Sepia Tone

Tuesday, May 04, 2004

Aravind Hospital & Dr. G.V

Published in Asia 21 in the issue dated August 2000.

Aravind Hospital- Quality Eye Care to the Poor

What is the connection between McDonald Pizza parlours and eye care for the poor ? Nothing – that is for you and me. But, a visionary ophthalmologist was able to see a connection. During one of his trips to the US, he thought if only we could provide professional eye care to the masses like McDonald parlours roll out thousands of pizzas in a day.

That spark in his brain was not a stray thought. Today, Aravind Eye Hospitals & Postgraduate Institute of Ophthalmology in Madurai, the temple city in southern India, performs over 120,000 cataract operations in a year, and enjoys the reputation of being the largest single eye care facility in the world, performing free and subsidised operations. The subsidised rate for an operation is Rs. 500. This also is charged only for the Intraocular lens(IOL). If a patient can’t afford this amount the operation is totally free and instead of implanting the IOL, the patient gets a pair of glasses after the surgery.

Besides the flagship hospital at Madurai, Aravind Eye Hospital has branches in five cities in Tamilnadu. Their success strategies are observed with interest by ophthalmic institution in India and abroad. So much so that its Postgraduate and Fellowship programmes as well as eye care training programmes attracts many aspiring ophthalmologists from around the world.

When you meet the frail looking Dr. G. Venkataswamy, 82, the man behind this mammoth venture, you think he should relax, now that he has fulfilled his mission. On the contrary, as Chairman of the organisation, first thing as he buzzes into his office at 8 am, is to surf the internet ( yes!), download latest developments around the world in his field, and give his daily directive to his staff about future targets and course of action.

Dr. G. V., as he is known at the hospital, does not feign any childhood dream of giving eye sight to the poor. He landed up in ophthalmology by a queer twist of fate. After his graduation in medicine form Madras university, he served the Indian army during World War II. But an unexpected attack of rheumatoid arthritis which crippled his fingers forced him to return to civilian life. He gave up his original desire to pursue gynecology for his postgraduation and instead picked up ophthalmology. Soon he mastered the art of handling scalpel with his twisted fingers and became a leading eye surgeon in the government hospital Madurai.

It was while working in the government hospital that he began concentrating on taking eye care to the masses. That was when the McDonald concept of delivering quality product at affordable cost impressed him. Why not replicate the success strategy of a fast food service in eye care service ?

An it worked. After retirement from government service in 1974, he began dispensing eye care. He converted his brother’s house into a small hospital with 11 beds. His sister and brother-in-law Dr. Natchiar and Dr. Namperumalswamy, both well known ophthalmologists, quit their respective jobs with the government service and pitched in to help him. And his contacts and friends while he was in government service helped him in providing technical help and funds too.

What is special about Aravind Eye Hospital is that although 60 % of its patients are provided free or subsidised eye care, the quality remains the same for everyone. “ Income from the 40% Paying patients helps us subsidise the costs for 60% poor patients, “ says Dr. Natchiar. Operating under a non-profit Trust called Goval Trust, the hospital’s credo is providing eye care to the mass, at affordable costs.

On the surface it looks like a “Robinhood” concept. But a lot of planning and organization goes into making this a charity venture which is economically feasible too. From registration to consultation and from operation to post operative care, the entire process goes through streamlined procedures. The hospital has a flow of about 2000 patients every day and with the help of computerized procedures they are guided through all the examinations without any chaos.

Aravind Hospital is able to handle such huge volume by keeping its costs low, and sourcing all its requirements form in-house resources. The Postgraduate Institute takes care of the human resources - the professionals, para medical workers and nurses - who opt to work in the Hospital. The lenses which are the costly aspect of any eye care venture- are supplied from the organisation’s lens making plant. Even repairs of medical equipment are done in house at a separate wing dedicated for that.

With a large volume of professionals and nurses, the medical teams work in clock wise precision following a well laid out procedure. The operations are in process almost continuously in 9 theaters which among them have a total of about 33 tables. As one operation is in finishing stage the other patient is prepared ready for the next. And the queue keeps moving on. The medical teams work in shifts and are totally dedicated to the hospital work. Since doctors do not divide their time between private practice and hospital work, they are able to give out their best. Sustained quality is ensured that way. Some of these theatres are reserved for specialized and complicated operations. All the latest development in ophthalmology, including Lasik Surgery is performed here.

