Aravind Eye

Care System
Eliminating needless
blindness
Founded by Dr. Govindappa Venkataswamy | India
What’s At Stake
12
12 million of the 37 million
people in the
world with blindness
are in India
(source: The Hindustan Times)
.02%
India faces a significant
shortage of optometrists:
.02% of the need is
currently being met. While
40k optometrists are
needed, there are only 8k
(source:Times of India)
India has the highest number of blind
people in the world. Of the 37 million
blind people across the globe, over 12
million are from India. The country faces
a significant shortage of optometrists;
while it needs 40,000 optometrists, it
has only 8,000. (source: Times of India)
Moreover, the public health system’s
capacity is inadequate to meet the health
services demands. However, 80% of all
vision impairments can be prevented
or cured if patients receive the right
treatment, and on time. (Source: WHO)
Aravind Hospitals was founded to
find sustainable ways to offer eye care,
particularly to prevent or cure blindness,
for all those who need treatment, regard-
less of ability to pay.
Business Model Innovation
If you had visited the 11-bed, Aravind
Eye Hospital in 1976, it would have been
hard to imagine that it would expand to
serve over 3.3 million outpatient visits
a year (source: endeva) , have its model
further replicated by over 320 hospitals
around the world, and inspire approach-
es to tackling other diseases.
Its drive to reinvent its model in radical
ways began with a moment of failure.
When its founding doctors, Dr. G. Ven-
kataswamy (Dr. V) and Dr. G.Natchiar
(Dr. GN), went to a neighboring city
to fundraise from donors - they were
turned away. They left with a deep
sense of frustration: they had spent
10 days they could have spent treating
patients - with nothing to show for it.
From this experience, came core princi-
ples that drive Aravind Eye to this day:
• Turn no patients away
• Give the highest level of care
• Be self sustainable - don’t
operate on external funds
One of the first innovations was to de-
sign services for anyone who is not able
to reach the existing eye care hospitals.
They began by visiting rural areas to
setup outreach camps that would offer
services such as patient screening - and
after finding that it was only bringing
At a Glance
in 7% of patients who needed care, they
setup permanent primary eye care Revenue Model
centers with the ability for doctors to
perform rem ote exams via cameras - in- • Earned income via
creasing reach to 40% within one year of product/services
adoption, and 70% by the second year. sales and consulting
Changing its business model was Innovation
another key way to scale its services: • Unaddressed Market
finding ways to lower their costs by
optimizing their resources. The first ap- • Pricing
proach is by having a dual pricing model, • Product design
where the wealthier, 50% of the patients,
pay for the cost of 50% of the patients • Supply chain
who cannot afford the surgeries other-
• Distribution
wise. The hospital provides
no differentiation in the quality of the • Sales and marketing
medical service,except that the patient
who pays gets a nicer outpatient experi-
ence with a private room.
Aravind Eye Hospital also optimized
their fixed costs - such as doctors and
the operating theatre - so that they
could begin performing almost 4 times
as many cataract surgeries in a day than
is the norm (from 15 surgeries per day
to more than 50-60 per day). This was
done by introducing a process innova-
tion where in a doctors was provided
two table for operating instead of 1 and
creating a new role to support them,
called the “middle-level ophthalmic overcome the prevailing wisdom that
personnel” (MLOP) to support the said that even though the Intra Ocular
doctor, so that doctors could focus on Lens (IOL) was a better procedure, it
surgeries instead of needing to spend should not extend to other developing
time on tasks such as record keeping, countries because of being too expensive.
suggesting lens options, or moving pa- It partnered with another social entre-
tients around in the theatre. By creating preneur, David Green, in 1992 to launch
special training, the role did not require its own non-profit, on-site lens manufac-
a nursing degree, thereby lowering the turing. And as a result of not needing to
cost of each support personnel by 1/5 rely on any intermediary suppliers, sales,
(from 50,000 to 10,000 rupees). Their or distributors, they were able to reduce
founder, Dr. V., was famously inspired to the cost radically, from $100 at the time,
make such changes based on observing to now only $2 per lense. It not only
the assembly line efficiency and volume serves Aravind but also over 150
of high quality service at place such as companies across the globe.
McDonald’s, visiting its Hamburger
University in Illinois, shadowing jan- Four years later, in 1996, they partnered
itors at airports to see how they clean with the Lions and SEWA foundation for
toilets, as well as catering staff at 5 star
the initial seed launch of the Lions Aravind
hotels, to look for ways to reach new Institute of Community Ophthalmology
heights of resource efficiency. (LAICO). LAICO provides consulting for
hospitals to improve their cataract surgical
But it didn’t stop rates as well. The Institute offers capac-
there - after growing to two new loca- ity building by training in clinical areas,
tions in Theni and Tirunelveli, Aravind training for improved administrative
still continuously looked for new ways and managerial processes, vision building
to reach the scale of the demand. Part- with leadership, and initial seed funding
nerships were key. As, Dr. Devendra, to kickstart the new approach. It offers
Manager Employee Engagement, de- active support for 2 years, followed by
scribes, “We realized that Aravind can’t ongoing mentorship as needed afterwards.
be everywhere. We have a global mission. As a result of openly sharing its model, the
So we see others with similar visions as Aravind model has been replicated in over
partners, and not as competition.” 300 eye hospitals in 30 countries, with
a number of those hospitals becoming
“We realized that Aravind can’t regional replicators of the model as well.
be everywhere. We have a global
mission. So we see others with A core part of Aravind’s training is
similar visions as partners, and to shift the mindsets in hospital and
not as competition.” eyecare towards explicitly committing
to find ways to sustainably serve who-
One of its first partnerships was to ever is in need - and work openly with
partners to meet the scale of the demand. glaucoma and focus on primary eye
As founder Dr. V. said, “Never restrict care” that could help prevent the need
demand. Build your capacity to meet for surgeries.
the demand” and that what’s needed
is “not leadership in the sense of
organizing and making it work. It’s
leadership that comes from empa-
thizing with the community.”

