ONE MISSION, MULTIPLE ROADS : ARAVIND EYE CARE SYSTEM IN 2009

Presented By:-

Team 1 

Source http://www.aravind.org

Source http://www.softexpune.org

AEH- Madurai

INTRODUCTION Aravind Eye Care Hospital is an ophthalmological hospital with several locations in India.

Currently located at Madurai, Pondicherry, Coimbatore, Theni, Tirunelveli, Kolkata & Amethi

Founded by Dr G. Venkataswamy in 1976 at Madurai

Awards (in 2008 -2009) Bill and Melinda Gates Award for Global Health

Acknowledged by Clinton Global Initiative in Sep 2008

Recognized by C.K.Prahalad in his book ‘The fortune at the bottom of pyramid’

AUROLAB - MADURAI

Source http://www.aravind.org

INTRODUCTION Mission

“Elimination of needless blindness” By the end of 2009 AECS had set up 31 Vision Centres and 5 Community Eye Clinics (Outreach Programme).

Aravind Managed Eye Care Services (AMECS) Dr V had been succeeded by Dr P. Namperumalsamy (Dr Nam)in 2006

Its manufacturing arm Aurolab had moved to new facility at Madurai.

AECS: HISTORICAL PERSPECTIVE Established by Dr V as a 11 bed hospital at Madurai in

1976. Dr V served Army Medical Corps from 1944 to 1948 Trained himself to do microsurgery and technique of

Intraocular Lens (IOL) insertion. AECS Policy

To serve paying as well as free patients.

Close control of costs, high productivity of doctors and achieving high volumes

AECS vital components - Values and spirituality

Mr. R.D. Thulasiraj (Executive & IT Director at LAICO)“Our operational model is heavily dependent on work culture values.The systems are built in our basic values”.

AECS: HISTORICAL PERSPECTIVE Focused on cataract surgery. Established 2 bed system of operation to increase productivity of doctors. Productivity rate of doctor 25 surgeries/day/doctor in contrast

to general avg of 5-6 surgeries/day/doctor.

High quality surgical and medical equipments used. Manufactured IOLs in house at Aurolab. Cost of Imported IOL $80 and Aurolab’s IOL $5. 60% of surgeries were done free or almost free. AECS grew quickly –

In 1997 - 1,23,095 Surgeries and 9,75,868 Outpatients per year

In 2003 - 2,02,066 Surgeries and 14,50,000 Outpatients per year

AECS: HISTORICAL PERSPECTIVE AECS created surplus income despite providing

free treatment. In 2002-03 it had surplus of Rs 219 Mn out of total income of Rs 423 Mn

UNIT Free/Subsidized Bed

Paying Beds

Total OT/Tables

Madurai 900 325 1225 13/49

Tirunelveli 482 158 640 5/16

Theni 123 40 163 2/8

Coimbatore 580 176 756 11/20

Pondicherry 600 136 736 8/21

Total 2685 835 3500 39/114

Exhibit 1 : AECS , no of beds in different Hospitals

Source: Data supplied by AECS

AESC did not consider the number of beds to be an important parameter as most of the cataract patients were discharged the same day.

Also, no. of mats had been converted to regular cost, and the average stay of the patient had reduced.

Hence the no. of surgeries done was a more meaningful indicator of its impact than the no. of beds

NO. OF SURGERIES UNDERTAKEN AND THE NO. OF OUTPATIENT VISITS OF

PAYING AND FREE PATIENTS, 2003-2009 Year

Paying

Free including camp

Total

OP visits Surgery

OP visits

Surgery

OP visits Surgery

2003 758,991 78,487 688,548

123,579 1,447,575

202,066

2004 870,171 85,745 765,860

141,690 1,636,031

227,435

2005 928,785 93,134 793,113

154,101 1.721,898

247,235

Jan 2006 till March 2007

1,140,765

104,108 1,037,572

147,989 2,178,336

252,097

April 2007 to March 2008

1,101,154

114,464 1,073,614

148,202 2,174,768

262,666

April 2008 to March 2009

1,182,137

131,295 1,273,811

138,282 2,455,948

269,577

Source: Data supplied by Aravind eye care system

OUTREACH ACTIVITIES BY AECS

AECS conducted a number of outreach activities in accordance with its mission.