Another interesting way the hospital cuts costs is to do away with cots for in-house patients in the “free” service unit. Instead clean mats are spread in huge rooms each of which can accommodate 50 to 100 patients at a time. Sleeping on floor is not uncommon in humid south Indian villages and so the patients don’t feel any discomfort this way. Thus the maintenance costs of beds is eliminated. The “paid” patients, however pay for the extra comforts they receive.

The Postgraduate Institute exchanges visits with reputed ophthalmic institution abroad and the training programmes are two way exercises. The personnel at the Aravind Hospital travel frequently abroad to impart their expertise to others, or they absorb some innovative techniques employed by international ophthalmic community.

There are no prior appointments in both the free and paid wings of the hospital. Patients start queuing up at 4 am, but the queue moves fast. After the initial compute registration, each counter of examination is clearly identified to avoid confusion and the queue moves without any delay. While preliminary examinations are done by trained technician detailed consultation is done by ophthalmologists at the end of the examining counters.

Aravind Eye Hospitals gets its name from the famous saint, Sri Aurobindo. Dr. G.V who is a staunch disciple of the saint, believes in silent talk with the God. Everyday before he enters his office he spends sometime at the “Meditation Room” energizing his spirits.

What distinguishes Aravind Eye Hospital from other hospitals is its work culture. The nurses are young and trained in-house. Once someone asked Dr. G.V to start a “Aravind Hospital” in his city. G.V said, why don’t you open a hospital yourself? You have enough motivation and money?” That person responded, “ I want a hospital with the Aravind culture. People are cordial here. They seem to respect people more than money. There is a certain amount of inner communion or compassion that seems to flow from them.”

And that is the hall mark. A genuine care that runs as undercurrent in the entire hospital activities.
Known as Temple City, Madurai is famous for Meenakshi temple, the biggest temple in the world. The ancient city is also known for its contribution to the growth of Tamil literature. Today, Aravind Eye Hospital stands as one more land mark of which the city can take pride in.

Interview With Dr. G.V.

Dr. G.Venkataswamy, Chairman, Aravind Eye Hospitals & Post Graduate Institute of Ophthalmology.

When Dr. Govindappa Venkataswamy, the eldest son of a farmer in a village near Madurai in Southern India, graduated in medicine in 1944 the World War II broke out and fired by patriotism he joined the Indian army and went to the war front. But he had to come back in three years, after developing severe rheumatoid arthritis. He was bedridden in a Madras Hospital for over a year. With acute stage of arthritis, he could not stand on his feet nor could hold a pen to write. But he was determined to carry on with his life with a positive attitude. For his post graduation he decided to take ophthalmology and learnt to do all the eye surgery with his crippled fingers. Soon he conquered his disability and used to do 100 eye operations in eye camps.( free camps held in rural area to promote eye care among he masses.) When such determination is channalised to charity work, it can do wonders, which is what is happening at Madurai, a city in Southern India.

Aravind Eye Hospitals & Post Graduate Institute of Ophthalmology, Madurai, a 1,16,000 sq.ft, 925 bed eye hospital cum institute with a patient flow of about 2000 everyday, renders subsidized eye care to 60% of its patients. As its founder –chairman, Dr. Venkataswamy is a household name in the southern districts of Tamil Nadu.

Honored by the Government of India with, “PadmaShree”, one of the prestigious awards of the country, and “Helen Keller International Award” by the UN for his pioneering work in fighting Cataract Blindness, Dr. Venkataswamy, 82, is continuing his work with the same zeal he began with. He is keen to keep up with the fast changing world. So much so, after a morning meditation he is at his office sharp by 8 a.m. everyday. And his first job is to log onto the Internet and find out the latest update on eye care worldwide. He not only updates himself but passes on the information to his team with his own ideas to to be implemented in the hospital. “ First thing all of us get to see on our tables are these little missives from the Chief…” remarks Dr. P. Namperumalswamy, Director of the Hospitals.

Asia 21 spoke to him about his motivations, his strategies and his visions.