LAICO has begun developing an

e-learning platform, Aurosiksha,
to reach more eye care professionals
seeking training - from ophthalmologists
and mid-level ophthalmic personnel, to
managers, technicians, and researchers,
as well as offering training of trainers.
Since launching, they have already
reached an additional 6,000 trainees
from 99 countries.

Aravind Eye Care System’s income

depends partly on grants (10%), however,
this is a part of it’s strategy to support
other hospitals to replicate its model,
and there is no dependence on govern-
ment subsidies or international aid for
its core operations.

Having achieved self-sustainability

and the impact of treating over 4 million
cataracts, what’s next? “It’s always
evolving,” says Dr. Devendra “We are
moving our focus from cataract to
other chronic eye-diseases - such as
Approach to System Change
How Aravind is creating efficiencies in the
eye care system in India

Aravind Eye Care system is an umbrella At a Glance

term for numerous, interrelated • Resources
services such as its hospitals, outreach • Roles

camps and centers, lens manufacturer, • Relationships

• Mindsets
training center, eye bank, and
more. It has been able to achieve
this remarkable scale of impact by
introducing new resources, roles, and
relationships in eye care
Eye care system in India
How Aravind is creating
efficiencies in the eye care
system in India

Before After

Resources Resources
-Payments of patients -Payments by patients (significantly reduced for poor patients)
-Telemedicine infrastructure.
-Open training materials for ophthalmic personnel

Rules & mindsets

-High quality service for those who can afford it
-“Patients need to come to us”
-“Hospitals need to operate within the limits of traditional hospital funding
models”.
Rules & mindsets
-Explicit commitments to sustainably serve whoever is in need, regardless of
Roles & Relationships ability to pay or who we need to work with
-i.e. “We need to get to the patients” and “Let’s work together to
eradicate blindness”.

