Aravind Eye Care System-Case Study

Aravind Eye Care System: Giving the Most Precious Gift 473
Aravind Eye Care System:

Giving the Most Precious Gift
Case
7
S. Manikutty and Neharika Vohra
In 1976 when Padmashree Dr. G. Venkataswamy,1 officio member. In 1976, the Govel Trust set up a modest
or Dr. V as he was popularly known, retired from the 11-bed hospital, named Aravind Eye Hospital (AEH), in
Government Medical College, Madurai,2 as head of the the house of one of Dr. V’s brothers at Madurai. In this
Department of Ophthalmology, he was determined to hospital, five beds were for paying patients and six were
continue his work of providing quality eye care to the reserved for free patients.
rich and poor alike—the work he had started at the By 2003, the humble 11-bed hospital had grown to be-
Government Medical College, Madurai. His work income the Aravind Eye Care System (AECS) comprising
volved organizing rural eye camps where vision was a chain of hospitals; a centre for manufacturing synthetic
checked and corrective glasses were prescribed, cataract lenses, sutures, and specific eye pharmaceuticals; an insti-
was diagnosed, and corrective and preventive measures tute for training; an institute for research; an international
for proper eye care were explained to patients. Dr. V was eye bank; a women and child care centre; a post-graduate
seized with the passion of eradicating needless blindness, institute of ophthalmology; and a centre for community
first from his home state Tamil Nadu, and then the coun- outreach programmes (Exhibit 1). In a span of 23 years,
try. He made this his life mission. It deeply pained him AEH in Madurai had become a 1500 bed hospital that
that an estimated 45 million people worldwide and 10 performed nearly 95,000 eye surgeries every year. In ad-
million in India had lost the precious gift of sight, most dition, there were four more AEHs located in Tirunelveli,
often quite needlessly. To carry out his mission, after re- Coimbatore, Theni, and Pondicherry (Puducherry, refer
tirement, Dr. V formed a non-profit organization, which to Case 2, Exhibit 1). The five hospitals together per-
he named Govel Trust, investing all his life savings in it3. formed a total of 190,000 surgeries every year, or about
He was the Chairman of the trust and his two brothers, 45 per cent of all eye surgeries done in Tamil Nadu and
two sisters and their spouses became the trust members five per cent in India. The persons at the helm of this
(Dr. V remained a bachelor throughout his life). The system were Dr. V, his sister, Dr. G. Natchiar, and her
President of Madurai Main Rotary was taken in as an ex husband, Dr. P. Namperumalsamy (Dr. Nam).
© 2004 by the Indian Institute of Management, Ahmedabad

Case material of the Indian Institute of Management, Ahmedabad. Cases of the Indian Institute of Management, Ahmedabad are prepared as
a basis for class discussion. Cases are not designed to present illustrations of either correct or incorrect handling of administrative problems.
The authors wish to thank Dr.V, Dr. Nam, Dr. Natchiar, Dr. S. Aravind, Mr. G. Srinivasan, Dr. Viji, Dr. Murali, Mr. Thulasiraj, and other doc-
tors and staff of different AEHs, and other units of Aravind Eye Care System for their help and cooperation. The Confederation of Indian
Industry (CII), Southern Region, Chennai, helped with initial contacts and bore the case writing cost.
474 Strategic Management
Exhibit 1 Aravind eye care system
Eye Care Facilities

(Aravind Eye Hospitals)
Lion Aravind Institute

Community outreach
of Community
programmes
Ophthalmology (LAICO)
Mission:
Education & Training To eradicate needless
Making technology
blindness by providing
Aravind PG Institute of affordable
appropriate compassionate
Ophthalmology Aurolab
and high quality eye care
for all
Research
Telemedicine Aravind Medical Research
Foundation
Eye Bank
Rotary Aravind
International Eye Bank
Source: Aravind Eye Care System.
In March 2003, one of the case writers met Dr. V, Dr. staff. Community outreach programmes are central to our mission,
Nam and Dr. Natchiar in Dr. V’s office. It was 8.30 in the since most of the blind are poor and are in rural areas.
morning and Dr. V, then 85, was busy planning his day’s
schedule. Dr. V began the interview by saying:
History
Despite all our efforts, so many people with vision problems with their
still have no access to hospitals. Much of the blindness can be corrected Dr. V was born in 1918 in a small village near Madurai.
through surgery. But they are afraid of operations. So we have to in- His father was a reasonably well-to-do farmer. Dr. V
crease the awareness of the causes of blindness and the need for early studied in the local school and then went to Chennai to
treatment. Even in villages where we conduct eye camps, only seven do medical studies. He completed his M.B.B.S. in 1944
per cent of people with eye problems turn up. We have to do more to from Madras University and joined the Army Medical
create demand. Corps in 1945, but was discharged in 1948 after he devel-
Most of this blindness is needless and curable. We have to eradicate oped severe rheumatoid arthritis. Arthritis incapacitated
all needless blindness… him to such an extent that he could not hold even a pen.
However, with sheer perseverance and will power, he not
Dr. Nam was equally enthusiastic about this vision:
only started to write but was also able to wield the sur-
At present we do about 3.6 million eye surgeries in India. If this geon’s scalpel.
can be increased to 5 million, needless blindness can be eradicated. He then joined Government Medical College, Madurai
We do about 2,600 surgeries per doctor per year in our Aravind Eye as an ophthalmic surgeon and rose to become the Head
Hospitals. The all India average is about 400. It is possible for other of the Department of Ophthalmology in1956. In 1961,
hospitals to come up to our level of productivity. We are willing to help
Dr. V pioneered a state-level programme of outreach eye
them to do so.
camps to address the problem of blindness in the state.
Dr. Nam further added: People living in distant villages came to these eye camps
to get their eyes tested, diagnosed, and treated. In 1965
We perform 95 per cent of our cataract surgeries with insertion of
Dr. V visited the United States to attend a conference on
intraocular lenses (IOL).4 The all India average of IOL surgeries is
only 60 per cent and in some states like Bihar, it is only 30 per cent. the rehabilitation of the blind. It was at this conference
We have to raise this percentage through training of doctors. in New York that he struck a life-long friendship with Sir
John Wilson, the founder of the Royal Commonwealth
Dr. Natchiar said: Society for the Blind (now known as Sight Savers
All our systems are oriented towards enabling the doctors to be at their International), an organization that had been support-
productive best. We support them through well-trained paramedical ing eye camps in India. Dr. V and Sir John Wilson met
the then Prime Minister of India, Mrs. Indira Gandhi, As a result, the AEH, Madurai started generating a
to seek support for setting up a national organization to surplus from the very beginning, and within one year, it
control blindness. Dr. V had also attended the then Chief opened another 30 bed hospital. In 1978, an exclusive
Minister of Tamil Nadu, Mr. M. Karunanidhi, who sup- 70-bed hospital was built for free patients. The hospital
ported government-sponsored eye camps all over Tamil presently used for paying patients was built in 1981 with
Nadu spearheaded by Dr. V. Thus, even before he retired, 250 beds in a five-storeyed building of 80,000 sq. ft. Dr.
Dr. V was overseeing the growing network of eye camps V and his team initially focused only on cataract surgery,
in the state. He had also developed a network of friends but other specialties such as retina, cornea, glaucoma,
and well wishers across India who empathized with his paediatric ophthalmology, neuro-ophthalmology, uvea,
passion for providing good quality affordable eye care. low vision, and orbit were gradually added. No com-
In 1976, when the Govel Trust was founded, Dr. V’s promises were ever made on equipments: they were of
sister Dr. G. Natchiar, and her husband Dr. Nam were the best quality and many were imported. However, the
also ophthalmologists at the Government Hospital, waiting halls, examination rooms, and doctors’ chambers
Madurai. So when Govel Trust decided to set up Aravind were spartan and utilitarian.
Eye Hospital (AEH) in Madurai, Dr. V persuaded them In 1984, a new 350 bed hospital was opened to cater
to join the hospital. Over the years other family members exclusively to free patients in Madurai. The top floor of
(all doctors) joined to head different specialties. Many this building housed the nurses’ quarters. From the begin-
(including Dr. V, Dr. Nam, and Dr. Natchiar) received ning, AEH had the policy of not conducting surgeries at
training in the United States and were highly competent eye camps as was the common practice at that time.7 The
surgeons. eye camps were for poor patients. Everyone who came
Dr. V was profoundly influenced by Mahatma Gandhi to these camps was checked free, and those who needed
and Sri Aurobindo Ghosh, the sage philosopher who surgery were brought to the main hospital. Patients did
had founded the ashram in Pondicherry. He always felt a not have to pay for the surgery but they had to bear the
strong urge to do something for the society (rather than cost of the intra ocular lens (IOL). The cost of IOLs
take from it). In an article in 2001 Dr. V wrote: was quite high. So in 1992, a new manufacturing facility,
Aurolab, was set up to produce IOLs at an affordable
Many people often ask me: What made me take up a task of such
magnitude at the age of 58? I guess I drew my inspiration from the cost. These lenses brought down the cost of IOL im-
legacy of our great forefathers… Besides, there were inspirational plant surgery to about `500 (which covered the cost of
leaders like Mahatma Gandhi and Sri Aurobindo whose philosophy IOL, special sutures, and medication). AEH also took up
and way of life influenced many. Naturally I felt impelled to give intense counselling on IOL implant surgery and health
something back to this great land of ours.5 education for both the walk-in free patients at the base
hospital and those attending eye camps. Though these
He named the hospital after Sri Aurobindo as a tribute patients were required to pay `500 for IOL implant, in
to the great sage. deserving cases, the doctor in charge at the Outpatients
Department had the power to waive even that cost.
Initial Growth Later, in 1995, when the Indian Government launched a
cataract blindness control programme with World Bank
In 1976, Dr. V put in his personal savings to set up AEH, funding and offered a subsidy for the camp patients, who
Madurai. However, for cataract surgeries of poor pa- were not charged this amount. In stages, the number of
tients from eye camps AEH received partial government free beds increased to the present number of 1,468 beds
support.6 From the beginning, Dr. V had insisted on fol- (1200 free and 268 paying) in the hospitals in Madurai.
lowing the policy of taking both paying and free patients. By the end of 1990s, Govel Trust had ventured into
The paying patients were charged moderately, same as other towns of Tamil Nadu. An 874 bed hospital was set
other comparable hospitals in the city. There were to be up in 1997 in Coimbatore, the second largest city in Tamil
no “five star” customers to cross-subsidize poor patients. Nadu. In 1985, a 100 bed hospital was opened at Theni,
Dr. V was certain that high productivity and large vol- the birth place of Dr. Nam, a small town 80 km west of
umes were necessary for the hospital to become viable, Madurai. Theni catered to additional eye camp patients.
and also to generate a surplus for providing funds for In 1988, another hospital with 400 beds was opened
expansion. at Tirunelveli, a town 160 km south of Madurai. Then
to cater to the people of north Tamil Nadu, in 2003, erally blind and another 8 million were blind in one eye.
a 750 bed hospital was set up in Pondicherry. Though About 36 million had low vision, needing regular moni-
Pondicherry was a Union Territory, it came within the toring.
geographical area of Tamil Nadu and it was also the town State wise variation in blindness across country was
where Aurobindo Ashram was located. As of 2003, the considerable. For example, in the age group of 50 years
five hospitals of AECS among them had a total of 3,649 and above (this group accounted for 90 per cent of
beds, of which 2,850 were for free patients and 799 were country’s blindness which was about 16 per cent of the
paying beds ( Refer Exhibit 2). population), it varied from 4.3 per cent in Kerala to 13.7
per cent in Karnataka.
Exhibit 2 Aravind eye care system: number of beds in dif-
ferent hospitals Exhibit 3 Categories of blindness
(As on 2003)
Category Definition Prevalence in the 50 years
Unit Free No. of beds Total Operation and older age group
Paying Theatres/Tables
India Tamil Nadu
Madurai 1100 315 1415 13/45*
Bilateral Both eyes < 6/60 – NPL 8.5 6.0
Tirunelveli 300 130 430 3/9
blindness
Theni 150 30 180 1/3
Social Both eyes <3/60 – NPL 5.3 4.0
Coimbatore 700 174 874 8/25 blindness
Pondicherry 600 150 750 8/25 Economic One eye < 6/60 – 3/60; 3.2 2.1
blindness Fellow eye < 6/00 – NPL
Total 2850 799 3649 33/107
* Consisting of 25 tables in free hospitals and 20 in paying hospitals. Unilateral One eye < 6/60; 5.1 6.8
Source: Aravind Eye Care System. blindness Fellow eye > = 6/18
Low vision One eye < 6/18 – 6/60; 23.8 28.5