What motivated you to start this institution? Was it just sudden or was the idea simmering in you for a long time - a childhood dream?… The eye career came much later. When I was in the government service in 1956 to 76. During the later part of these years, I used to feel how nice it would be to run an institution. During this period, Government of India had borrowed a lot of wheat and maize and all those things. India had taken about Rs. 5000 or Rs.10000 crores loans. America said that they did not want the money. But will keep the fund aside for health care and other development work in India. So there were lots of grants at that time. One of the areas identified at that time was rehabilitation of the blind. Initially I had a grant to start a rehabilitation center for blind here. That gave me the opportunity to visit America often and also helped me build up contacts with several leading American institutions. That gave me the first motivation. How nice it would be if we could have institutions like these in India, I thought. – dynamic, doing research….

So, when did you actually launch this venture?

After my retirement in 1976, we started in a small way.

How small? Could you elaborate the beginnings?

You see, in those days even as we were in government service we were allowed to do private consultation also. Only consultations. For operations we had to come to the hospital. My sister who is also an ophthalmologist was with me. And her husband, had his own practice. When I retired I had a house of my brother. We converted that into a clinic, where I can do surgery also. We put a small shed which can accommodate 70 to 100 patients for consultations and we made a small operation theatre also. Since my sister was still working in the government, she would support me in the evenings. Even when I was working for government, we used to have eye camps. During those days I met Sir. John Wilson, founder – director of Sight Savers International ( formerly the British Empire and then the Commonwealth Society for the Blind). He used to support me even while I was working in government. Initially he gave me ideas and monetary support to organize eye camps. My contact with people invo
lved in eye care, and philanthropists grew.

Did you start giving free treatment even as you began your private clinic in 1976 ?

Yes. The philanthropists and the people with whom I worked during my service years wanted me to continue my work for the blind. That was a period when a lot of Gandhians ( those who follow Mahatma Gandhi’s ideals) institutions like Gandhi Gram, were interested in rural development and they helped me with immense support. The programme got popular and drew the attention of big industrialists who wanted to help the cause.

What was one major aspect which prompted them to help you?

They could see that many sightless people could get their eye sight back with simple operation, in a programme which did not have huge investments.

The government service achieved the same objective. How different was your service from the existing government service?

People put a lot of trust in me as a committed person. They had faith in my Gandhian values. Even though I was doing a free service people had confidence that I would not compromise on quality. For instance, our camps were meant for poor people. But even rich would come there and say that they would like to be operated by me.

They were willing to pay for you?

They were. But I would not accept any money. But they were supporting the camps. For instance, Lions club organised camp in a small town where we did 700 operations. The government used to give us only Rs. 750 per camp. These organizers would give me support saying, ‘ Why do you bother about money? You do the operations. We will feed the patients and look after them.’ The rich people who were treated by me would organize the eye camps. The concept of eye camps which located the people with eye diseases became popular. So, when I started my private institution the demand was already there. Initially we had about 20 to 30 “paid” beds also. The ratio was something like, 70 “free” patients and 30 “paid” ones. The eye camps ensured the constant flow of patients. On any national day or festival, or to mark the birthday of my father – these free eye camps were held.

So, the eye camps became a social trend?

Yes. This way community participation also increased. People began to organize eye camps when they wanted to do some charity work to mark some special occasions in their personal lives.

How did you get external help to build your infrastructure?

Sir. John was willing to help me. Also, when you are committed, help comes to you from all directions.

How did you manage to rope in the team of professionals to help with you in charity work?

Since I had the support from many people, I could afford to pay salaries to professionals, who were willing to lend me a hand in my work. There were occasions when we faced financial crunch and we had to raise money by mortgaging the house. But luckily for me my entire family pitched in.. For instance, the buildings were constructed by my brother who is an engineer and has a construction firm. Couple of years later, my sister and her husband left their government service and gave me professional support full time. And those who worked for us were willing to work long hours with minimum compensation. Also, our growth was gradual. We expanded only when we had enough funds.

What was the most difficult part of those initial years?

It was the public perception during those initial years. People would say, ‘ah… he is a retired old man…. He is running a small clinic…’ They could not imagine that someone could think of building an institution after retirement. So, it was a big job to attract doctors to work for me. They thought that they did not have much career scope with me.

How did you mange to convince them?