Roles & Relationships

Train Before provide

After trainning and
mutual support to

Ophthalmology training
Hospitals Train
institutions Traditional
medical schools

Lens manufactures
Patients

Ophthalmic opticians:
Fully trained ophthalmic
opticians

Results
-Quality of service: good
Hospitals: Ophthalmic opticians:
-Cost of service: high Social venture focusing on Fully trained ophthalmic
-Accessibility: low (too expensive for most people in India) impact and affordability con- opticians
duct outreach & education Mid-level ophthalmic per-
-Economic value created: doctors, hospitals, lens manufacturers (high mar- (inc. telemedicine) via sonnel
gin, low volume) For only those that can
afford it pay for treatment
physically to. Ophthalmology training
institutions
Rural camps and centers Traditional medical schools
Ophthalmology e-learning
platform.

Patients Lens manufactures

On-site social venture focusing
on impact and affordability

Results
-Quality of service: same
-Cost of service: low
-Accessibility: high
-Economic value created: doctors, hospitals, lens manufacturers (lower margin,
higher volume than before)

*This is a simplified systems diagram, and not intended to be comprehensive. The analysis uses the “5Rs framework” developed by USAID.
More information can be found here at usaidlearninglab.org
 Before
Resources Hospitals that provides eyecare are expensive or inaccessible
Lense needed for the most effective surgeries are considered
too expensive and inaccessible for those who are poor
Training and education is expensive and only offered
in-person, limiting how many trained eyecare professionals
are available to less than is needed by the population
Roles & Relationships The majority of eye care tasks are performed by highly trained
professionals - mainly doctors and nurses; they are highly paid
and there are not enough professionals to meet the demand
Hospitals are run in a way to maximize profit and do not
regularly work with other, outside hospitals
After
Created a cross-subsidized hospital model, where funds from
people who can pay at one hospital are used to cover costs for
people who can’t pay at a second sister-hospital that shares the
same staff. The quality of care is the same at each hospital, with
the main difference being the privacy and quality of facilities
for outpatient care
Traveling outreach camps, stationary vision centers with
telemedicine capabilities, and offering transportation and
accomodation for rural patients increase the number of new
patients in rural areas by up to 30%
The establishment of on-site manufacturing lowered the cost
of lens needed for surgery from $100 to $2 by simplifying the
supply chain.
The e-learning platform, Aurosiksha, enables more eye care
professionals to gain training without needing to travel
Tasks that do not require specialized tasks are transferred to
new role - Mid level ophthalmic personnel (MLOP). So they
don’t have to spend time with records, suggesting lens, moving
the patient around in the theatre. The resource optimization
helps to reduce the overall costs per patient, and enabled 4
times as many surgeries to be performed
The Lions Aravind Institute of Community Ophthalmology
(LAICO) pro vides consulting to hospitals on improving their
cataract surgical rates and creates a ripple effect: encouraging
hospitals to train additional hospitals to replicate the model as
well (training the trainers)
 Before After

Rules & Mindsets Healthcare centers work within their own company’s network
and focus on meeting the immediate demand from those that
can afford their services
High care quality for the poor is not considered practical
or realistic
A core part of Aravind’s training is to shift the mindsets in hospital
and eyecare towards the idea that it is feasible and sustainable
to provide high quality care to those that are poor, and that its
necessary and beneficial to work with others as partners - not
competitors - towards meeting the scale of the demand

Results Large prevalence of needless (preventive) blindness in Affordable eye care is available at scale and reaching rural
developing countries. populations, while allowing hospitals to remain self-sustaining

Many cases of eye-diseases going unidentified, especially High-quality training for eye care professionals is more easily
in rural populations accessible and affordable

Only one organization had the capacity to conduct this Hospitals are openly replicating the high-impact model,
work under this system and training other hospitals to do the same

Innovation in medical process to increase surgeon

productivity by optimizing staff tasks has spread to the
treatments of other diseases
The Impact

· Aravind Eyecare System treats over 4.1 million At a Glance

outpatient visits a year, with over 32 million patients
• Growth
treated and over 470.000 surgeries performed since
• Joint Ventures/
its founding. Innovations by Aravind and its network Partnerships
of partners have lead to results such as increasing the
• Open Source
productivity so that it is able to perform 4x as many
surgeries than the norm and the quality of care • Campaigns/
Movement Building
remains high, with surgical complications at half
• Training/ Consulting
that of eye hospitals in Britain

