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«It was year 1976. Padmashree Dr. G. Venkataswamy1, popularly referred to as Dr. V., had just retired from the Government Medical College, Madurai2 as ...»

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It was year 1976. Padmashree Dr. G. Venkataswamy1, popularly referred to as Dr. V.,

had just retired from the Government Medical College, Madurai2 as the Head of the

Department of Ophthalmology. Rather than settling for a quiet retired life, Dr. V. was

determined to continue the work he was doing at the Government Medical College, especially organizing rural eye camps to check sight, prescribe needed corrective glasses,

do cataract and other surgeries as needed and advise corrective and preventive measures:

in short, providing quality eye care. This was to be provided to the poor and the rich alike. To Dr. V., this was more than a job to spend his time: he was a person seized with a passion to eradicate needless blindness. For an estimated 45 million people worldwide, and nine million in India, the precious gift of sight had been snatched away, most often quite needlessly. His vision was simple yet grand: eradicate needless blindness at least in Tamil Nadu, his home state, if not in the entire India.

With this mission, after his retirement, Dr. V formed a non-profit trust, namely, the Govel Trust3 with himself as the Chairman and his two brothers, two sisters and their spouses, and an ex officio member, namely, the Madurai Main Rotary President as trust members.

In 1976, the Govel Trust began with running a modest 11 bed hospital, named as the Aravind Eye Hospital, in Dr. V.’s brother's house at Madurai, with a mission of serving the poor blind people. In this hospital, five beds were for patients who would pay to get treatment and six were reserved for those who would be offered free treatment.

By 2003, the humble 11 bed hospital had grown into The Aravind Eye Care System. The Aravind Eye Care System was not merely a chain of hospitals, but was an eye care system consisting of a centre for manufacturing synthetic lenses, sutures, and some eye pharmaceuticals; an institute for training; an institute for research; an international eye bank; a women and child care centre; a post graduate institute of ophthalmology awarding M.S. degrees and offering fellowship programmes; and a centre for community outreach programs (see Exhibit 1 for the “Aravind Eye Care System”). The Aravind Eye Hospital (AEH) at Madurai had grown to a 1500 bed hospital performing nearly 95,000 eye surgeries every year. In addition to Madurai, there were four more Aravind Eye Hospitals located at Tirunelveli, Coimbatore, Theni, and Pondicherry (see Map 1 for the location of these places). The five hospitals together performed a total of 190,000 surgeries every year, or nearly 45 percent of all eye surgeries done in the state of Tamil Awarded in 1972 by the Government of India. Padmashree is one of the top civilian honours conferred by the Government every year for outstanding work in different fields.

Madurai is a famous temple city and is the third largest city in the State of Tamil Nadu, South India.

Named after Mr.. Govindaswamy, Dr. V’s father; Venkataswamy, Dr. V. himself and Mrs Lakshmi, Dr.

V’s mother.

Prepared by Profs. S. Manikutty and Neharika Vohra of the Indian Institute of Management, Ahmedabad, 2003. The authors wish to thank the doctors and other personnel of the Aravind Eye Care System for making this case study possible. Especially we wish to place on record our deep appreciation of the support given by Dr. V., Dr. Nam, Dr. Natchiar, Dr. Thulasiraj, Dr. Aravind Srinivasan, Dr. Murali and Dr. Usha. The CII, Chennai chapter supported this case writing and we wish to thank them.

Nadu and five percent in India. In charge of this system were Dr. V., his sister, Dr. G.

Natchiar, and her husband, Dr. P. Namperumalsamy (“Dr. Nam”).

The various members of the Govel Trust worked ceaselessly to improve their services and to reach closer to their goal of eradicating needless blindness. In March 2003, when one of the case writers met Dr. V., now 85, at the appointed time of 8.30 A.M. in the latter’s office, Dr. V., was busy planning the day. After the preliminaries, he opened the

conversation as follows:

Despite all our efforts, so many people with problems with their vision have still no access to hospitals. Much of the blindness can be corrected through surgery.