From Hospital to Eye Care System Fellow eye < 6/18 – NPL
Initial focus of the Govel Trust was on building hospi- Source: National survey on blindness—2001–2002, summary,
tals and reaching out to the poor with quality surgery. Quarterly Newsletter of National Programme for Control of Blindness
& Vision 2020: The Right to Sight Initiative, 1(2), July-September
However, Dr. V soon realized that to achieve the ultimate
2002.
goal of eradicating needless blindness through afford-
able and quality eye care AEHs, would have to under-
Cataract was the most common cause of blindness,
take several other activities. Thus, over the years, AEHs
accounting for 62.6 per cent, followed by uncorrected
evolved to become Aravind Eye Care System (AECS).
refractive errors (19.7 per cent). The other important
AECS went into manufacturing of lens, undertook re-
causes for bilateral blindness were glaucoma (5.8 per
search and training activities, got involved in community
cent) and posterior segment pathology (4.7 per cent).
health, etc. In 2003,the main divisions of AECS 2003
Exhibit 4 gives a cross-section of the human eye,
were Aurolab for manufacturing intraocular lenses;
and a brief description of the common diseases and
Lions Aravind Institute of Community Ophthalmology
their treatment. Every year around 9000 ophthalmolo-
(LATCO), a training centre; Aravind Medical Research
gists undertook an estimated 3.7 million cataract surger-
Foundation, a centre for ophthalmic research; Aravind
ies in India. In Tamil Nadu (population as per Census
Centre for Women, Children and Community Health,
2001: 62,110,839), 370,031 cataract surgeries were done
a research centre for women and children; and the eye
in 2001–2002. Government hospitals did about 7.17 per
bank, the Rotary Aravind International Eye Bank.
cent of these; 10.16 per cent were done in eye camps,
7.86 per cent in private clinics, and the rest (74.82 per
Blindness in India cent) by non-profit organizations like AEH.8 Other ma-
jor private eye hospitals in Tamil Nadu and the number
Blindness can be classified into different categories of surgeries done by them per year, as per the informa-
(Exhibit 3). In India, about 12 million people were bilat- tion given by Aravind Eye Care System, were as follows:
Exhibit 4 the human eye and its diseases and cross section of human eye
Muscle
Retina Lens
Iris
Macula
Trabecular meshwork
Cornea
Optic nerve Anterior

