competition “to eliminate needless blindness”

270 Eye Hospitals worldwide

Sharing makes you strongerLions Aravind Institute of community Ophthalmology

To contribute to the prevention and control of global blindness through Teaching, Training, Consultancy, Research, Publications & Advocacy

Promoting Best Practices

Patient access Efficiency Patient care and quality Sustainability with social

responsibility

Publications Capacity Building

Impact: Strengthen eye care programmes capacity to deliver high quality, increase access and be financially viable

Impact of Capacity Building ProcessCataract Surgery (40 Hospitals)

0

20000

40000

60000

80000

100000

1 yr Before 1 yr After 2 yrs After

52506

Cost Recovery

60%

91445

Cost Recovery

90%

76995

CapacityBuilding

Established in 1992 to address the high cost of ophthalmic supplies which had to be imported

Making Eye Care Affordable

Used in 120 countries

Price of IOL came down from $ 100 to $ 2 – making cataract surgery affordable

10 million people see the world through Aurolab’s lenses

7% of global market

Intraocular Lens Division

Pharmaceutical Division

Suture Division Blades Division

InstrumentsDivision

Dr. G. Venkataswamy Eye Research Institute

RCT

Epidemiology

Operations Research

Biostatistics

Genetics

Proteomics

Cell Biology

GLP Facilities

Pharmacology

Microbiology

Immunology Information Technology

Drug Trials

Product Development

Broader Relevance?

Is it applicable to developed countries&

outside of eye care?

ARAVIND EYE CARE SYSTEM

NHS*-UK vs. Aravind

No. of eye surgeriesOphthalmologists

graduating annually

71%59%

(*National Health Service – Main provider of Healthcare in UK)

Cost of delivering eye care< 1% of what it costs in UK

Why is the cost 100 times more?

• It is beyond the simplistic “UK isn’t India”• Consider:

– Efficiency– Clinical process– Cost of supplies– Regulations– Defensive medicine

ARAVIND EYE CARE SYSTEM

Insights

Large population

Cost-effective interventions

Cuts across all economic strata Equity issues

Cost control

Efficiency

Focus on quality Patient centred care

Productivity

Achieving scale

Compassion

Owning the Problem

Conditions Solutions

Aravind’s Evolution1st Decade(1978-1987)

Setting up & developing hospitalsComing into existence Community outreachFocus on Cataract Services

2nd Decade(1988-1997)

Refining & Scaling up internallyMore Hospitals – TVL, CBEEstablishing Aurolab & LAICOEducation and Training

3rd Decade(1998-2007)

Foundation for scaling up externallyExtensive capacity building workExperimenting with Managed HospitalsRapid Growth in Specialty Care Focus on Research

Enhancing Better Eye Care Service Delivery

Increase from quarter million to one million surgeries and serve 6 million outpatients a year

Increase presence in 100 locations (in areas of need)

Clinical and Medical Research Dr. G.V Institute of Medical Research

Through Quality & Affordable Products Aurolab

STILL… This is the Current Reality!

Courtesy: Allen Foster

Pursuing Our MissionEliminating needless blindness

much has been done and much remains to be done . . .

“Intelligence & Capabilities are not enough. There must be the joy of doing something beautiful..”

Dr. V