But they are afraid of operations. So we have to increase the awareness of the causes of blindness and the need for early treatment. Even in villages where we conduct eye camps, only seven percent of people having eye problems turn up.

We have to do more to create demand.

Most of this blindness is needless and curable. We have to eradicate all needless blindness…

Dr. Nam was equally enthusiastic about this vision:

At present we do about 3.6 million eye surgeries in India. If this can be increased to 5 million, needless blindness can be eradicated. We do about 2600 surgeries per doctor per year in our Aravind Eye Hospitals. The all India average is about

400. It is possible for other hospitals to come to our level of productivity. We are willing to help them to do so.

Said Dr. Natchiar:

All our systems are oriented towards enabling the doctors to be at their productive best. We support them through well-trained paramedical staff. Community outreach programmes are central to our mission, since most of the blind are poor and are in rural areas.

Continued Dr. Nam:

We perform 95 percent of our cataract surgeries with insertion of Intraocular Lenses (IOLs)4. The all India average of IOL surgeries is only 60 percent, and in some states like Bihar, it is only 30 percent. We have to bring up this percentage through training of doctors.

Intra Ocular lens (IOL) was a tiny artificial lens inserted into the eye after removal of the natural lens affected by cataract. Earlier, after the removal of the natural lens, a thick positive powered glass (known as aphakic glass) was required to be worn by the patient. IOL obviated this need.

Aravind Eye Care System: History

Inception Dr. V. was born in 1918 in a small village near Madurai as the son of a reasonably wellto-do farmer. He grew up in rural surroundings and was educated in local schools and colleges. He completed his M.B.B.S. in 1944 from Madras University, joined Army Medical Corps in 1945, and was discharged in 1948 due to rheumatoid arthritis. This was a difficult time for him, for he was practically bed ridden, unable to stand up or even hold a pen. His fingers were crippled. Due to sheer perseverance and great will power, he was able not only to start writing but also to wield the surgeon’s scalpel. He then joined the Government service as an eye surgeon. He eventually became the Head of the Department of Ophthalmology at the Government Madurai Medical College in 1956.

During his service Dr. V. pioneered state-level programs in 1961 to address blindness by establishing mobile eye camps. Villagers living in distant villages were reached by the mobile eye camps where their eyes were tested, diagnosed, and treated. In 1965 Dr. V.

visited the United States for the first time to attend a conference on the rehabilitation of the blind. It was at this conference in New York that Dr. V. struck a life-long friendship with Sir John Wilson, the founder of the Royal Commonwealth Society for the Blind (now known as Sight Savers International), an organization that was supporting eye camps in India. Dr. V and Sir John Wilson went to the then Prime Minister of India, Mrs.

Indira Gandhi, to ask for support for a national organization to control blindness. Dr. V.

in the meanwhile had also accompanied the then Chief Minister of Tamil Nadu, Mr.

Karunanidhi for his eye treatment, and the latter supported the government sponsored eye camps all over Tamil Nadu spearheaded by Dr. V. Even before Dr. V. retired, he was overseeing the growing network of eye camps all over Tamil Nadu and had developed a network of friends and well wishers across India who empathized with his passion for providing good quality affordable eye care.

Dr. V. was profoundly influenced by Mahatma Gandhi and Sri Aurobindo Ghosh, the sage philosopher who founded the famous ashram at Pondicherry. A strong need to give to society (rather than take from it) was imbibed in Dr. V. The name Aravind in the

Aravind Eye Hospital was chosen to honour Sri Aurobindo. Wrote Dr. V:

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 legacy of our great forefathers… Besides, there were inspirational leaders like Mahatma Gandhi and Sri Aurobindo whose philosophy and way of life influenced many. Naturally I felt impelled to give something back to this great land of ours5.

Aravind Eye Care System (2001). “Promises to Keep." Aravind Eye Care System, Madurai: 2001.