chamber
Aquecus
humor
Muscle
Cross section of the eye
Source: Taken from Jetwings, March 2003- p 132.
Common Eye Diseases
Cataract is a medical condition in which the lens of the eye becomes progressively opaque and the vision gets blurred. The degenera-
tion takes place over five to ten years. Earlier, the surgical procedure was to remove the lens after it had become fully opaque (when it
reached maturity) and in its place the patient was prescribed to wear spectacles commonly known as aphakic glasses which had thick,
positive power lenses. The new technique was to insert a tiny artificial intra-ocular lens (IOL) inside the eye in place of the natural lens. In
IOL surgeries, patients did not require long hospitalization, the post-operative recovery was faster, and sight was restored in a short span
(in a week to ten days). Further improvement was the availability of IOL lens that could be “folded” and inserted into the eye through a
small opening. Once placed inside, it “opened out”. These lenses required very small incision and hence recovery period was also short.
With multi-focal lenses it became possible to take care of both distant and near vision. However, till as late as 2003, about 40 per cent of
cataract surgeries in India followed the traditional procedure using aphakic lenses.
Another major breakthrough in ophthalmic surgery came with the introduction of phaco emulsification technique, wherein the opaque
natural eye lens was first pulverized using ultrasonic beams and then extracted by suction. IOL was then inserted as usual. This technique
enabled a patient to return home two to three hours after the surgery.
IOL insertion required advanced training of surgeons in microsurgery. In trained hands, the time taken to conduct the actual surgery, IOL
and non IOL were same: about 12–15 minutes. Phaco surgery required both highly trained doctors and special and expensive equipment.
Minimum cost of a good equipment to do phaco surgery was `600,000.
Glaucoma is the second common cause of blindness. It is caused when the level of aqueous humor, the fluid in the anterior chamber of
the eye, increases as a result of a blockage of the exit passage, which leads to pressure build up in the eye. In severe cases it can dam-
age the retina and the optic nerve. Unlike cataract, glaucoma is a silent killer of vision. The patient would get no symptoms or warnings.
Diabetics are prone to glaucoma. While cataract is usually age related, glaucoma can attack a person at any age. Because of its insidious
nature, the preventive measure is regular eye check up.
Pathology of the posterior segment include the cornea and retina. These involve highly skilled surgeries. Retinal surgeries can be done
using lasers. Corneal surgeries involve quite a variety of surgeries, including eye transplants.
Uncorrected refractive errors are usually corrected by spectacles and later on by contact lenses, but recently LASIK surgeries involving
laser incisions to alter the shape of the eye ball are becoming common. With small powers, LASIK surgeries could eliminate the need for
spectacles/contact lenses; with higher powers, it could substantially reduce the power.
Sankara Nethralaya, Chennai 25,000 As on 2003, the all India average of IOL implanta-
tion surgery was 65.4 per cent of which Tamil Nadu
Joseph Eye Hospital, Tiruchirapalli 27,000
with 91 per cent surgeries was at the top followed by
Sankara Eye Society, Coimbatore 30,000 Andhra Pradesh (79.7 per cent), Orissa (79.3 per cent),
K.G. Eye Hospital, Coimbatore 6,000 and Maharashtra (71.5 per cent).9
Eye camps were a popular way to reach out to ru- ting was done in-house. The system of in-house specta-
ral population. Generally charitable trusts or individuals cle shop at AEH thus saved a patient’s time. They would
sponsored eye camps. Prior to the date of the camp, there leave the hospital with glasses, within a time slot of three
would be a publicity campaign through pasting of post- to four hours.
ers, distribution of pamphlets and announcements from For those patients who needed surgery, there were
moving vehicles. The cost of surgery and treatment was two options. Subject to availability of rooms, they could
supported by the State and Central Governments and in- decide to get admitted immediately or schedule a later
stitutions such as the World Bank. Eye camp check-ups date. Paying patients could also choose the mode of sur-
and subsequent treatment were free for patients. gery, the type of lens to be fitted and the type of room.
They had the option of deciding on the doctor who
would to carry out the surgery.11 All these requests were
Work Flow at AEH fed into the computer, and patients would be handed
out an admission/reservation slip.12. AEH had a set of
Outpatient Departments counsellors who explained the various options, surgical
The workflow at the outpatient departments (OPD) of procedures, post-operative care needed, cost of different
different units of AEHs, both paying and free, was essen- types of surgeries, cost of rooms, and generally helped
tially the same10. All OPDs began work at 7 a.m. Patients patients to make their choice. Dr. Aravind Srinivasan, a
would gather much before the starting hour and wait in senior doctor, who accompanied one of the case writers
the designated waiting areas. Sharp at 7 a.m., the registra- on a tour of the hospital said:
tion process would begin. The computerized registration In many hospitals, many of these functions (especially refraction test-
took about one minute per patient. After registration, pa- ing) are carried out by doctors. We seek to maximize the doctors’
tients would move to the case counter located adjacent to contribution by helping them to devote their time mainly to medical
the waiting hall. The case history of the patient would be advising. Tests that can be done by paramedical staff are assigned
taken by the staff and a computerized case sheet would only to them. Our counsellors are highly trained to help patients to
be given to the patients. Then they would be escorted to take informed decisions, so that doctors are not required to spend their
time on such matters.
the designated doctor. Three computers were kept for
recording new cases and one for old cases. These com- The flow of patients was smooth. They received clear
puters could handle around 200 cases per hour. Trained directions and paramedical personnel were stationed at
paramedical staff did the preliminary checks of patients, critical places for directing people, thus avoiding con-
and paramedics trained in refraction testing conducted fusion and crowding. As a result the waiting halls were
the basic refraction tests. There were four to five exami- not crowded—quite unusual in a hospital of this size in
nation stations where the resident doctors examined the India.
patients. They would record their diagnoses and recom- All surgeries were done in the morning. Afternoons
mendations. After this, a permanent doctor of the hospi- were for attending OD. The doctors were rotated
tal would examine the patient, check the diagnosis and the between free and paying hospitals, so that both cat-
recommendations of the resident doctor, and confirm egories of patients received similar quality of medical
the diagnosis and treatment, or modify them, as needed. attention.
The whole process usually took about two hours but it
could vary depending on the tests needed. The OPD in
the paying units examined around 1000 patients a day, six
Surgical Wards
days a week. The workflow in the surgical wards in Madurai was
Patients who were advised glasses after the refraction equally smooth and efficient. At 6.45 a.m., one of the
tests had the option of going to one of the spectacle case writers was picked up by Dr. Aravind Srinivasan to
shops located in the hospital. These shops were run as observe the procedure for cataract surgery.
a separate profit centre. These shops sold spectacles at At 7 a.m., the doctor and the case writer were in their
a price lower than the market rate. Both free and pay- surgical gowns and masks. The names of patients un-
ing hospitals had separate shops but the prices of similar dergoing surgery during the day had been put up in each
spectacles were the same. Patients received the spectacles operation theatre. This scheduling was done by using a
the same day because the grinding of the glasses and fit- software that incorporated the patient’s preferences for
a particular doctor. The nursing staff reported at 6.30 five to ten minutes break for tea. I usually do about 25 surgeries in a
a.m., and the patients for the day were already in the ward half-day session. Most do this number.
adjacent to the operating theatres. The patients who were In the afternoon, the operating theatres were scrubbed
to be operated were administered local anaesthetic injec- and cleaned and instruments sterilized. The patients who
tions, and their eyes were washed and disinfected. At 7.15 had already been operated on were moved back to their
a.m., when the case writer accompanied Dr. Srinivasan wards.
inside the operation theatre two patients were on two The procedure in the hospitals at Theni and
adjacent operating tables. Most hospitals avoid two op- Coimbatore was similar. AEH, Coimbatore was a newer
erating tables in the operation theatre because of high and a better, well-designed and integrated hospital. It had
risk of infection. However, AEH had been following this all the specialties and facilities needed for conducting the
system from its inception and had not had any problems, Dip NB (equivalent to MS) programme. It also conduct-
perhaps because, generally eye patients were otherwise ed short-term specialized programmes for doctors from
healthy and the chance of cross infection was considered other developing countries. The basic workflow for out-
to be very small. patients and surgeries was the same as it was in Madurai.
The operation theatre had four operating tables, laid AEH Theni was smaller than other hospitals and did not
side by side. Two doctors would operate, each on two do paediatric and retinal surgeries.
adjacent tables. Dr. Aravind’s first patient was already Exhibit 5 gives the details of number of surgeries
on the first table, with microscope focused, instruments done and outpatients attended to from 1997 to 2003 by
ready and the nurses fully attentive. The case writer all hospitals under the AECS. Even in a small hospital
watched Dr. Srinivasan carry out a phaco procedure like Theni, the three doctors stationed there performed
on the TV screen; the procedure was being transmitted 6,000 surgeries every year. We were told that in most eye
through a camera attached to the microscope. The doc- hospitals, a surgeon did about 300 surgeries per year,
tor kept giving a description of what he was doing for while in AEHs they did about 2,500 surgeries per year.
the benefit of the case writer. The entire procedure took Exhibit 6 gives details of out patients’ visits and major
about 12 minutes; the team consisted of one doctor and surgeries done in each hospital of the AECS.
four nurses.
By the time the first operation was over, the second Exhibit 5 Surgeries done and OP visits, 1997–2003
patient was ready to be operated on with the microscope
focused on the eye. Dr. Srinivasan moved straight to the Year Paying Free including Total
second table. Meanwhile, the first patient was bandaged Camp
by the nurses and moved out. The third patient walked in OP visits Surgery OP visits Surgery OP visits Surgery
and was sitting on a bench in the theatre. As soon as the
1997 401,518 42,808 574,350 80,287 975,868 123,095
first patient moved out, the third patient was put on the
first table and was readied for the operation. 1998 465,496 49,275 697,649 108,552 1,163,145 157,827
The case writer observed that, as soon as the second
1999 530,253 55,460 752,819 127,708 1,283,072 183,168
surgery was over, the doctor moved back to the first table
with virtually no loss of time. He was constantly moving 2000 567,105 58,267 763,888 134,498 1,330,993 192,765
between the two tables with hardly any break. In the same 2001 603,800 63,265 725,210 127,893 1,329,070 191,158
way, another doctor operated on the third and the fourth
tables. After the day’s surgeries Dr. Srinivasan said: 2002 650,047 68,055 749,324 128,384 1,399,371 196,425
I work like this the entire morning from 7 a.m. till 1 p.m. or 1.30 2003 758,991 78,487 688,584 123,579 1,447,575 202,066
p.m., or even later, if there are a large number of patients to be at- Source: Aravind Eye Care System.
tended to. Most doctors take a short time off for breakfast and a brief Note: The above figures are for all the hospitals of the AECS.
Exhibit 6 Patient statistics for different units of the aecs, 2003

Madurai Tirunelveli Theni Coimbatore Pondicherry Total
Outpatient Visits
Paying 288,709 147,900 45,043 211,672 65,667 758,991
Free (Direct & Camp) 273,926 116,979 38,579 217,518 41,582 688,584
Of the above:
Hospital OP visits 415,995 198,849 63,937 293,317 86,883 1,058,981
Eye camp OP visits 146,640 66,030 19,685 135,873 20,366 388,594
Total 562,635 264,879 83,622 429,190 107,249 1,447,575
# eye camps 379 268 63 386 62 1,158
Surgery
Paying 37,377 14,097 2,224 19,024 5,765 78,487
Free (Direct & Camp) 60,273 18,403 5,711 32,658 6,534 123,579
Total 97,650 32,500 7,935 51,682 12,299 202,066
Some major types of surgeries
ECCE without IOL 1,075 267 62 836 185 2,425
ECCE with IOL 28,358 4,607 6,448 8,276 978 48,667
ECCE IOL with phaco 11,760 16,133 377 7,117 2,340 37,727
Small incision cataract surgery with IOL 29,696 2,693 0 23,478 5,463 61,330
Laser photocoagulation 6,885 3,503 160 3,652 1,005 15,205
Dr. Aravind Srinivasan explained: The data on the complication rates of AECS’ hospi-
tals revealed that quality of surgery was given high pri-
We work like this for six days a week. On most Sundays we go out to
eye camps and spend at least half a day testing patients. Sometimes if ority. AECS management kept a very close track of the
one is lucky, one may get one Sunday off in a month. intra-operative as well as post-operative complication
rates. According to AECS doctors, the major complica-
He continued: tions were under control and the figures for complica-
Besides surgery, we do outpatient work, and many do research as well. tions were considered highly satisfactory. All the same,
To us, this hospital is our life. We have dedicated our lives for this each case of complication was traced to the operating
one mission. team that had performed it and the reasons identified.
The paying wards had regular beds but the free wards Corrective action, including training of whoever was
had “beds” in the form of mats placed on the floor. Two found deficient, was undertaken. Exhibit 7 gives the
types of mats were used to distinguish eye camp patients complication rates of AEH, Madurai, in 2002. Exhibit 7a
from walk-in free patients. The use of mats enabled bet- provides complication rates of AEH, Coimbatore, and
ter utilization of floor space—about 30 patients could be that of the Royal College of Ophthalmologists, UK.
accommodated in one room.
AEH, Madurai, had an excellent IT system that kept
track of all patients. The system generated daily sched-
Eye Camps and Community Outreach
ules taking into account the load on that day, patients’ Programmes
preference for any doctor, and pending work. This en- The AECS considered its community outreach pro-
abled the hospital administration to keep track of the grammes to be absolutely vital to its mission. The only
workload in different units. Details of complications in way people in most rural areas could get access to eye
terms of categories of patients and surgeons were main- care was through eye camps. These camps were orga-
tained. Abstracts of medical records of patients were en- nized by different agencies and conducted differently.
tered into the system, including their past clinical visits, AECS conducted about 1500 eye camps every year.
and this enabled a history sheet to be generated for an Each of the hospitals of AECS had its own set of camp
old patient quickly. organizers who planned their activities for each calendar
Exhibit 7 free section complication details, aeh, madurai, 2003
Name Intra-operative Post-operative Total
# % # % # %
A/C Shallow 1 0.00 17 0.02 18 0.02
Blood Clot 0 0.00 53 0.08 53 0.08
Cornea Oedema 0 0.00 152 0.23 152 0.23
Cortex 0 0.00 2 0.00 2 0.00
Endopthalmitis 0 0.00 59 0.09 59 0.09
Hyphema 0 0.00 38 0.05 38 0.05
Hypopyon 0 0.00 63 0.09 63 0.09
Iridodialysis 0 0.00 1 0.00 1 0.00
Iris Prolapse 0 0.00 2 0.00 2 0.00
Posterior Capsular Rent with IOL 670 1.02 1 0.00 671 1.02
Posterior Capsular Rent (No IOL) 87 0.13 0 0.00 87 0.13
Striate Kerotopathy 0 0.00 70 0.10 70 0.10
Vitreous disturbance 695 1.06 0 0.00 695 1.06
Zonular Dialysis 86 0.13 0 0.00 86 0.13
Total surgeries done: 65,180

