Remember ME - You Me and Dementia

Thursday, January 13, 2011

Trust built on vision

The Aravind eyecare organisation, which does 1,000 surgeries and 6,000 consultations every day, was inspired by the MacDonald’s model of efficiency and affordability.

After coping with myopia (near-sightedness) from the age of 7, I grew more than a little careless because my eyes didn’t seem to be getting any worse after years of heavy computer use. In my 40s, however, I needed an additional pair of reading glasses. Then things started going wrong. That was when I encountered Aravind, the world’s largest eyecare service provider -- in terms of surgical volume and number of patients treated. Aravind is a trust situated in the heart of Madurai, Tamil Nadu.

What is unusual about Aravind is the manner in which it was set up and how it grew. And the model it follows to keep healthcare within reach of almost everyone. It remains a mystery as to why Aravind’s efforts are well known to the outside world but barely acknowledged in India. Indeed, there is more information on Aravind on the Stanford networks and inspirational TED talks than there are articles in the Indian media.

Madurai, known as the temple city, is also said to be the oldest inhabited city on the Indian peninsula. This city of 1.2 million people is the second largest city in Tamil Nadu. And it draws eye patients from all over India thanks to the dream of a retired doctor.

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It was just past 6 am when an enthusiastic rickshaw driver dropped me at the hospital where patients were already beginning to queue up. In the clean, orderly reception area -- there is a crowd, but no pushing -- a notice board spells out the hospital’s mission: ‘To eliminate needless blindness’.

By the time I left Aravind, after eating a Rs 20 simple rice plate, I was impressed by a number of things including the efficiency, scalability, respect with which the hospital treats its patients (even the poorest), and above all, the organisation’s logic and deep insight into how to make things work in a resource-poor, talent-rich country.

If only other non-profits and trusts were like Aravind, there would be serious hope for change in our country. No longer would the business of doing good simply mean tiny, well-funded projects with insignificant impact and lack of scalability.

* * *

Aravind calls itself “the largest and most productive eyecare facility in the world, in terms of surgical volume and number of patients treated”. Besides its hospitals, it has a manufacturing centre for ophthalmic products, an international research foundation and a resource and training centre “that is revolutionising hundreds of eyecare programmes across the developing world”. Aravind says its focus is to reach people who need eyecare but don’t seek it as many live far from a doctor, or treatment is too costly.

Aravind’s figures are impressive: “From April 2006 to March 2007, including the work done in the managed eye hospitals, over 2.3 million outpatients were treated, and over 270,444 surgeries were performed.” (Source:

These are phenomenal numbers given the small network of hospitals (in Madurai, Theni, Tiruneleveli, Coimbatore and Pondicherry, and three ‘managing’ hospitals including one in Amethi, Uttar Pradesh, and Kolkata). Aravind started out as an 11-bed hospital in 1978!

Without any sense of false pride, Aravind’s leadership team member Thulasiraj Ravilla (59) says in a TED talk: “I’ve come here to share with you an experiment, of how to get rid of one form of human suffering.” Ravilla is executive director of the Lions Aravind Institute of Community Ophthalmology. (See the talk here:

The video explains “what it means to be blind” by letting a Tamil-speaking village woman talk of her plight. Consider the figures: one in five Indians (a staggering 200 million) would need eyecare. Today, Aravind reaches about 5% of this figure, with 4,000 beds in five hospitals, 33 primary eyecare centres, and its managed eye hospitals.

On a typical day, they do about 1,000 surgeries, see 6,000 out-patients, hold five or six outreach camps, and offer 500 “telemedicine” consultations, apart from training doctors.

The inspiration to do all this every day, “and to do it well”, comes from Aravind’s founder, Dr Govindappa Venkataswamy (Dr V). Born in 1918 in a small village, Venkataswamy got a medical degree in 1944 and joined the Indian Army Medical Corps. But he was forced to retire in 1948 after severe rheumatoid arthritis left his fingers crippled.

This changed the course of his life. Venkataswamy continued in ophthalmology, training himself to hold a scalpel and to perform cataract surgery. He conducted an estimated 1 lakh successful eye surgeries.

Journalists who met him a short while before he passed away, were surprised to learn that Aravind’s eyecare model was inspired by MacDonald’s. Venkataswamy wanted to offer eyecare with the same efficiency as MacDonald’s, and build a “franchisee model” that would continue to grow.

At the OPD, everyone is treated with dignity and respect. And the charge is a mere Rs 50, except when additional tests are required.

Aravind’a reputation comes, apparently, from some smart thinking. It works to minimise downtime. Physician time is maximised by focusing on judgement-oriented activities, leaving other tasks to specially-trained “ophthalmic technicians”.

These technicians are young women who have passed high school and have undergone a detailed two-year training course in ophthalmic techniques. Four to five of these girls support each doctor, taking some of the pressure off the doctor. The ones I encountered at Madurai were capable and smart enough to run the patients’ arrival centre, taking rudimentary eye tests and preparing patients to be checked by doctors, etc.

“My eyes have been dilated,” I told the young lady who was peering into my pupils with a torch. “They’re only semi-dilated,” she replied politely but firmly putting a couple more drops into them.

Aravind’s global reputation also comes from software-assisted formal outcome monitoring, improvement programmes -- what it calls “standardisation without stifling innovation”, and collaboration and exchange programmes.
(See this audio interview

What’s important is that the organisation believes its work can be replicated in other eyecare ventures, and beyond. Oddly, there wasn’t “any plan to become what we are”. But vision and orientation played a crucial role. Together with caring for the needy, there is a private practice component that helps generate revenue. Free eye camps for the poor though have been operational right from the start.

Aravind has always tried to live within its means. This has made them cost-conscious and “very efficient in what we do”; something most non-profits and NGOs can learn a lot from. Every activity has been put through a sustainability test.

Online interviews call this “compassionate capitalism”. Others see it as socialism in action -- you pay what you can afford, and get the treatment you need. Nobody is forced to pay, though those who pay get better facilities and private rooms. The treatment remains the same.

Aravind has made real attempts to reach out to people who can’t afford to come to them; those not yet “part of the market”. They have worked with Lions and Rotary clubs, churches and temples, to extend their reach to villages.

As Ravilla says in interviews, they quickly realised that ‘free’ eye camps weren’t really free at all. Unless a really poor person gets his transportation costs to the hospital, food whilst under treatment, and medication for the post-operation period, he still will not be able to afford the so-called ‘free’ treatment.

Entry costs at Aravind are low; the consulting fee is just Rs 50. And that could last for three visits or three months! Costly equipment too is kept in use for much of the day, allowing them to earn and also finance their expansion.

Doctors, operating theatres and high-end equipment are never kept idle. Though I didn’t experience it myself, in the operating theatre a doctor has two operating tables ready for him, saving on time between operations.

Another small miracle is how Aravind manages to lower the cost of ophthalmic equipment by taking up some of the production in India. Aurolab (, the manufacturing division of Aravind Eye Hospital, offers ophthalmic consumables at affordable prices to other developing countries. Since 1992, Aurolab has supplied more than 7 million lenses to its customers in India and over 120 countries worldwide. Established in 1992, Aurolab has set up manufacturing facilities to produce intra-ocular lenses (IOLs), suture needles, pharmaceuticals, spectacle lenses and hearing aids.

Outcomes are monitored carefully and every attempt is made at standardisation. Collaborations with global institutions help.

Aravind has shown that being not-for-profit and being a trust does not mean one has to be small!

By Frederick Noronha a Goa-based writer.


Forget yourself for others, and others will never forget you.

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