By giving them good salaries. Many of them did not have any jobs to begin with. Our strength was our reputation as good eye surgeons. People realized that with talent we could have made more money for ourselves. Instead they saw that we put all our money into this institution. Moreover ours was not just eye hospital alone. When we began to offer post graduate programmes in eye care and hospital management, our credibility as a non – profit making institution was established. Soon we started building our own man-power through training courses. Soon we got affiliated to Madurai University and got recognition from Indian Council for Medical Research also. Today we run 7 fellowship programmes, besides other specialty courses.

Whom do you identify as your role model?

Sir John Wilson. He invented me. In those days World Health Organization did not have any specific programme for eye care. There were some organizations here and there for the blind. He founded the Royal Society for the Blind. In 1972-73, he brought together all the associations at a meeting in Jerusalem. There he announced that every country should have a National Programme for Control of Blind. (NPCB). India was one of the countries agreed for that.

You have often expressed curiosity about McDonald’s franchise concept. Do you think it can be copied in your field to evolve more hospitals on Aravind’s model.?

We are not strong enough for that. For one, the main motive behind franchise concept is making money. In a fast food chain, 20 to 30 thousands hamburgers are rolled out at a time.
However, the training we give under our “Capacity Building” programme is similar to that. In our client hospital it is already being run by the locals. We try to find out how far we can improve upon that. If you open branches or run a franchise, a lot of care should go into monitoring the uniform quality. We also have to take into account the local culture, which we should adapt to our way of doing things. However, we have 5 branches in TamilNadu which are run on same pattern as our Madurai hospital.

How do you go about replicating your model in other places?

Today there are numerous people without eye sight throughout India and the world. And there are eye care centres. Our experts visit many states and even other countries in Africa and South East Asia to impart training and help set up units on our model. Lions International has a US$ 140 million global programme for blindness. They have asked us to help in these countries. We basically give training and help set up units by utilising the available resources. My dream is to bring eyesight to the masses everywhere in the world.”

You are more inclined towards charity work. But not everyone can afford to be philanthropic. What is your advice to run a successful eye care centre serving the poor and at the sametime making it economically viable?

In any management, the leadership is very important. Secondly there should be realisation that the world is shrinking and globalization has brought more awareness in people. They expect quality. As long as one can offer quality services at affordable price there is nothing wrong in making profits.

You have built a brand equity in eye care services. When you impart training to others do you market your brand in terms of certificates or any kind of acknowledgement? How do you attach value to the training you gave?

When we give training it is just practical approach. Our name anyway spreads through word of mouth. A lot of people come here from all over the world to our institute. And after their training most of them add “Aravind Alumni” to the list of their qualifications!

About your concept of free treatment for the poor – is it absolutely free?

Not like that. Most of the patients are ignorant of their eye problems and many hesitate to have any treatment at all – because either they are not aware that their problem can be cured or they think it is unaffordable. Most work in the farming fields. If the eye sight is poor, they just take it as their destiny and would remain jobless. Some are afraid that the treatment would be very expensive. But at the same time total free treatment hurts their dignity. So, we tell them that we would charge only for the lenses sutures, and the medicines and if they could pay that nominal charges he can get the treatment and go back to work, it gives them confidence. Paying an amount – however small it might be – gives them a sense of dignity. If it is totally free, they will not realize the value also. Today some resent total free treatment. They volunteer to pay. Also, a lot of the villagers have realized the importance of getting their vision back and they have also realized that th
ey need not live blind, cursing their fate.

Could you relate a moving experience in your long career?

There are many. But, what worry me always is the social repercussions of the blindness. For instance, there was this widowed mother. She had two sons and a daughter – all of them laborers. When she lost her sight gradually she could not go out for work. The sons and the daughter refused to support the blind – therefore unproductive – mother. She went to live with her sister and came to know about our hospital. She got her sight back and went back to work. Now, the sons wanted her to come back. But this woman got wiser by now and told them that she would stay with her sister till her end.Similarly in another example a young wife who unfortunately got cataract, was deserted by her husband. Some others feel that it is a waste of money or effort to give eye care to the old relatives. Such social behaviors are real tragic.

What is your dream for future?

Right now, I want to keep a multimedia database of all our activities and organizational system. We have video records of all our operations. Similarly I want records for housekeeping also – preferably in Tamil. ( native language) So that the bottom levels staff can understand the concepts clearly. And I want my hospital to build a strong web network and reach more people world – wide, through video conferencing and other communication tools.