Exhibit 7(a) Medical complications at AEH, coimbatore and the royal college of ophthalmologists, UK.
Adverse Events During Surgery Adverse Events Within 48 hours of Surgery
Event Aravind, UK National Event Aravind, UK national

Coimbatore Survey Coimbatore Survey
N=22,912 N=18,472 N=22.912 N=17,257
Capsule rupture and vitreous loss 2.0% 4.4% Corneal Oedema 8.0% 9.0%
Incomplete cortical clean up 0.75% 1.00% Uveitis more than expected 5.0% 5.6%
Iris trauma 0.3% 0.7% Peri-ocular bruising and edema 1.0% 1.4%
more than expected
Persistent iris prolapse 0.01% 0.07% Weak leak/rupture 0.67% 1.2%
Anterior chamber collapse 0.3% 0.5% Hyphaema 0.9% 1.1%
Loss of nuclear fragment into vitreous 0.2% 0.3% Retained lens material 0.87% 1.1%
Wounds 0.30% 0.25% Vitreous to section 0.1% 0.3%
Choroidal haemorrhage ------ 0.07% Endophthamitis 0.05% 0.03%
Loss of intra ocular lens into vitreous 0.01% 0.16% Hypopyon 0.04% 0.02%
Other* 0.7% 1.5%
Source: The Aravind eye care system: delivering the most precious gift in C.K. Prahalad (2004), The Fortune at the Bottom of the Pyramid.
N.J.: Wharton Publishing.
year, and these were coordinated from Madurai. Generally put together, getting a pair of glasses became prohibitively expensive.
each district had a camp organizer who would set a tar- As a result, we found out that many people who were checked at the
get for the year based on the population, estimated per- camps did not bother to get their glasses and the cycle of needless blind-
centage of blind people, estimated turnout at the camps, ness/poor sight continued.
and percentage needing surgeries. The camp organizers We decided that if this cycle had to be circumvented, it was important
then had to find sponsors. However, finding sponsors to be able to provide glasses to eye camp patients soon after the refrac-
was not a problem. They comprised local NGOs, Lions tive errors had been detected. An analysis of the data revealed that
and Rotary Clubs, local industrialists and businessmen, the most time-consuming part of readying the spectacles was preparing
the glasses correctly as per prescription. Based on the large data AEH
and philanthropists. Sponsors took care of the expenses
had of the probable refractive needs of patients, a forecast was made
connected with the publicity such as pamphlets, banners, before each eye camp as to how many lenses in each power should be
and announcements from moving vehicles using a public taken to the camp to meet the projected need. The fitting of the glass
address system, and the organization of the camps (usu- to the frame was done at the camp site and spectacles were provided
ally in some school or public place). The camps were held there and then to patients. However, patients did have the choice of not
usually on Saturdays and Sundays and started early in the buying the spectacles at the camp.
morning. Lunch arrangements were made for those who
had to undergo surgery at the base hospital. These ex- In the advertisement of the camp, patients coming for
penses were also borne by the sponsors. The sponsors the check-up were usually advised to come prepared to
provided free transportation to and from the hospital to go to the base hospital for surgery, if necessary. Thus,
the patients. The hospital, in turn, met the cost of surgery, most of them came with their bags and, often, with rela-
stay, and food in the hospital. It also provided free post tives who could accompany them. Persons needing and
operative medication for 40 days. willing to undergo surgery were then counselled about
Doctors (mostly post-graduate residents) and para- the procedure, length of stay, and facilities at the base
medical staff usually reached the camp site previous eve- hospital. If they agreed to surgery, then they were taken
ning to supervise the arrangements and, depending on to the base hospital after lunch. They would be operated
the distance, would camp for the night. In the morning, upon either the next day or the day after depending on
patients were first registered with the help of local volun- the workload. Their basic needs such as food during their
teers, and then given a case sheet and an identity card. The stay were taken care of by AECS.
identity cards helped in future follow-ups. The paramedi- Generally people from the same or adjoining villages
cal staff conducted the preliminary tests for refraction, travelled together, were operated on the same day, and
and patients above 40 years of age were tested for intra- stayed together in the hospital. They thus formed a sup-
ocular pressure to screen for glaucoma. Senior doctors port group. This group of patients and relatives returned
evaluated the test findings, carried out final examination, after about three days in a transport provided by the hos-
reviewed patient records, and then made the final diagno- pital. The hospital also met the cost of surgery including
sis and prescribed treatment. An optician also accompa- cost of IOLs, sutures, and post-operative medication for
nied the team, with a large stock of spectacles with com- forty days, of which the government reimbursed to the
monly prescribed powers. Thus, those who were advised extent of `500 per patient.13 The cost of the doctors’
glasses could purchase them on the spot and the glasses travel to and from the campsites was mostly met by the
would be delivered to them within one hour. About 75 to hospital.
90 per cent opted to purchase spectacles at the camp site The cost of an eye camp to the sponsor varied de-
and over 85 per cent got them immediately. The rest got pending on the nature of the camp. A small camp with
them the following week at the same campsite, or they 300 outpatients (leading to about 60 surgeries) generally
were couriered to them at AECS’ cost. This innovation cost `6,700 while a large camp with 1,000 outpatients
of having a mobile optical shop at campsite was decided and 200 surgeries could cost `42,500 to the sponsor.
after a study of barriers to refractive correction. Mr. R.D. The Theni hospital conducted eye camps in two
Thulasiraj, Executive Director, LAICO, (who was earlier districts in the adjoining state of Kerala and AEH
the administrator of AEH, Madurai) explained: Pondicherry was expected to reach out to some of the
villages in the neighbouring state of Andhra Pradesh.
We found that the cost associated in procuring a pair of glasses (which Exhibit 8 gives the number of camps organized by
included a couple of visits to the shop, a second visit to the doctor for AECS from 1998 to 2002 and the numbers of patients
a final check up, etc.) was higher than the actual cost of the pair of treated from camps (apart from “walk-in” free patients
glasses. If the cost of time, travel, and other incidental expenses were
at the hospitals).
Exhibit 8 eye camps organized and patients treated, tested by ophthalmic assistants and later by ophthal-
1997–2003 mologists. In 2002, 68,528 children in 80 schools were
Year No. of Camps Patients Surgeries of
screened and 3,075 were given glasses to correct refrac-
Organized Seen “Camp” Patients tive errors.
1997 1041 287,571 40,389
Use of IT Kiosks for Tele advice
1998 1346 373,997 65,926
1999 1488 413,580 87,084

