Aravind

‘Enhancing Access & Affordability’

Aravind Eye Care System

Dr.R.D.Ravindran Chairman

Aravind Eye Hospitals India

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

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.

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

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, Theni District

No Name of the Village

Resi House

Total Popln. Male Female

Boys under 6 yrs

Girls under 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 Kamatchipuram 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

Villages with 10km radius of camp site (Devathanpatty, Theni District)

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 Line of sight

Collaboration with Univ. of Berkeley (PhD students)

Investment: • Digital Camera + Adapter

• US$ 250

Vs. • Digital Fundus Camera:

• US$ 25,000

Innovation: Low-cost imaging

technology

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

Aravind Eye Hospital

Vision Center

Community Center

• Access: eg: No one in Theni district needs to travel for more than 10km for their eye care

• 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

Solution 2: Taking advanced care to villages

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

Persons Cost in Rs.

Transport Other Expenses

Lost Wages Total

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

• Completing all investigations on a single visit

• Eliminating unnecessary tests

• No waiting list

• Minimizing length of stay

Costs of access, lost wages, and incidental expenses can be significant

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

Scenario A B

Surgeon 1 1

Tables 1 2

Scrub nurse 1 2

Instrument sets 1 6

Surgeries/hour 1 6 - 8

Surgical productivity

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

0 1000 2000 3000

India

Aravind

Bangladesh

Thailand

Indonesia

Ensuring quality

Ensuring good outcomes overall

Good medicine

Monitoring complication

Clinical protocol

Patient perspective

Communication Dignity &

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

Patient is an equal partner in the treatment process

Patient counselling • Clinical procedure/

pamphlet • Length of stay and

cost • Post op.

instructions • SMS reminders

Ensuring compliance

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.

Tamil Nadu

Pondicherry (2003)

Coimbatore (1997)

Theni (1984)

Madurai (1978)

Tirunelveli (1988)

Aravind Eye Hospitals

•7 hospitals/4000 beds •6 Outpatient clinics •39 Vision Centers •2 managed eye hospitals

• Outpatient visits -

2,390,958 Surgeries/procedures

305,000

NHS*-UK vs. Aravind

No. of eye surgeries

59%

(*National Health Service – Main provider of health care in UK)

0

5

10

15

20

25

30

80-8

181

-82

82-8

383

-84

84-8

585

-86

86-8

787

-88

88-8

989

-90

90-9

191

-92

92-9

393

-94

94-9

595

-96

96-9

7

97-9

898

-99

99-0

000

-01

01-0

202

-03

03-0

404

-05

'05-

06'0

6-07

07-0

808

-09

Expense

Revenue

DOING GOOD DOING WELL

Camp 33% Paying 45%

Free 22%

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