EYE CAMPS were the most important for they symbolized the organization’s determination to reach out to the people in the villages.

COMPREHENSIVE EYE CAMPS was the most important type of eye camp, where, complete examination of eye was done, spectacles were prescribed and delivered on the spot in about 70% of the cases

EYE CAMPS CONDUCTED, 2003-2009

Year No. of camps organized

Patients seen Surgeries of “camp” patients

2003 1158 388,594 81,357

2004 1271 433,502 95,249

2005 1335 437,224 98,3262006 1442 412,683 92,3462007 1448 377,377 87,667

2008 1302 320,563 69,580

2009 1319 314,780 71,869

Source: Data supplied by Aravind Eye Care System

AECS also organized diabetic retinopathy (DR) camps, refractive error camps, eye screening camps for school children, pediatric camps, and mobile van DR screening camps.

AECS had also setup its training institute, Arvind Post-Graduate Institute of Ophthalmology (APGIM) which offered PG program, fellowship program for super specialization and Ophthalmic Assistant’s training.

Its manufacturing arm, Aurolab, produced IOLs and medical consumables for eye care, like sutures and medications at low cost.

AECS achieved economies of scale by providing medical consumables to other hospitals and ophthalmologists outside AECS since its inception.

This was also in consonance with its mission of elimination of needless blindness.

This helped many hospitals not only in India but also abroad to conduct surgeries at a much lower cost.

Some of the pioneering products from Aurolabs are: Auroflex-EV, negative aspheric IOLs for better contrast and visibility in low light conditions, green laser photo coagulators etc.

R&D

INITIATIVES Aravind Medical Research Foundation expanded its research activities dramatically with the commissioning of Dr. G. Venkataswamy Research Institute on 1st October, 2008.

It was engaged in cutting edge research in all the areas connected to eye diseases.

Some researches going here are:

1. Vision Rehabilitation

2. Glucoma Studies

3. Retina Services and Drug Trials

4. Orbit and Oculoplasty

5. Cornea Clinic

LAICO AECS ‘ training arm, Lions Aravind Institute of

Community Ophthalmology (LAICO) offered training programs to outside hospitals to improve their practices.

LAICO provided programs both in techniques of surgery and in management of doctors, hospital managers and paramedics.

LAICO provides training programs both at its facilities at Madhurai, at customer sites and also in a number of foreign countries.

It also undertook consultancy for improving the performance of hospitals, with need assessment, vision building workshops, follow-up visits and monitoring.

CHANGES IN ENVIRONMENT

INCIDENCE OF CATARACT AS THE MAJOR CAUSE FOR

BLINDNESSCataract accounted for 62.6% of blindness.

Increased awareness resulted in early surgeries.

Cataract Surgery Rate(CSR) ( average per million of population) India : 5000 Tamil Nadu : 9000 Bihar : 600

Increase in % of Intraocular Lens(IOL)

High degree of operational efficiency enabled AECS to provide free surgeries to as much as 60% of its patients.

Source : Aarvind Eye Care System(2009),activity report,2008-2009

Category of surgery # Surgeries Percentage

Cataract 204,672 66.23

Laser Procedures 57,958 18.76

Retina & Vitreous surgery 8,393 2.72

Trab & combined procedures 7,099 2.30

Lacrimal surgeries 5,218 1.69

Other orbit & Oculoplasty surgeries

6,336 2.05

Ocular injuries 1,164 0.38

Pterygium 3,565 1.15

LASIK refractive surgery 3,459 1.12

Other surgeries 9,458 0.55

Total surgeries 309,015 100

REDUCED DEMAND FOR FREE SERVICES

General improvement in the living conditions.

Expectation of patients going up.Multiple insurance schemes

Private State sponsored

CHANGES IN THE DEMAND FOR OTHER AREAS OF EYE CARE

Diabetic Retinotherapy (DR) – that included control of diabetes,refraction correction and prevention and treatment of glaucoma.

Unlike cataract,DR was preventableFocus on prevention and early attention then cure, effective screening for diabetes and monitoring of the patients.