This initiative was launched with the help of the Indian
Institute of Technology (IIT), Chennai. Under the guid-
2000 1548 426,350 93,519 ance of Dr. Ashok Jhunjhunwala, a faculty member of
2001 1480 422,373 88,585 the institute, a number of IT kiosks were put up all over
Tamil Nadu by a company called n-Logue. In one cluster
2002 1549 461,762 92,372
of villages near Melur, about 40 km. from Madurai, the
2003 1158 388,594 81,357 IT kiosks were provided with web cameras that enabled
(incl.Pondicherry) patients to screen the picture of their eyes and email
Source: Aravind Eye Care System. them along with a voice description of the problem to
doctors at AEH, Madurai. One doctor was nominated
to take care of these emails. The doctor would make the
Other Community Outreach Programmes diagnosis based on the description given by the patient
and the picture sent and advise the patient suitably. This
Diabetic Retinopathy Management Project was, however, not an on-line service.
This project was initiated in 2000 with the aim to create
awareness about diabetic retinopathy in the rural com- Other Units and Activities of AECS
munities. In 2002, 46 eye camps were organized in which
11,644 persons were examined. Of these, 3,443 were dia- Aurolab
betic, who were screened for retinopathy, and of these
533 were found to have retinopathy. Some of them were The cost of surgery was always a central concern at
advised surgery. Extensive campaigns were also conduct- AECS. As explained earlier, AECS had decided on
ed through leaflets, posters, and booklets on diabetes and adopting the IOL implant surgery as the standard op-
its effect on the retina. erative procedure for all cataract cases. However, the
cost of IOL lenses which had to be imported was very
high, about $80–100, and this made the cost of surgery
Community Based Rehabilitation Project
quite high. In 1991, AECS set up Aurolab as a separate
In 1996, Theni hospital, with the support of Sight non-profit trust to manufacture lenses. Its mission was
Savers International, undertook the rehabilitation of to achieve “local production at an appropriate cost”.
incurably blind people by providing community based Some of the members of the Aurolab Board were also
support. House-to-house identification of eye problems members of the Govel Trust. The technology was ob-
and screening camps were organized and patients with tained from IOL International, Florida, USA, for a one-
eye problems were treated. Rehabilitation consisted of time fee for technology transfer along with a buyback
teaching the incurably blind people skills in orientation, arrangement. This helped in maintaining quality. This
mobility, and activities of daily living. Some were eco- venture was also supported by Seva Foundation, Sight
nomically rehabilitated through building of appropriate Savers International, the Combat Blindness Foundation,
skills. USA, Canadian International Development Agency
(CIDA) through Seva Service Society, and David Green,
an Ashoka Fellow and Executive Director of Project
Eye Screening of School Children
Impact Inc. in California.
In this project, teachers were trained to detect eye de- Out of the 220 employees of Aurolab, 10 per cent
fects in children to take early corrective measures. They were diploma or graduate engineers, pharmacists, and
were also taught to measure visual acuity, identify signs marketing personnel; and 90 per cent were women tech-
of squint and vitamin deficiency. The children were then nicians. Girls from rural areas with 12 years of formal
education were selected and given the same training that The Spectacle Lens Division set up in 1999 provided
was given to ophthalmic assistants, for a period of six technical support services to AECS’ in-house spectacle
months. Then for the next 18 months, they were given shops for the production of spectacles, quality control,
specialized training in manufacturing of lenses. and training of personnel. Ever since World Health
Raw material for lenses was imported from US/UK. Organization (WHO) had identified detection and cor-
Soon Aurolab was selling the rigid IOL lenses for less rection of refractive errors through spectacle lenses as a
than US $5. By 2002, it was producing about one-sixth major requirement for reducing avoidable blindness, the
of the total number of low-end lenses produced in the division focussed its attention on this aspect. A labora-
world. However, it also produced the foldable and the tory with plastic lens surfacing and computerized edging
superior category acrylic lenses. It was able to get the facility was established to research and refine the process.
CE Mark (a mark of quality) and ISO 9002 certification. Lens edging facilities were established close to the optical
In 2003, by working single shift, Aurolab was produc- shops for quicker delivery. Technology for applying hard
ing around 600,000 lenses per year. Large NGOs such coating to both sides of the lens to make it scratch resis-
as CBM, Lions, and Rotary bought IOL lenses from tant and for providing colour tints to lenses to satisfy the
Aurolab, and supplied them to various eye hospitals all needs of low vision patients had also been acquired.
over the world. This increased sales worldwide, and 33
per cent of the lenses produced by IOL were exported. Lions Aravind Institute of Community
Of the remaining 67 per cent, 20–25 per cent were con-
sumed by AEH and the rest were sold in the open market
Ophthalmology (LAICO)
in India. Since its inception, Aurolab had supplied more In the early 1990s, AECS started collaborating with
than 2 million lenses to NGOs in India and about 120 Lions Club International Foundation, a voluntary orga-
countries world over. nization for community service. In 1992, with the sup-
While the cost of lenses came down, the price of port of Lions Club International Sight First Programme
sutures remained high. This now became a need to be and Seva Sight Programme, AECS established Lions
addressed. In 1998, Aurolab diversified into manufactur- Aravind Institute of Community Ophthalmology
ing of sutures used in IOL surgery. It set up the Sutures (LAICO). The objective of LAICO was to improve
Division. The sutures are made from silk and nylon and
the planning, efficiency, and effectiveness of eye hos-
come attached to a tiny stainless steel needle. The cost of
pitals with a special focus on developing countries. It
sutures produced at Aurolab was one-fourth the price of
contributed to eye care through teaching, training, re-
imported ones.
search, and consultancy. It offered long term courses in
The Managing Director of Aurolab, Dr. Balakrishnan, hospital management as well as short duration skill de-
Ph.D., said with pride: velopment courses in the area of community outreach,
Aurolab was responsible in driving down the prices of IOL all around social marketing, and instruments maintenance. These
the world. Our lenses are of high quality, but priced low; that takes us courses were offered at very reasonable fees. The list
nearer to our goal of eliminating needless blindness. of courses, duration, and fees charged in March 2003
are given in Exhibit 9. Till 2003, LAICO had already
Thereafter, Aurolab decided to diversify further and
worked with 149 eye hospitals in India, Africa, and
started two new Divisions: Pharmaceutical Division and
South East Asia. It was Asia’s first international facility
the Spectacle Lens Division.
The Pharmaceutical Division produced pharmaceuti- for training blindness prevention workers in India and
cals used in cataract surgery and other eye-related ailments other parts of the world.
at a reasonable cost. These pharmaceuticals were either LAICO also provided capacity building services to
not easily available or available at a high cost. In 2002, other hospitals. Its staff would first visit the hospitals
it formulated 25 drugs and was the sole Indian manu- requesting support, assess and identify their problems,
facturer for Econazole, Coltrimazole, and Prednisolone bottlenecks, and constraints. Then it would invite some
Sodium Phosphate eye drops.14 Aurolab pharmaceuticals personnel from these hospitals for training at LAICO.
and suture needles were covered under the Indian Drug Training consisted of visiting the hospitals under AECS
Control Act and were WHO GMP certified. The inter- and the outreach camps to study the workflow. At the
national certification also made it possible to sell the for- end of the training, the participants would have to pres-
mulations in the international market.
Exhibit 9 Training courses offered at LAICO and course fees
Courses Duration Course Fee for partici- Course Fee for overseas
pants from India/Nepal* participants
(` ) ($)
Management Training for Heads of Eye Hospitals One week 10,000 330
Management Training for Eye Care Programme Managers Two weeks 15,000 500
Management Training & Systems Development for Hospital One month 15,000 500
Administrators/Managers
Certificate Course for Clinical & Supervisory Skills Development Three months 25,000 850
in Ophthalmic Paramedical Personnel
Community Outreach Course Four weeks 7,500 250
Instruments Maintenance Technicians Course Six weeks 10,000 325
Instruments Maintenance Ophthalmologist Course Five days 2,000 70
* Fee does not include lodging and boarding

ent a full action plan, implement it, and the progress # Hospitals Performing Surgeries
would be assessed after six to nine months. 1 year before 2 years after
Till 2003, LAICO had made interventions in UP, intervention intervention
West Bengal, Orissa, Delhi, and a few other states in < 1000 surgeries 21 9
India. Its international intervention included Malawi, 1000 – 2999 surgeries 16 20
Kenya, Zimbabwe, and Zambia. In some countries, in 3000 – 4999 surgeries 3 8
addition to training doctors, nurses from AECS were > = 5000 surgeries 0 3
sent for a month to impart rigorous training to the nurs-
ing staff there. Dramatic improvements were recorded Cost Recovery Percentage (Income/Expenditure) # Hospitals
in functioning wherever LAICO had intervened. Mr. M. 1 year before 2 years after
P. Saravanan, a faculty member of LAICO, narrated the intervention intervention
following intervention experience in Chitrakoot: < 60% 10 4

