In this talk organised by MMA in partnership with IIMA, Mr Thulasiraj Ravilla, Executive Director, LAICO & Director Operations, Aravind Eye Care, speaks on the lessons learned in providing care to the needy.
Our first hospital came into existence in 1976 as a post retirement activity of Dr. G Venkataswamy (Dr V). He retired from government service on a very small pension. There wasn’t much wealth around. When his brother built a house, Dr V told him not to move into the house. He started using it as the very first hospital. The four bedrooms became the ward and one of the bedrooms became an operating theatre. That’s how it began.
Today we are in multiple locations, covering Tamil Nadu, Pondicherry and Andhra Pradesh, serving roughly a population of about 10 crores or 100 million. We have seven large hospitals, in each of which we see between 1,000 to 3,000 patients each day; seven smaller hospitals and a number of rural clinics. Typically on an average day, we see between 15,000 to 20,000 patients, most of them in the hospital and some of them in the outreach work. Surgeries vary from 1,500 to 2,000 plus. We do a fair bit of outreach and a lot of academic work as well.
Last year, we handled more than 43 lakh outpatient consultations and more than five lakh surgeries. Close to half of them today are offered free or at a much subsidised rate. It used to be at a much higher proportion when we started. This volume would be somewhat equal to what is done in all of the UK by the NHS, at a very small fraction of their cost. Their budget is about 2.4Bn pounds to deliver similar care.
An Illuminating Purpose
Over time, we have expanded our scope to do a significant amount of research work. We have published more than 350 articles in peer-reviewed journals. We do a lot of consulting and capacity building with a slight twist in the sense that clients don’t pay us. Because of our drive for the purpose, we set up this institute. We do quite a lot of manufacturing as well.
Right from day one, Dr V wanted to continue eye care after his retirement. Even in the government, he was doing a lot of community work and he wanted a means to continue doing that. Our purpose is quite simple. It is “To eliminate needless blindness.” We didn’t put any boundaries around it—geographic or otherwise. Let me discuss some of our approaches that helped us get to where we are today.
Approach 1: Close the Care Loop
When we started in 1976, we used to organise a lot of outreach eye camps and many patients used to be advised to undergo surgery. All these people came to the camp because they could not see. After diagnosing, we would tell them that they have cataract and we would offer them free surgery. But what we found was that very few people came to the hospital for the free surgery and it was really puzzling.
So we did a formal study. We picked at random 100 patients—those that we advised—and then went back to their homes to find out whether they got operated or not. We were able to track 82 patients and we found that less than 15% of them had got operated over that time. It should have been a year or two since the time of diagnosis and advice. We looked at the remaining 85% to see whether they had good vision and if that was why they did not want to come, but the reality was that they were all literally blind.
The other puzzling factor was that most of them wanted to go for surgery and they wanted their sight back. This was a bit of a contradiction. When we dug a little deeper, we found that many of them did not have the means to travel to Madurai. Because they were old and blind, they needed someone to accompany them to the hospital and in those days, surgery required one week of hospitalisation unlike today where you come and leave in a couple of hours. We had put the onus on the patient to come to the hospital and get operated, stay for a week and make arrangements for their food.
I Shall Live With Blindness
This study made us realise that not charging is not the same as being free for the patient. This was an important realisation. This was a sophisticated study that got published and one of the early publications on barriers to healthcare. The real impact of this came when we had a camp in Thiruparankundram—the temple town near Madurai. A beggar by name Sambavan was totally blind. When we diagnosed and offered free surgery to him, he felt very grateful. He fell at Dr V’s feet to bless him but he said, “Sir, I’ll have to forgo this kind offer of yours because if I don’t beg, I won’t have any money to feed myself. So I will probably live with my blindness.” That brought home the message and a very practical approach.