Glaucoma if left untreated also lead to blindness.

Refraction correction too had become an important area of concern.

CAUSES FOR BLINDNESS IN INDIA IN 2003

Percentage Cataract 62.6Refractive errors 19.7Corneal blindness 0.9Glaucoma 5.8others 11.0Source : vision 2020 document

EXPECTATIONS FROM DOCTOR

Doctor’s salaries were becoming highly competitive .

They were looking for opportunities to establish there name and in particular, looking for opportunities to do research , publish papers , to take part in conference and network among peers .

These would increase doctors competences and also the hospital’s visibility .

COMPETITION

New hospitals with better looking building and better room and food facilities were coming up.

New hospital enticed the doctor’s with better pay but none of them offered comparative scope for professional advancement.

Most of the doctor’s in these private chains were ex-AECS personnel.

CONTINUED INCIDENCE OF BLINDNESS Out of 45 million blind population in the world , 7 million

were in india .

12 million bilaterally blind persons in india with VA less than 6/60

11,000 eye surgeons in India

1 for about 100,000 people

50% qualified eye surgeons are “non operating “ surgeons

Many of the operating surgeons could not perform IOL surgeries .

These factor impacted the overall effectiveness of anti-cataract campaign

Paediatric blindness was also an area to be addressed . About 0.8 per 1000 children were estimated to have serious vision problem .

ARVIND EYE CARE SYSTEM RESPONSES

1. REDUCED PERCENTAGE OF CATARACT SURGERIES & EXPANSION INTO OTHER AREAS

Absolute number still increased but as a percentage it

reduced.

Laser surgeries = 20% of AESCS’s surgeries

Performed in smaller units too- like in Theni &

Tirunelveli.

Other areas gained importance

2. REDUCTION IN EYE CAMPS

Four types of eye camps:

1. Traditional comprehensive eye camps

2. Diabetic retinopathy(DR) screening camps

(Mobile van screening camps)

3. Refraction Camps

4. School Eye Screening Camps

Camps provided a benefit of increased reach and number of

patients attended

Still only 8% of the people requiring screens were being

screened

3. ESTABLISHMENT OF A NETWORK OF VISION CENTRES (VC) AND COMMUNITY EYE CLINICS(CEC) VC: small unit staffed with an opthalmic technician and had

telemedicine support from the base hospital and an admin

support person with doctor available on video.

31 VCs (plan to increase to about 50) with each serving a

population of about 50,000 operating from rented buildings.

Patients were charged Rs.20

CECs: larger than VCs but smaller than hospitals with

1doctor visit per day and one of each- optician, field

organizer, optical shop person, nurse. Had diagnostics

facility, prescribe and delivery spectacles. 5 CECs with

around 60-70 patients/day & served a population of about

3,00,000

5. OTHER OUTREACH ACTIVITIES

• School camps- 210,139 students (base) & 67,237 students (VCs)

• Mobile screening vans.

• Paediatric screening camps

• Refraction camps

6. Arvind Managed Eye Care Services (AMECS)

• Trained Doctors in other hospitals to improve their efficiency

• AECS neither provided any facilities nor made any investment

• Selected personnel were sent to supervise the activities

• 5 yr agreement.

7. UPGRADING OF FACILITIES• Private rooms- new block @ AEH, Madurai• Floor mats for free patients• AECS’ Centre for Patient Empowerment intended to improve

eye care awareness in patients and the community

8. Emphasis On Research• Focus on research on- DR, transplantation of cells etc.• Means of providing development opportunities to

doctors- optional 1 day/week off- international conferences etc.- a “retention” strategy.

• Research- a source of funds: about Rs 15million (2008-09).

• Brand new research facility -in 2008- Dr.G. Venkataswamy Eye Research Institute, Rs 290 mn.

• 25 research scholars in 2009.