60 – 79% 4 6
In Chitrakoot, they were doing 20,000 to 25,000 surgeries a year.
80 – 99% 6 5
Ninety per cent of this was done in a three-month period. Of the
> = 100% 5 10
surgeries, 70 to 80 per cent were non-IOL surgeries. Only in slack
periods would they take up IOL. After our intervention, they were Source: S. Saravanan (2003), Organizational capacity building: a
able to do 25,000 to 30,000 surgeries a year; all IOL. Our aim in model developed by aravind eye care system,” Illumination, 3(1)
January-March, .20-21.
such interventions was to enhance not only their capabilities but also
their skills. LAICO, in collaboration with the International
The performance of hospitals before and after inter- Agency for Prevention of Blindness (IAPB), had com-
vention is presented in Exhibit 10. Data are for 40 hospi- mitted itself to the global initiative of “Vision 2020: The
tals two years after intervention. Right to Sight” Mr. Thulasiraj was the regional chairman
of the IAPB, Southeast Asia Region, and was, thus, in-
Exhibit 10 result of aravind’s intervention in other hospitals volved in the policy making for eradicating blindness at
the national and international levels.
# Surgeries Done
IOL Non IOL Total
Aravind Medical Research Foundation
1 year prior to intervention 18558 33948 52506
(AMRF)
1 year after intervention 40055 36940 76995
2 years after intervention 51291 40154 91445 AMRF coordinated all the research undertaken by dif-
ferent units of AECS. Several clinical studies, population
based studies, and social and health systems researches 2001 1. Molecular genetics of juveline onset primary angle
were conducted using the data readily available in the hos- glaucoma
2. Genetics and structural analysis of myocillin protein
pitals and the community outreach programmes. Many of
involved in juvenile onset primary angle glaucoma
these research projects were supported by different agen- 3. Aetiology and pathology mechanism of leptospiro-
cies and some by AEH itself. Research covered a variety sis uveitis
of fields like clinical trials to evaluate alternate surgical 4. Improving child health through health education
project
techniques and drug therapies, impact of vitamin supple- 2002 1. Corneal epithelial stem cells for clinical and toxico-
ments on morbidity and mortality of infants and children, logical applications
beneficiary assessment, impact assessment of cataract in- 2. Prevention of traumatic corneal ulcer: A multicenter
intervention project in South East Asia
tervention, barriers experienced by patients in accessing
eye care sources, and infrastructure utilization in eye care. Source: Promises to Keep…, Annual Report (2001) Madurai: Aravind
Eye Care System, .40-42.
Dr. VR. Muthukkaruppan, who was earlier Professor of
Immunology at the Madurai Kamaraj University, and the
former Vice Chancellor of Bharathidasan University, Aravind Centre for Women, Children, and
Tiruchirapalli, had been appointed to provide leadership Community Health (ACWCCH)
to the research efforts of AMRF.
Exhibit 11 gives details of ongoing and completed re- The centre was started in 1984 with the aim of reducing
search projects. nutrition-related blindness in children through preventive
health care. It worked with government’s public health
Exhibit 11 Major research projects programmes of immunization, education programmes
on nutrition, and training programmes to create aware-
Major Projects Completed
1984 Study of Eales’ disease ness. It conducted regular village health programmes and
1986 Operations research for effective delivery of cataract training programmes for village health care workers.
services
1986 Rapid survey techniques for blindness and cataract
assessment Rotary Aravind International Eye Bank
1987 Effect of small doses of vitamin A in children under five
years of age
(RAIEB)
1989 Safety and efficacy of vanadium stainless steel (VSS)
sutures in cataract surgery RAIEB was established in 1998 and was one of the four
1989 Study on salt pan Keratitis eye banks in the country affiliated to the International
1992 Madurai IOL study Federation of Eye Banks. Till 2003, the bank had pro-
1993 Childhood cataract in South India
1994 Aravind comprehensive eye survey
cessed 4,383 eyes and AECS had conducted 2,181 trans-
1994 Series of drug trial with Ofloxacin on patients with sup- plants.
purative Keratitis
1998 Vitamin A supplementation in newborns (VASIN) study.
Major Ongoing Projects

Aravind Post-Graduate Institute of
1995 Molecular genetics of congenital cataracts in man and
Ophthalmology
mouse
1997 Newly recognized presumed Trematode induced ocu- As part of its efforts to train ophthalmologists, in 1982
lar inflammation in children AECS introduced post graduate residency programme at
1998 1. Role of antioxidants in prevention of cataract its Madurai unit, and with this, the name of the hospital
2. Vitamin A supplementation in newborns (VASIN) study
1999 Value of culture and serology in ophthalmic complica-
was changed to Aravind Eye Hospital and Post-Graduate
tion of leptospirosis Institute of Ophthalmology (AEH&PGIO). As of 2003
2000 1. Diabetic retinopathy (action research project) AEH&PGIO had admitted around 30 resident doctors.
2. Molecular genetics for hereditary glaucoma
3. Paediatrics parasitic eye diseases
Admission was strictly on merit. No capitation fee was
4. Trial study of lensectomy vs. lens aspiration and ever collected even when the going rate in 2003 was about
primary capsulotomy in children `1.5 to 2 million at other private teaching hospitals. It
5. Culture of rubella virus from proven cases of con- was affiliated to Dr. MGR Medical University, Chennai,
genital rubella syndrome
6. Molecular and genetic basis of congenital contract and offered Diploma in Ophthalmology (DO), and MS
7. Trials on paediatric glaucoma in Ophthalmology (MS). In 2001, eight candidates had
8. Certain drug trials in corneal ulcers and conjunctivitis earned their DO and four graduated with MS. In 2002, six
graduated in DO and four in MS. In affiliation with the other six months were spent in apprenticeship under a trainer nurse
National Board of Examination, New Delhi, the AECS working in the same department. There was one-on-one training at
also offered the Diplomate of the National Board. Nine each step. During the last six months, they worked on their own with
students qualified in 2001, and 13 in 2002. In affiliation some guidance from senior nurses and doctors. The medium of instruc-
with the Royal College of Ophthalmologists, London, tion was essentially Tamil (the language spoken in the state); they were
membership of the Royal College of Ophthalmologists also taught some basic medical terminology in English and were given
(MRCOpth) and FRCS were offered. Four candidates training in basic conversational English.
passed Part 1 of the MRCOpth in 200215 and four can- The nurses’ training was designed after the training programme of
didates received their FRCS. It also took fellows for ophthalmic assistants that Dr. V had coordinated in 1973 for the
super specialization in fields of retina-vitreous, cornea, rehabilitation work funded by the USAID. The training programme
paediatric ophthalmology, glaucoma, anterior chamber, did not lead to a degree. However, there were efforts underway in
and uvea. In addition, it conducted various short-term February 2003 to formalize the programme and the training modules
courses for practising ophthalmologists. were being upgraded with the help of qualified volunteers from the
USA.
Dr. Natchiar added:
Recruitment and Training
At the end of two years, we take parents’ consent before absorbing the
AEH laid great stress on the kind of people it recruited. girls permanently. In our experience, 99 per cent of the trainees stay
Dr. Natchiar, who was in charge of training of paramedi- on with us. Those who we consider to be unsuitable, mainly because of
cal staff, told the case writers: their attitude, are not given job offers.
We have a ratio of about 1:6 between doctors and nurses. Then we During the three years of their service as permanent employ-
have also about 40 counsellors. We have about 900 girls between ees, ophthalmic assistants were also imparted training in cooking,
our four hospitals and Aurolab. We generally recruit girls from ru- housekeeping, tailoring, etc. This helped them to be prepared for be-
ral background. We do not prefer urban girls. We take girls in the coming good housewives in the future. The cost for these programmes
age range of 17 to 19; very rarely more than 19. We look for girls was borne by AECS. Voluntary bhajan (devotional songs) and
with right attitude from large families, preferably farmers’ families. yoga sessions were organized in the evening. The nurses were en-
Knowledge and skills are important, but they come second. We never couraged to be always kind to patients and approach them with
advertise. Once a year, we put up a notice for recruitment in our hospi- gratitude for providing them an opportunity to serve. The nurses
tals and word of mouth carries the news. We receive around 400–500 were asked to save a part of their salary, so that they had a sizable
applications and we take about 60–100 girls per year. Selection for sum for their marriage.
all the hospitals is done at Madurai and Tirunelveli. I along with Dr.
According to Dr. Natchiar:
Usha (a younger ophthalmologist and a member of the family who was
being groomed to head the recruitment and training of nurses) and the More than salaries, it is the recognition that they get in society. They
head nurse are involved in all selections. Parents are always called for get a lot of respect. Not only do they get very good training and experi-
the interview. ence, they also have an opportunity to go abroad, even if it is for short
We look for the right kind of person. We do not give any consideration periods. All these are seen as positive factors.
to any letters of recommendation. The nurses too corroborated Dr. Natchiar’s views. One
After recruitment, we give them two years’ training. The training is of the senior nurses said:
considered to be excellent and is recognized in the USA, and the
Government of India is considering adopting our training syllabus for I work harder than the government hospital nurses and I get paid a
nurses’ training. During the training period, we rotate them among little less or the same as them, but I get much more respect in society.
different units of our different hospitals. When I travel in the bus, someone generally recognizes that I work in
Aravind Eye Hospital and would offer me a seat, or be nice to me. I
In the first four months, they were given training in basic sciences and really feel happy about it.
human anatomy and physiology. The trainers and Dr. Usha, who
headed the training of nurses, would select ophthalmic assistants from Both Dr. Usha and Dr. V stressed that ophthalmic as-
this group. They would be further trained to work in the outpatient sistants were at the core of AECS’ success. Their con-
department, operation theatre, counselling, etc. Though the criteria for tribution to the smooth functioning of the hospitals of
making such decisions were not clearly articulated, they were well un- AECS was immense. The senior assistants appreciated
derstood by the team. In the next eight months, they received special the atmosphere of peace and efficient functioning of the
training for the department they were chosen for. Following this, an- hospitals and set an example for the junior staff.
All AECS hospitals abounded in photographs of Sri On an average, AECS doctors (at Madurai) spent 60
Aurobindo and Mother, and staff members were ex- per cent of their time in clinical work, 20 per cent teach-
pected to imbibe the values of service. When the new ing, and 20 per cent in research. But this varied consider-
unit was opened in Pondicherry, two old time “founder” ably among doctors. Though doctors were not allowed
sweepers from Madurai were sent to inculcate the right to miss surgical work, they could take time off from
attitude and values in the new cleaners. One of the doc- OPD to pursue research. They could apply for research
tors very succinctly described the ethos of AEH: grant from AECS which in turn would channel the fund
through Aravind Medical Research Foundation or get
We have a unique culture based on service. All the doctors speak softly
to patients and nurses. No one shouts. If a doctor behaves in an unac- from outside funding agencies. They were also encour-
ceptable manner, word goes around the hospital in no time, and the aged to teach at LAICO.
doctor is in trouble. We believe mutual respect to be our core value. AECS ensured professional growth of all the doc-
tors. They regularly organized Journal Rounds, which all
Doctors were crucial at AEH. Most were inducted medical officers and Fellows were required to attend. At
as residents. About 30 MBBS doctors were taken in the this forum, a doctor or a Fellow would pick up an article
three-year residency programme which led to a masters’ of interest from a journal and present it to others. In
degree in surgery (MS). During the residency period they the Grand Rounds, doctors from different AEHs would
received a stipend. The residents were given training in have a tele-discussion on a particular topic.
all branches of ophthalmic surgery. At the end of the One of the medical officers explained the advantages
training, many were offered jobs as permanent medical of being at AEH:
officers in different AEHs, and most accepted the offer.
AEH also offered a Fellowship Programme for do- I see the following plus points here. I am at my home place. We get
a very good exposure to the latest surgical techniques. We also get
ing super specialization after an MS degree in areas like,
opportunities to practice tele-medicine with eminent people.16 If you
retina-vitreous, cornea, paediatric ophthalmology, glau-
want to be abreast of latest techniques in ophthalmology, this is the
coma, uvea, and orbit. Duration of the programme was best place. We get opportunities to do research, attend international
18 months and it did not lead to any degree. During the conferences and present papers. We can attend one or even more than
course of the programme, the Fellows received a stipend. one conference each year.
There were 15 fellows pursuing different specializations I am in charge of the newly set up Vision Rehabilitation Centre. My
in 2003. long term mission is to develop this centre using new techniques such as
The case writers interviewed some of the Fellows. magnifying devices. By developing skills for the visually handicapped,
They felt that in their MS course in other colleges they I’ll be able to improve the quality of their life. I plan to set up similar
did not get adequate exposure to surgery. They also felt rehabilitation centres in other hospitals too.
that AECS gave them wider choice in specialization. To
quote one Fellow: Asked whether he found time for research in the midst
of all these activities, he said:
We did not get adequate surgical exposure in MS. This is usually
the case with many colleges, especially in north India. Here I have Time is not a problem. Those interested can find time.
been exposed to not only different kinds of IOL surgeries but even But this view was not shared by all. To some, this heavy
in plastic surgery. In Delhi, where I had studied, we did not have so work load was not conducive for research:
many different cases. The college did not even have a phaco machine.
We used to do about one or two cases of surgery a month whereas here It is all right to say you have a lot of opportunities to do research. But
we do around 30 a day! after a long day of 12 or 13 hours, how many can find the energy to
do research? Every day is a full day here.
A large number of Fellows were from other parts of
India and so they went back to their home states after Another doctor had this to say:
completion of training. Those who joined AEHs were We do commit ourselves totally to the cause of eradication of avoidable
largely locals. blindness. That means we have to do a certain number of surgeries
Unlike many large hospitals AEH employed only full every day. But subject to this, we have quite a lot of flexibility.
time doctors and did not allow any doctors to do private
practice. Dr. V clearly stated: There was good understanding between medical of-
ficers and ophthalmic assistants. This bonhomie devel-
We do not think part time or external doctors can develop institutional oped as a result of frequent visits to eye camps where
loyalties. They also may not develop the skills we need. they worked closely as a team.
Quality was strictly monitored at AECS. Morbidity from 1997–98 till 2001–2, Exhibit 13 gives the income
meetings were organized every week in a non-threaten- and expenditure statement of 2001–2.
ing manner. Complication rates of individual surgeons as
well as that of the hospital were calculated every month. Exhibit 12 Income and expenditure, 1997–98 to 2002–03
Dr. V and others gave a lot of stress on the quality of eye (` million)
care. According to Dr. Nam: Income Expenditure Surplus
Our destination is “good sight”. We provide our doctors with the best 1997–98 180.3 81.7 98.6
that is available in the world. We train them through exchange pro- 1998–99 239.5 123.2 116.3
grammes with prestigious medical schools all around the world. We
1999–2000 276.3 143.2 133.1
have set up very rewarding collaborative research programmes with
several universities. 2000–2001 340.4 156.6 183.8
2001–2002 388.0 177.5 210.5
One of the case writers met a resident who had come
from Harvard Medical School. He told the case writer: 2002–2003 423.7 204.7 219.0
I’ve had more clinical experience here than any of my classmates at Exhibit 13 Income statement, 2002–2003
Harvard. In Harvard, I would only read about rare eye diseases; here (` million)
I get to see them.
Medical service 16.21
However, AECS did face the problem of retention of Operation charges 254.32
doctors. According to Mr. Thulasiraj, Executive Director
Treatment charges 22.84
of LAICO:
Consulting fees 23.73
Doctor turnover is a problem. The retention is only for about three to
X Ray & Laboratory charges 4.32
four years. Every year we lose 20 to 25 doctors. India produces about
800 ophthalmologists a year. Can we get from that pool? We also have Tuition fees and course fees 4.79
the fellow pool of about 25 or so. Grants in aid 37.80
However, both Dr. Nam and Mr. Thulasiraj were con- Donations 3.74
fident that this was not a serious issue because, though Interest received 45.92
earlier, doctors at AECS were paid less than the market Dividends received 2.50
rate, it was not so any more. Their salaries were now at
Miscellaneous income 1.93
par with those from other hospitals. The only difference
Total 418.10
was, at other places, with private practice, they could
make more money. Expenditure
However, Mr. Thulasiraj added: Staff Salary 41.22

