Aravind Eye Care System

‘Enhancing Access & Affordability’

Dr.R.D.Ravindran Chairman Aravind Eye Hospitals Aravind Blindness Magnitude

• 45 million blind, worldwide • 12 million blind in India • 300,000 of them children Aravind 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

Aravind Challenges - underserved population • Managing fluctuating incomes/low affordability • Difficult living conditions • Unfamiliar with many products, technologies & procedures • Seek trusted advice • Demand respect • Face disadvantages in market

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

Dr.Venkatasamy, feeling the urgent need, started an eye clinic in 1976 on his retirement with 11 beds, to create an alternate, sustainable eye care system to supplement the government’s efforts. Our challenges

• Creating access • Making it affordable • Ensuring quality • Resource scarcity (Capital and HR)

Universal concerns ?? - variable levels

India: Population 1.1 billion 200 million need eye care Addressing the access barriers

Community outreach • 40-45 screening camps/week • Community participation • Free surgery, food & transportation

Performance of outreach in 2008-09 Number of Screening Camps 2,131 Eye Camp outpatient visit 676,281 Surgeries through Eye Camps 70,798 GIS for planning outreach publicity & tracking under-served areas Camp location : Devadanapatti, District Villages with 10km radius of camp site (Devathanpatty, )

Boys Girls Name of the Resi Total No Male Female under under House Popln. Village 6 yrs 6 yrs 1 Keelavadagarai 1,204 5,207 2,658 2,549 410 372 2 Silvarpatty 1,347 6,039 3,073 2,966 455 403 3 459 2,013 1,109 904 118 101 4 Melmangalam 1,659 6,982 3,523 3,459 489 457 5 Jeyamangalam 3,676 16,151 8,346 7,805 1,232 1,042 6 D.Vadipatty 132 592 305 287 53 28 7 Pudukottai 439 1,930 993 937 155 137 8 Devadanapatty 3,968 17,905 9,096 8,809 1,282 1,200 9 Genguvarpatty 3,687 15,732 7,943 7,789 1,219 1,030 10 Parambikaradu 126 554 270 284 49 32 11 Poolathur 814 3,229 1,629 1,600 256 207 Total 17,511 76,334 38,945 37,389 5,718 5,009

Resulted in a 30% increase on camp productivity(patients per camp) 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 Enhancing access Vision Centers • Permanent facility in rural areas • Covering small population - 50,000 • Staffed by technicians (tough to get doctors to work in villages)

Challenge: • Comprehensive eye exam • Ensuring quality – right diagnosis & prescription Low Cost Wi-Fi 802.11b Connectivity (4 MBPS Up to 75 KM)

. Unidirectional antenna Collaboration with Univ. of . Line of sight Berkeley (PhD students) Innovation: Low-cost imaging technology

Investment: • Digital Camera + Adapter • US$ 250 Vs. • Digital Fundus Camera: • US$ 25,000 EMR with image integration Vision Centers – how they work Performance – 39 Centers

• Every day we video-consult with 700 patients • 70 to 80 are given corrective glasses • 35 to 40 patients are advised to have surgery • 35 to 40 diabetics are counselled regarding DR Impact - Access

• Access: eg: No one in Theni district needs to travel for more than 10km for their eye care Aravind Eye Hospital Vision Center Community Center Solution 2: Taking advanced care to villages

• Goes to remote places • Known diabetic pts. Fundus images are taken • Recorded in a specialized software and transmitted to the Reading Grading Center at the Base Hospital

Achieving Universal Access

Key strategies:

• Designing services for the non-customer • Community involvement • Monitoring Impact – reaching the unreached

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

ARAVIND EYE CARE SYSTEM Making it affordable

•When most can’t pay •For the provider with limited resources Defining costs

• Provider perspective - price of service/product

• Customer/community perspective – Time investment and lost wages – Cost of access – Similar costs incurred by accompanying person – Price of service/product as above – Cost of repeat visits Vision Center – Saved costs

Cost in Rs. Persons Other Lost Transport Total Expenses Wages Visiting the nearest eye hospital for care: Patient 1 25 50 100 175 Patient attendant 1 25 50 100 175 Total 50 100 200 350 To the Vision Centre Patient 1 10 20 50 80 Patient attendant 0.5 5 10 25 40 Total 15 30 75 120 Savings: `. 230 per visit (roughly `. 46 lakhs for the 20,000 patients seen monthly) Processes to minimize ‘patients’ costs Costs of access, lost wages, and incidental expenses can be significant

• Completing all investigations on a single visit • Eliminating unnecessary tests • No waiting list • Minimizing length of stay Costs associated – Patient

• Cost of spectacles - Rs. 175 – Rs. 250 • Cost of getting glasses – Rs.150 to 250 Involves 2 to 4 trips for: • examination • ordering the glasses • getting the glasses • ensuring that the glasses are right. • The above costs can be reduced to 0 with the strategy of free examination and on the spot delivery Provider: Cost-efficiency

• Managing bottlenecks • Eliminating waste – idling of resources – inappropriate use of resources • Ensuring high quality – doing it right every time – building patient trust and compliance Delegation of work

• Routine skill-based repetitive work are delegated to paramedical staff – refraction – preparing patients for surgery • Any type of measurement is not done by physicians Efficiency – Balancing resources Surgical productivity Scenario A B Surgeon 1 1 Tables 1 2 Scrub nurse 1 2 Instrument sets 1 6 Surgeries/hour 1 6 - 8 Aravind (Wo)manpower

• 400+ village high school girls given job specific training each year • Perform most of the routine clinical tasks • Results in higher quality, productivity and lowers cost Surgeon Productivity: A comparison

Indonesia

Thailand

Bangladesh

Aravind

India

0 1000 2000 3000 Ensuring quality

Ensuring good outcomes overall

Good Patient medicine perspective

Monitoring Clinical Dignity & complication protocol Communication Compassion Clinical protocols

Guidelines for clinical areas: • Guidelines for advising surgery • Post op. follow up guidelines • Treatment/Follow up guidelines for common disorders (Glaucoma) Protocol for surgical training of physicians

• Start wet lab surgery in the third month of residency • Step surgery during the 4th month • Operate every day during the 5th or 6th month • Develop the capacity to do large volume by the 24th month

FOCUS ON THE Patient Ensuring compliance

Patient counselling • Clinical procedure/ pamphlet • Length of stay and cost • Post op. instructions • SMS reminders

Patient is an equal partner in the treatment process

Summary

• Addressing these issues: – of access – ensuring quality, resulting in high productivity

Helped us to bring down the cost and make the eye care affordable in our setting. Aravind Eye Hospitals

Pondicherry Coimbatore (1997) (2003)

•7 hospitals/4000Tamil beds Nadu

•6 Outpatient clinics Theni (1984) •39 Vision Centers •2 managed eye hospitals

Outpatient visits - Surgeries/proceduresMadurai (1978) • 2,390,958Tirunelveli (1988) 305,000 NHS*-UK vs. Aravind (*National Health Service – Main provider of health care in UK)

59%

No. of eye surgeries

DOING GOOD 30 DOING WELL 25 Paying 45% Camp 33% 20

Free 22% 15

10 Expense 5 Revenue

0 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 07-08 08-09 '05-06 '06-07 Social entrepreneurism

 Vision  Developing the right perspectives  Innovation  Mindset  Leadership

“When you grow in spiritual consciousness, we identify with all that is in the world, so there is no exploitation, it is ourselves we are helping, it is ourselves we are healing” - Dr. G. Venkataswamy