EXHIBIT 12ARTICLES PUBLISHED BY AECS’ STAFF IN INTERNATIONAL AND NATIONAL PEER REVIEW JOURNALS,2004-08

Year No. of Publications

2004 46

2005 49

2006 70

2007 65

2008 73

Total 303

Source: Data as supplied by AECS

EXHIBIT 13NUMBER OF PUBLISHED RESEARCH ARTICLES BY STAFF OF DR. G. V. EYE RESEARCH FOUNDATION, 2004-08

2004 4

2005 2

2006 8

2007 8

2008 12

Total 34

Source: Data as supplied by AECS

ISSUES IN FUTURE

1.BASIC VISION FOR AECS “Our emphasis is to be at par with the best eye hospitals in the

world without diluting our vision....We see our activities in four

broad areas- paediatric eye care, cataract, retinopathy, glaucoma,

and refraction”

- Dr. Nam

They have plenty resources and therefore various options are

available.

“We are a highly mission driven set of people. Resources are not

the only consideration in deciding the direction of growth”

- Dr. Kim

2. GROWTH DIRECTIONS

• There were a number of directions that AECS could

take; the real problem was one of prioritization. The

various directions ,as suggested by the key personnel

at Aravind eye care, are as follows:

a) According to Dr. Nam: Diabetes is a challenge. To reach 46 million diabetics in

India , innovative methods are needed. E.g. Paramedic

Cataract prevention, refraction correction, glaucoma, etc. Will

become important.

Thus, Dr. Nam said, “We need to move in multiple directions.”

b) According to Mr. Thulasiraj:

“ We have a tremendous opportunity in the treatment of refractive errors.” “We can set up a network of Refraction Centers.”

He also saw big opportunity in training. He saw opportunities in LAICO.

There will also be a Projects Division to manage research projects.

c) According to Dr. Aravind:

“Resources are not a problem. The challenge today is our aspiration, not our resources. How do we retain the same hunger and the same passion?”

Dr. Thulasiraj also shared similar concern- “ We have to address mindset issues. We are diffident about moving out of our comfort zone.”

3. GEOGRAPHIC EXPANSION There were different views on whether and how to grow

beyond Tamil Nadu. They are as follows:

1. Concerns about culture:

a) Dr. Nam felt that expansion to other Indian states is an

issue. He said “ Culture is an important issue for us.”

Speaking about his concerns, he further said “We still

have our doubts on the feasibility of transmission of

values like compassionate care”

b) Dr. Kim and Mr. Thulasiraj shared similar concern about

culture transferability. Dr. Kim said “Business models

should not obscure our hospital’s growth model.”.

2. AECS executives saw opportunities to expand

globally in certain activities

a) According to Dr. Nam: “DR (Diabetes Retinopathy) can

be studied adopting a global approach.”

b) Dr. Kim – “ We are moving into research , especially in

specialities. We have to give new services that are

currently not available but necessary for eye care to

stay ahead of competition .”

c) Mr. Thulasiraj said “ We have a global opportunity. There

are 135 countries in the world with a population of less

than 20 million each.” “We can thus give our knowledge

and offer our services in many of these countries.”

4. HR ISSUES A major challenge was to develop a large cadre of doctors, nurses and paramedics, especially because they had to be imbibed with the right values. The various challenges are:

1. Training:

a) Dr. Nam said “We need to train more ophthalmologists in DR surgical procedures. Knowledge management is important. We are doing this through our Virtual Academy.”

b) Dr. Kim said that MLOP (Middle Level Ophthalmic Personnel) training is becoming an important activity.

2. Developing next generation: Dr. Aravind said, “the older generation

is now in the sixties. And except for a few, the younger generation is in forties. There could be a situation when the younger generation would have to take over responsibilities before they are fully ready.”

AECS is preparing itself for the same. For example, LAICO is developing a cadre of managers for AECS.

CONCLUSION• Change of metrics from no. of beds

to no. of surgeries.• Standardization is helpful in

achieving efficiency.• Prepared for problems and Ready

for the risk management.• For the long run, the organization

have to take necessary steps to succeed.

LEARNING FROM THE CASE

STANDARDIZATION

MAKE AWARENESS

RESEARCH AND DEVELOPMENT

READY TO TAP OPPORTUNITIES

LEARNING- TIME TO TIME

GIVE BACK TO SOCIETY

LASIK AND OTHER EYE SURGERIES

THANK YOU