As part of a blog series on Social Entrepreneurs, we spoke to Thulsi Ravilla, Executive Director of Aravind Eye Care System, about democratizing healthcare and eliminating blindness among the poor. Aravind Eye Care Systems was founded in 1976 as a way of dealing with avoidable blindness in India. Since then the social enterprise, which has been profiled by scholars and researchers looking to understand and replicate its success, has treated millions of patients, largely from rural poor communities.
After almost 40 years of operation, what does Aravind Eye Care Systems look like today?
Aravind started off small, with a few members of staff and no budget, but a broad purpose to reduce human suffering. What we knew how to do well was eye care, so that became our focus. The market is huge – one in four people will at some point require some form of eye care – but the penetration is small, perhaps around 15%-20% in India.
Almost all our growth has been organic. Last year we grew by around 7%, and demand keeps on increasing, particularly because we try to reach “non-customers” – poor people not actively seeking care – and as the market expands, so too must our capacity. Today we average approximately 12,000-15,000 outpatient visits and 1,500 surgeries each day.
Our focus on serving everyone translates into affordable services for all – our prices go from negative (where we pay for transport to help patients access care) to zero (for patients who walk into the hospital but cannot afford treatment) to positive (for patients who can afford to pay). When we started, only 30% to 35% of our patients could pay; now we’re hovering around 45%. Those patient fees allow us to provide the same care to our “non-customers” for free or at a deeply discounted price.
In the 1990s, we advocated for this methodology to become the standard approach in the industry, which it now is, so it’s not just Aravind that has grown but the sector as a whole. In 1992 there were 800,000 surgeries performed in India; last year there were approximately 6 million.
How much of a role has this advocacy side of things played in the growth of your company and the industry as a whole?
Let me give a couple of examples. In the 1990s, we used funding from the World Health Organization to carry out a population-based study of two types of surgery to treat blindness. We found that after the conventional surgery, 50% of patients remained “technically blind”. After the second type of surgery – which involves implanting a lens inside the eye – that figure fell to 5%.
We took our findings to decision-makers across government and industry. When they saw the evidence, the health ministry virtually banned the conventional method overnight. We actually had to pull them back a bit and put in place a transitional process so everyone could be trained in the modern procedures.
Here’s another example. In India, healthcare planning is based on five-year plans, and funding levels increase incrementally from one five-year plan to the next. The government’s allocation for eye care in 2002-2007 was equivalent to around $100 million; that would have increased by 10% to around $110,000 million for the next five-year period. We were part of a consortium of eye care providers asked to draft a plan for the 2008-2013 period, and rather than map out what we would do with $110 million, we asked what the eye care needs of the country were as a whole, calculated what was being provided, defined the gap, and estimated what level of government funding and support would be required to bridge that gap.
Our calculations showed that we would need $500 million over the five-year period, which the health ministry said it could not provide. But we still presented the plan to the planning commission, and showed them the evidence of how the allocation would be spent and how the targets could be achieved. Ultimately, the funding was approved close to that level.
Having said that, a lot of policy-making happens through personal relationships. You need to build trust and to have the right people’s ears at the right time. You also need to have some structure through which people will listen to you. In our case, that structure is a consortium of international funding agencies and national agencies that together provide around 30% to 40 % of eye care services in the country. It is important to have that muscle power to influence policy-making.
Your international training centre, the Lions Aravind Institute of Community Ophthalmology, has helped staff at hundreds of other hospitals learn and adopt your methodologies and technologies. Tell us more about that.
In the 1980s, I carried out an analysis of eye care services in other hospitals and found they were routinely operating at around 15% to 20% of their maximum capacity, despite constant complaints of inadequate resources. It was this paradox that made me realize Aravind could achieve our mission of eliminating blindness by helping other hospitals match their operating efficiency with their capacity. A training centre was the best way of doing this. We knew the demand was there, because funding agencies had since the beginning been intrigued by our methodology.
Our replication efforts are not a way for us to increase revenue. The hospitals we work with don’t pay us – on the contrary, we pay them to undergo the change processes with funding we raise. But as blindness does not respect geographical borders, the training centre is core to our mission.
Right now we’re working with five hospitals in Ethiopia, Kenya, Zambia and Nigeria. Thanks to about $2.5 million from the Hilton Foundation and Bloomberg Philanthropy, we’re able to offer each hospital close to $250,000 to make process improvements and $50,000-$60,000 towards training and technical input such as software. The process improvements will help the hospitals double their output within 18 to 24 months and they should see their cost recovery go from 55% to 90%.
And how do you choose what hospitals to work with?
We ask international funding agencies to share their partners list. We then speak with the hospitals to establish which ones would make the biggest improvements if they had structured technical guidance. Some funding agencies give us both their list of hospitals and the grant money to work with them.
What steps are involved in helping these hospitals adopt your methodologies?
Once we decide to work with a hospital, we carry out some research on them and do a site visit. We study the hospital’s clinical processes, their administrative processes, their governing structure, and we get a feel for the actual people who are involved and the market dynamics in which they operate. That helps us identify the opportunities and see where the gaps are. We provide this feedback and prepare the entire hospital team for the changes that will take place.
Then we invite a team of four people to come from the hospital to our institute in India where we put them through a strategic planning process. Over eight days we teach them the principles of our model and the details of how we operate, and we help them develop their own strategy. We spend a lot of time on pricing and a business plan and we walk them through how to increase their patient volume. If they’re performing 1,000 surgeries, the improvements we put in place will typically allow them to increase that by three or four times.
The last step is change management. We hold one-on-one meetings with hospital leadership, as they are key to making these changes happen. We also ask that the four-person team who came to our institute share the strategy with the board members or trustees and hospital staff, and then fine tune the plan. They use our software application so they can base their decision-making on hard evidence, and then they can figure out what will work best in their specific context.
The most important thing for us as we replicate our model is that the principles stay the same. The processes adopted must result in positive clinical outcomes and patient experience. And the hospitals must adopt a pricing model that makes their services accessible to all – even those who can’t afford to pay.
Thulsi Ravilla was interviewed by Katherine Milligan, Director and Head of the Schwab Foundation for Social Entrepreneurship.
Image: Patients sit in a hospital of the Aravind Eye Care System in Madurai, India, March 3, 2010. REUTERS/Reinhard Krause