We went back to the drawing board to redesign our services. We decided to provide, in addition to free surgery, free transportation to the hospital and back, as well as food when they are in the hospital. To avoid the need for someone to come with them, which in our cultural context is a necessity, we said we would escort them and bring them back as a group. We assured the family that we would take care of the patient. That seemed to have worked. In the very first camp that we did with this redesign, around 70% of the patients who were advised, landed up in the hospital and immediately had surgery. This is the notion of closing the loop.
Prescription Doesn’t Help
We came about another example. In the early days of the outreach, we used to prescribe glasses. We were not sure if people bought the glasses when we prescribed them. Prescribing a glass requires a lot of effort like taking them to an optometrist who has all the necessary equipment to do that. Again, we did a study and it was an intervention trial. In some camps, we decided to give the glasses on the spot in the camp site itself, while in some camps, we only gave them a prescription. We went back three months later to their homes and found that where we gave only a prescription, less than 25% of them had actually bought the glasses and were wearing them. But in the group where they got the glasses given at the camp site itself, 80 percent of them were wearing glasses.
So in the outreach, we set up an optical shop under a tree or in a classroom. The person could choose the frame that they would like. We also had our own algorithm, considering a wide variety of inventory of lenses and anticipating what powers might be prescribed. As the patients were waiting, we would edge the lens, fit it and then they would try it on. Thus the QC happened right there. The patient tried it out and was able to see. This is something that they pay for. It is not that it is given free. We had completely eliminated the cost of procurement. If we didn’t do this, the patient would have to make at least two or three trips to the nearest town—one to place an order, one to get the glasses and if there is a delay, go back again and that will often cost quite a bit more than the cost of glasses themselves. These have all been our insights.
We recognize that providing services isn’t good enough. We have to enable the customer to access it. This probably holds good far beyond eye care as well. In our case, it stems from owning the problem. We all tend to draw some boundaries. Most healthcare providers will draw the boundary around diagnosis and prescription of treatment. Accessing the care is completely left to the patient and very few monitor that. Because we monitored, we were able to recognise the impact of doing this. Again, looking back from a business point of view, the customer satisfaction happens only when they get the benefit of the intervention. That cannot happen until the patient is able to follow through the advice. The more and more we did this, our own reputation in the market also grew.
Approach 2: Focus On Non-Customers
Because our purpose was to eliminate needless blindness, the focus shifted to those who are not seeking care. Those who seek care would get it in any case. Our approach used to be doing eye camps. Some of the camps used to attract thousands of patients. In the pre-covid year, we had more than 3,000 outreach camps, saw more than five lakh patients and close to one lakh patients received surgery—cataract plus other surgeries. Even though we had such high numbers, our founder asked the question, “Is this good enough? Are we reaching everyone? Will we reach our purpose that we stated?”
Again, we did a formal study wherein we organised 50 eye camps. We went back into those communities, house-to-house and found out how many people had eye problems and for which they felt they needed help. We made a list of all those patients. We went back to our records and found out that only 7% of them came to the eye camps and it was very disappointing. We knew that the eye camps draw a large number of people. Until this study was done in 1999, for almost 25 years, we were lulled by the high numerator that we saw. We didn’t pay attention to the denominator and once we did that, we recognised that we were not even scratching the surface through our approach of outreach and something else needed to be done.
The question was, “Can we have our permanent hospital-like facility, instead of having an eye camp, which we do once a year for a period of five to six hours, usually at our convenience and based on availability of doctors, etc?” We realised the community can’t access it. So we came up with the design and the first technology enabled centre was opened in 2004. Those days, the internet was not there in the villages. We put up our own towers and created our own closed user group network using Wi-Fi, going over long distances. This is a design that we came up with.
A patient walks into the centre and pays 20 rupees, which is good for three visits. There is a technician who is well trained to do a complete eye exam as you would get it done in an ophthalmologist’s office. We also check for other things like blood pressure, sugar and intraocular pressure. A doctor at the remote end is able to talk to the patient and every patient gets a tele-consultation. Today we do about 3,000 consultations each day and ours is probably one of the largest models. If a particular patient requires only glasses, it is made available right at the centre itself. So within half an hour of their coming with a problem, it is completely resolved. This focus helped quite a bit.