Growth Dr. V. started a modest hospital with his personal savings and with partial government support6 for cataract surgeries done on poor patients from eye camps. From the beginning, a policy was put in place – there would be paying as well as free patients. The paying patients would be charged only moderately and not more than comparable hospitals in the city. There were to be no “five star” customers to cross subsidize the poor patients. Dr. V was certain that high productivity and volumes were necessary if the hospital had to be viable and generate a surplus for providing funds for expansion.

Indeed, the hospital generated a surplus from the very beginning and using such surplus generated it was possible to open a 30 bed hospital within a year, in 1977. A 70-bed hospital meant exclusively for free patients was built in 1978. The existing paying hospital building was opened in 1981 with 250 beds and 80,000 sq. ft. of space over five floors. The initial focus was on cataract surgery, but other specialties such as retina, cornea, glaucoma, paediatric ophthalmology, neuro-ophthalmology, uvea, low vision and orbit were gradually added. No compromises were ever made on the equipment: they were of the best quality and many were imported. However, the rooms (including those of doctors), waiting halls, and examination rooms were utilitarian.

Dr. V’s sister, Dr. G. Natchiar her husband, Dr. Nam (who were also members of the Govel Trust), Dr. Nam's sister and her husband, all ophthalmologists at that time working in the government hospital at Madurai, were persuaded by Dr. V. to join in the very early stages of setting up of the hospital. Over the years other family members (all doctors) joined to head the different specialties. Many (including Dr. V., Dr. Nam, and Dr.

Natchiar) had received training in the United States and had the reputation of being highly competent surgeons.

In 1984, a new 350 bed free hospital was opened to cater exclusively to free patients in Madurai. The top floor of this building accommodated the nurses’ quarters. A basic model adopted by Aravind from the very beginning was that no surgeries were done at the eye camp sites, as was the common practice at that time. All patients were checked at the camps and those patients needing surgery were brought to the main hospital. The eye camp patients were for all poor patients and their treatment was “free” in the sense that the patients did not have to pay for the surgery. But the cost of IOLs was still quite high, and from 1992, IOLs were sourced from the new manufacturing facility, Aurolab set up to produce IOLs at an affordable cost. Usage of these lenses brought down the cost of providing cataract surgery with an IOL implant to about Rs.500 (essentially to cover the cost of IOLs, special sutures and medications). Through intense counselling and health education, IOL was systematically promoted both in eye camps and to the walk-in free patients at the base hospital. Both camp and walk-in free patients were required to pay Rs.500 for IOL surgeries, but for deserving cases, this could be waived by the doctor in charge at the Out Patients Department. Later, in 1995 when the Government of India launched a cataract blindness control programme with World Bank funding and offered a Partial in the sense that though the government paid an amount for each surgery performed on poor patients from eye camps, this fell quite short of the total cost of the operation.

subsidy for the camp patients, the camp patients were not charged this amount. In stages, the number of beds increased to the present 1468 beds (1200 free and 268 paying) in the hospitals in Madurai.

In addition, other hospitals in other towns in Tamil Nadu were also being opened. In 1985, a 100 bed hospital at Theni, a small town 80 kilometres west of Madurai was opened (the desire for this was that it was Dr. Nam’s birth place), mainly to cater for additional eye camp patients. A hospital with 400 beds was opened at Tirunelveli, a town 160 kilometres south of Madurai, in 1988. A 874 bed hospital was opened in 1997 at Coimbatore, the second largest city of Tamil Nadu to cater for the needs of the population in that area, and a 750 bed hospital at Pondicherry (a Union Territory but within the geographical area of Tamil Nadu) in 2003 to cater for the people living in northern Tamil Nadu (besides, it was the town where the Aurobindo Ashram was located). As of 2003, the five Aravind Eye Hospitals between them had a total of 3649 beds, consisting of 2850 free and 799 paying beds (for details of the beds in each unit, see Exhibit 2).

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