IOL cost 39.74
What we can offer is a good work environment, a good name, and a
status based on our high integrity. We also offer good salaries and op- Medicines 15.97
portunities for personal growth. With this we should be able to retain Electricity 15.40
enough doctors.
Hospital linen 1.02
Camp expenses 6.57
Financials Interest expenses 0.15

Library books 0.29
Though majority of the patients were treated free, AECS
Water supply 1.31
had always been financially self-supporting. Right from
its inception, it did not take any government grants or Depreciation 46.00
donations (except for the support given by the govern- Miscellaneous expenditures 37.04
ment towards eye camp patients), and till today it had Excess of income over expenditure 213.39
not applied for any other government grants for service Total 418.10
delivery. Exhibit 12 gives the income and expenditure
Mr. G. Srinivasan, brother of Dr. V, and the Founder-

Phaco with Surgery Two days’ Medicines Total Cost
Secretary of the Govel Trust looked after the entire fi- Foldable IOL room rent
nance and accounts of AECS. In the initial years, Govel
Trust had borrowed some funds from the State Bank of Suite AC 9500 1500 700 11900
India by pledging the properties of the trustees. The hos- Deluxe AC 8500 800 700 10200
pital or the trust did not try to raise any funds through
donation. AEH Madurai was self-supporting right from A Special 8500 400 700 9800
the beginning and was able to meet all its recurring ex- A 8500 240 700 9700
penditure. After five years, it accumulated adequate sur-
plus for its own development and also for the establish- B 8500 160 700 9600
ment of new hospitals in Theni, Tirunelveli, Coimbatore,
C 8500 60 700 9500
and Pondicherry. The rates charged by AECS for surgery
and hospital stay were quite moderate. Exhibit 14 gives Phaco with Surgery Two days’ Medicines Total
the details of the rates charged at AEH Madurai. Other Acrylic 3 Piece room rent Cost
AEHs too met all their operational costs through patient IOL
revenues and generated surplus to contribute to the de-
Suite AC 12500 1500 700 14900
velopment of subsequent hospitals. Though donations
were accepted and welcome, the hospital consciously Deluxe AC 11500 800 700 13200
chose to remain financially viable essentially through pa-
A Special 11500 400 700 12800
tient revenues for its core activities of patient care, com-
munity work and training. Mr. G. Srinivasan stated, ‘Tight A 11500 240 700 12700
financial control, on time accounting, coupled with ap-
B 11500 160 700 12600
propriate pricing and transparency are the reasons for
this financial success.’ C 11500 60 700 12500
Exhibit 14 Rate card of AEH, madurai (`)

Cataract without Surgery Two days’ Medicines Total
Cataract Surgery Two days’ Medicines Total Cost IOL room rent Cost
with IOL room rent
Suite AC 3500 1500 700 5900
Suite AC 5500 2000 700 8700
Deluxe AC 2000 800 700 3700
Deluxe AC 4500 1200 700 6600
A Special 4500 600 700 6600 A Special 2000 400 700 3300
A 4000 300 700 5300 A 1500 240 700 2700
B 3250 200 700 4400 B 1250 160 700 2300
C 2750 60 700 3800 C 1100 60 700 2100