Eyeing for AI
Today we are incorporating new technologies. We have been working with Google for several years and they have developed a cloud-based AI service, wherein the technician just takes an image of the retina and then pastes it in the application. We have developed the front end. It takes literally 10 to 12 seconds for a complete analysis of the retina-whether there is a diabetic retinopathy, if the patient needs to be referred to, how severe the condition is, etc. These have been validated through independent studies. This brought in a much higher level of diagnostic calibre into the hands of the primary care provider. We now have 103 of these Vision Centers dotting across Tamil Nadu. Last year, we handled over seven lakh patients through this network.
When we set up the vision centers, we got a little bit wiser and became denominator focused. We could estimate the number of people who are likely to have an eye problem and it is around 25% of the population. Everybody above 40 may need glasses or something more complex. This is what we found. The 91 vision centres covered a little less than 8 million people. Within that group, more than two million people had registered, which is about 26 percent. So we feel that we probably have a hundred percent market coverage through this approach of sustained work.
Promoting Best Practices
Having done this, a part of our purpose is also to promote best practices elsewhere. We are working with many governments, for them to adopt this care, so that eye care becomes available and accessible. Each vision center covers about 8 to 10 km radius. The access becomes very simple and easy. We are working to propagate this model far beyond Aravind. The insight was that building the market requires a lot of proactiveness, which is not default amongst healthcare providers, who tend to be very reactive to those who present themselves.
Approach 3: Perspective to Cost
The next approach that we took was about how we viewed the cost. Typically, the approach tends to be viewing the cost with respect to how much we charge. But then we realised that we need to really work on the total cost to the patient, which includes lost wages and many other things. So once we had that recognition, we came up with the patient-centric service design. We never had any appointments because appointments actually add cost to the patient. If there was no appointment, they can easily combine it with something else like coming to the town for shopping or a wedding. There are so many other opportunities they can leverage.
We also don’t have any waiting lines. If surgery is advised today, the next day they would get it done. We work on completing the care on a single visit, which tremendously reduces their cost. Because we have multiple tiers of care, we are also able to do the care at appropriate local levels. Every hospital in our system has a paying and a free section. The patient is free to choose where they want to go. There is no gatekeeping mechanism. It is completely on an honour system.
Focus on Efficiency and Quality
On the hospital side, we focused on efficiency and quality, both of which drive costs down, and also on managing bottlenecks. To ensure quality, we broke down the notion of patient centricity into actionable modules or domains. We came up with 10 areas and we were able to develop separate systems to ensure quality. We also have robust patient feedback. Quality at one level is clinical outcome and at the other level, it is the patient experience which we constantly monitor and give feedback to the individual teams, usually in a benchmarked manner. Every clinic will have their score as well as the score of others which tends to drive improvement.
On the clinical side as well, we have done a lot of work. Post-surgery, the infection rate used to be about seven or eight per 10,000 which was the acceptable international level. But to our chairman, who is an ophthalmologist, this was not acceptable. After doing some literature search and study, he came up with the process of injecting a very small quantity of antibiotic in the eye at the end of the surgery. After this, the infection rates have come down. It is now the standard procedure across all the hospitals for every surgery and our infection rates are between zero to one or two per 10,000, which is 1/4th of what is reported in the UK or US. So the clinical outcomes have been very tightly monitored and we can quite confidently say that our infection or any complication rate is probably about half to one-third or one-fourth of what is reported in the west.
Lean Tools That Helped
The other aspect around efficiency was with HR and within the HR, it is the doctors—the ophthalmologists. We wanted to optimise their output. If a surgeon had one table and one set of instruments and somebody supporting them, they can at best do one surgery per hour. But to the same surgeon, if you give another table with another support staff and more instrument sets, the same surgeon can do six to eight surgeries per hour. Basically, we are leveraging the dead time that they wait between surgeries.