Phaco with Surgery Two days’ Medicines Total Cost
IOL room rent
Both Dr.V. and Dr. Nam stressed that not only was AECS
Suite AC 6500 1500 700 8900 self-sufficient in terms of operational income and expen-
Deluxe AC 6000 800 700 7700
diture, but it also took care of capital expenditure for all
expansion and new units. Dr. V told the case writers:
A Special 6000 400 700 7300
You management people will tell me, why don’t you go to the bank, take
A 5500 240 700 6700 loans and grow faster? Cost of debt is low. But we, as a policy, will not
B 5000 160 700 6100 go to the bank for loans, since it will compromise our freedom.
C 4750 60 700 5700 At AECS, they believed in gradual growth. Expansion

would take place only after enough funds had been ac-
cumulated. Dr. V saw no conflict between his objective ner. Information was freely shared with everyone. The
of speedy eradication of blindness and the policy of top management believed in “leading by doing”. Once
gradual growth. He felt: one of the case writers found Dr. V and Dr. Aravind
Srinivasan picking up pieces of paper from the floor
It is important to preserve our financial self-sufficiency. Also there is a
limit to the rate at which we can grow effectively without compromising and handing them over to the first sweeper they met.
on the basic values of the organization. They did not shout or get upset with the sweeper but by
their action demonstrated the value of cleanliness and
humility.
There was a conscious attempt to imbibe the work-
Organization Structure place with spiritual ethos. AEH Madurai had a medita-
AECS worked under the Govel Trust of which Dr. tion room where some of the personal belongings of
V was the chairman, Dr. Nam the director, and Dr. Sri Aurobindo had been kept. Dr. V visited this room
Natchiar the joint director. Exhibit 15 gives the orga- every day. And though no one was compelled to go to
nization structure.All AEHs reported to Dr. Nam. The the meditation room; many staff members and patients
heads of different units or clinics in AEHs who were went there on their own accord. In Dr. V’s words, “There
generally senior medical officers reported directly to Dr. is an atmosphere of spirituality in the hospital.”
Nam. Post-graduate and Fellow students were under the AEH in Madurai also had a small crèche for the very
respective clinic heads. However, nursing and other para- small children of the staff. Same care was given to all
medical staffs were under the joint director. Heads of children irrespective of their parent’s position in the or-
other units like LAICO too reported to Dr. Nam. ganization, including doctors.
There were weekly meetings of all the heads of the As on February 2003, the staff strength of AEH Madurai
hospitals, in which all operational and strategic matters was 762. For about 113 doctors, there were 307 nurses, 38
were discussed. Dr. Nam would either visit other AEHs counsellors, and 304 other staff. The pattern of staffing in
or talk to the heads on telephone. other units was broadly similar. Exhibit 16 gives the break-
AECS functioned in an open and transparent man- up of staff strength for different units of AECS.
Exhibit 15 Aravind hospital: organization structure (medical)
Govel Trust
Chairman (Dr. V)
Jt. Director
Director (Dr. Nam)
(Dr. Natchiar)
Sr. Med. Officers

(in clinics)
Med. Officers Nursing staff

(employees of hospitals) paramedical staff
P.G.
Fellows
Fellows
students
Note: The above is the structure of the Madurai Hospital. The structure of other hospitals was similar. Compiled by the case writers after
discussions with the executives of the Aravind Eye Care System.
Exhibit 16 Break-up of staff strength in different units of to be improved; counselling needs to be improved. It is in these areas
AEHS (2003) that we hope to make a difference.
Category Madurai Theni Tirunelveli Coimbatore Pondicherry Mr. Thulasiraj added:
Medical 38 2 10 22 13
I can see many management issues coming up. There is going to be a
Officers
need to restructure ourselves. There is considerable geographical spread
Fellows & 62 3 16 23 3 as well as functional diversity. How should we restructure?
PGs
We are still too centralized in our decisions. Too many decisions are
Paramedics 259 21 100 148 56
taken here in Madurai. We also have to broad base our leadership.
Counsellors 34 2 16 17 7 Too much energy is coming from Madurai. How do we stimulate simi-
Others 310 18 59 72 58 lar efforts from other units?
Total 703 46 201 282 137 A lot of our strength comes from what I call “unconscious compe-
Source: Data supplied by Aravind Eye Care System.
tence.” Our strength is really not our technical skills or equipment.
This can be easily replicated. Values are our unique strength. Values
are the real reason for efficiency. We must find ways of sustaining and
Future Directions strengthening our values and culture. Integrating the culture of all our
units is very important.
Though happy and satisfied with his achievements so far,
Integrity is a hallmark of this place. We never give commissions to
Dr. V felt he had a long way to go. His vision was no
other doctors, chemists, or other hospitals for special tests. We tell other
longer focused just on the functioning of AECS, but on
diagnostic facilities what they should charge a poor patient sent from
the larger issue of how to make a lasting impact on the
AECS for a particular test (e.g. MRI or CT scan) and they oblige.
problem of blindness. Dr. V said:
We have been able to have our way. We should be able to keep this
I am now seriously wondering how to develop sustainable systems. integrity intact.
Only by strengthening the existing hospitals this can be achieved. I
feel doctors in India are heavily underutilized. They are engaged in Dr. Aravind Srinivasan said:
activities unrelated to their work. We have to find a way to improve the
One of our key strategic future steps is to develop dual specialties
functioning of hospitals so as to increase the productivity of doctors.
among our doctors. We would like to retain and get the best out of our
Moreover, despite all our efforts, only about seven per cent of the target doctors. One way may be to provide more meaning to their work. We
population come to camps. We have to increase this percentage too. are trying to help doctors develop at least one other specialty. We can
We also have to upgrade the skills of doctors to enable them to perform then involve them in the running of the AECS. We also need to find
IOL surgeries. This will make a huge difference in the recuperation resources to fund our research projects and build more linkages with
time and subsequent ability to earn one’s living. Post-operative care has eye care institutions all over the world.
Notes
��
7. Surgical
��
eye camps are not very common now and are offi- ��
1. Awarded in 1972 by the Government of India. Padmashree is
cially discouraged by the government.
one of the top civilian honours conferred by the government
8. Achievements under cataract blindness control project: 1994-
every year for outstanding work in different fields.
2002, Quarterly Newsletter of National Programme for Con-
2. Madurai is a famous temple city and is the third largest city in
trol of Blindness and Vision 2020: The Right to Sight Initiative,
Tamil Nadu.
1 (2), July-September 2002.
3. The name was formed taking the first letter of Dr. V’s father
9. Ibid.
name, Govind aswamy, his own name Venkataswamy, and his
10. The description below has been based on the observations of
mother’s name Lakshmi.
the case writers at the Madurai hospital.
4. See later.
11. Free patients could not choose their doctors. We were told that
5. Aravind Eye Care System (2001), Promises to keep. Madurai:
actual exercising of this facility even by paying patients was not
Aravind Eye Care System.
very common.
6. Partial in the sense that though the government paid an
12. For free patients, phaco surgery was not available. Of course,
amount for each surgery performed on poor patients in the
all except those contra-indicated were given IOLs, but free pa-
eye camps, this fell quite short of the total cost of the sur-
tients were given only rigid lenses.
gery.
13. Actually, this was reimbursed based not on the number of 15. In 2002, out of 11 candidates who appeared from India, five
patients operated but who turned up at the follow-up camp. were from AECS. . Out of the 7 candidates who cleared that
Since many did not turn up in these camps, the hospitals were year, four were from AECS.
denied reimbursement to that extent. 16. More specifically, primary open angle glaucoma. There are
14. Aravind Eye Care System (2001) Activities Report. Madurai: other types of glaucoma, the incidence of which is rare.
AECS.

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Aravind Eye Care System: Giving the Most Precious Gift 473

Aravind Eye Care System:

© 2004 by the Indian Institute of Management, Ahmedabad

Exhibit 1 Aravind eye care system

Eye Care Facilities

Lion Aravind Institute

Source: Aravind Eye Care System.

Low vision One eye < 6/18 – 6/60; 23.8 28.5

Optic nerve Anterior

Cross section of the eye

Source: Taken from Jetwings, March 2003- p 132.

Common Eye Diseases

Exhibit 6 Patient statistics for different units of the aecs, 2003

Exhibit 7 free section complication details, aeh, madurai, 2003

Name Intra-operative Post-operative Total

A/C Shallow 1 0.00 17 0.02 18 0.02

Blood Clot 0 0.00 53 0.08 53 0.08

Cornea Oedema 0 0.00 152 0.23 152 0.23

Cortex 0 0.00 2 0.00 2 0.00

Endopthalmitis 0 0.00 59 0.09 59 0.09

Hyphema 0 0.00 38 0.05 38 0.05

Hypopyon 0 0.00 63 0.09 63 0.09

Iridodialysis 0 0.00 1 0.00 1 0.00

Iris Prolapse 0 0.00 2 0.00 2 0.00

Posterior Capsular Rent (No IOL) 87 0.13 0 0.00 87 0.13

Striate Kerotopathy 0 0.00 70 0.10 70 0.10

Vitreous disturbance 695 1.06 0 0.00 695 1.06

Zonular Dialysis 86 0.13 0 0.00 86 0.13

Total surgeries done: 65,180

Adverse Events During Surgery Adverse Events Within 48 hours of Surgery

Event Aravind, UK National Event Aravind, UK national

Persistent iris prolapse 0.01% 0.07% Weak leak/rupture 0.67% 1.2%

Anterior chamber collapse 0.3% 0.5% Hyphaema 0.9% 1.1%

Wounds 0.30% 0.25% Vitreous to section 0.1% 0.3%

Choroidal haemorrhage ------ 0.07% Endophthamitis 0.05% 0.03%

Other* 0.7% 1.5%

1999 1488 413,580 87,084

Exhibit 9 Training courses offered at LAICO and course fees

Community Outreach Course Four weeks 7,500 250

Instruments Maintenance Technicians Course Six weeks 10,000 325

Instruments Maintenance Ophthalmologist Course Five days 2,000 70

* Fee does not include lodging and boarding

following intervention experience in Chitrakoot: < 60% 10 4

Major Ongoing Projects

However, Mr. Thulasiraj added: Staff Salary 41.22

Financials Interest expenses 0.15

Mr. G. Srinivasan, brother of Dr. V, and the Founder-

Exhibit 14 Rate card of AEH, madurai (`)

A 4000 300 700 5300 A 1500 240 700 2700

B 3250 200 700 4400 B 1250 160 700 2300

C 2750 60 700 3800 C 1100 60 700 2100

Source: Aravind Eye Care System.

C 4750 60 700 5700 At AECS, they believed in gradual growth. Expansion

Exhibit 15 Aravind hospital: organization structure (medical)

Sr. Med. Officers

Med. Officers Nursing staff

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