When a surgeon is operating on one table, the next patient is made ready on the other table. Once the surgery is done, the surgeon just swings the microscope over to the other side. Even the position of the microscope is done in such a way that we don’t fiddle it too much to refocus. Such process improvements have helped us achieve a much higher level of productivity, which in a way drives our financial model as well. But beyond these techniques, it is the ethos that our founder put in, that really matters. Having empathy and compassion helps us think in a certain manner.
The Challenges and Opportunities
Every one of us has challenges in our lives and in the organisations that we run. We clearly have two options—either we complain or figure out what we can do about it. In the early 1970s and 80s, cataract surgery meant that you did the surgery and gave the person a pair of thick glasses. In the late 1980s, the technology emerged by which you could implant a lens inside the eye. In the early days, it used to cost around $300 per lens. Even the rich in India could not afford that. So the World Health Organization, Government of India and all the funding agencies felt that this technology was not suited for developing countries because of the prohibitive cost. In their mind, the budget that they had, would only go to fewer people if we adopted this technology.
That is when we took the plunge of starting a manufacturing unit even though we had no experience in it. We now make and sell about 3 million IOLs per year, which is roughly 10 to 12 percent of the global market. When Auro Lab launched the product, we had a 10x price disruption. If a lens cost about hundred dollars, our starting price used to be around ten dollars and today it is much less.
The other challenge that we had with HR was not having enough trained nurses and doctors. Over the years, we worked to develop our internal pipeline. We have 330 doctors who are consultants. We also have 400 doctors in training, either to become an ophthalmologist or a subspecialist. They keep feeding into the pool to take care of attrition. We follow the same system with our support staff as well.
We are also working on technologies which can be de-skilled, because if there’s one common problem in HR, it is finding people. We can either de-skill or use technologies to reduce that need. We also worked quite a bit on creating an enabling work environment, basically removing the frustration elements. Our people enjoy working. We have a day care centre as most of our staff are young women and they all have tiny babies. We take care of all the costs.
Sustainability and the Triple Win
The other area that we have been working on is the environment. Healthcare in India accounts for five percent of our carbon footprint. In the US, it is about 14%. We felt we had a moral responsibility to reduce it, so we adopted very lean, clinical protocols and recycled the biomedical waste from surgeries. The studies have shown that our carbon emissions per surgery is 1/20th of what is reported in the west.
We have been developing over the years models for environmental sustainability wherein we have been paying attention to the building. Most of our hospitals are net zero grid energy. That means, we generate our own solar power or purchase solar and wind power from outside. All our hospitals have water recycling. We recycle about two million litres of water per day.
We pay a lot of attention to the use of all the resources. A lot of our lean protocols reduce travel for the patients. All our staff have housing in the campus, so we eliminate the travel to work. Many of these approaches have helped us to score a triple win. Because when we pay attention to environment and do appropriate things, we get triple benefits:
- We reduce the efforts for the patients.
- We are able to get more patients and it ends up costing less for the care providers.
- Together, the carbon emissions come down.
The broad impact of all these approaches has helped us to be on a continuous growth path over the years, except for a dip during the covid. We have a large offering of training programs. We have more than 40 courses and trained more than 12,000 eye care professionals from across the world. We have produced more than 1,000 ophthalmologists and several sub specialists.
In 1992, we set up an Institute to help other eye hospitals to perform better, basically by sharing the best practices and that has helped us to add close to 800,000 to a million additional surgeries per year happening in perpetuity. We have lots of publications. Financially, we are quite well off. In fact, as a principle, we don’t raise money for our core caregiving process. We have a healthy surplus after meeting all the care for the poor patients, which goes in for expansion and growth. As a strategy, we promote competition because many more players are required to achieve our broad purpose of eliminating needless blindness.