· Aravind’s onsite lens manufacturer has been able to

drive down the cost of lense needed for eye surgery
from $100 to $2. It has produced lens for over 20 million
people in over 140 countries across the globe
· The Aravind Eyecare model has been replicated by
over 320 hospitals in 27 countries around the world
and has lead to these hospitals also spreading the
model further. For example, in 2013, Visualiza hospital
in Guatemala learned from Aravind’s model and, with
the support of other partners as well, grew to perform
over 20% of all cataract surgeries for its country despite
having only 2% of the nation’s ophthalmologists,
having only 55 staff, and having
the majority of patients either subsidized (80%) of free
(10%). Visualiza has then conducted capacity building
for clinics in other countries including Peru, Nicaragua,
Haiti, Mexico and Honduras, with the clinic in Peru
doubling its key clinical indicators in less than 2 years.
The Lumbini Eye Institute(LEI) is another example.
Following capacity building with Aravind and other
partners, they were able to scale to provide 25% of all
eyecare surgeries in Nepal and is building institutional
linkages in countries such as Tibet and Cambodia

· Aravind’s approach to creating greater access to

affordable, high quality care has been applied to
other areas of healthcare such as maternity hospitals,
cancer treatment, and AIDs prevention; for example,
AIDS prevention circumcision surgeries by those
using the World Health Organization’s guidelines have
increased the surgeries possible per day has increased
from 5 to 7 times the norm
Key Ingredients for Success

Look for Pathways to Scale Be-

yond Growth: This enables organizations to over-
come the financing bottleneck that
Once it had established a Aravind observed in the past, allow-
successful, high-impact model, Ar- ing those that have been trained to
avind did begin its quest to scale its take the first step in applying their
impact by beginning to grow its loca- learnings to their own model.
tions, and established hospitals in two
new, high-demand areas. However, it Have a shared-vision to Create
realized that even at this rate, it was Partners, Not Competitors:
still not going to reach the scale
of the millions of people who were By continuously looking for new ways
still facing unnecessary blindness, to scale and showing in their deci-
both in India and abroad. It’s with this sions that finding ways to meet the
in mind that they deliberately sought full demand of their target population
new strategies to reach scale, such as was a priority, Aravind has generated a
open-source consultation, training, strong network
and consulting, developing trainings of partners. In order to do that, part-
for trainers of eyecare staff, and out- ners who share their vision have been
reach and education campaigns. key. As Dr. Devendra, describes, “We
realized that Aravind can’t be
Enable Start-up Resources & everywhere. We have a global
Seed Funding for Open-Source mission. So we see others with sim-
Replication: ilar visions as partners, and not as
competition.”
In order to enable others to
replicate their model, Aravind pur-
posely set out to raise funds for
other organizations and NGOs.
Doing so has been a key component
to Aravind’s replication success.
Dr. Devendra describes how,
“We raise funds that can be used
for initial vision building work-
shops, trainings, and have creat-
ed provisions to allows for funds
to be given to the replicating or-
ganization directly as well so that
they can kickstart the project
they have ideated while attend-
ing trainings hosted by Aravind.”
Pitfalls to Avoid
1 Choose Investors Carefully: Dr. Deven-
dra identifies one the biggest challeng-
es that startups face as entering into
funding or angel investor obligations
that dilute the organization’s original
impact-purpose. He recommends that
you carefully choose your funding
partners and only agree to commit-
ments that will not take away from
your organization’s impact-purpose,
taking every decision from this lense.
Ideally, Dr. Devendra recommends,
find a business model that would allow
you to become self-sufficient without
relying on other fundraisers and angel
investors. He describes how,
“We won’t take the money if it doesn’t
carry our mission forward. For oth-
ers who don’t have that value system
-just because money is coming their
mission might diverge. We have seen
this happening.”
2 Align Values with Vision: Ensuring that
all leadership and staff are fully aligned
with the type of values that are needed
to truly deliver on their vision has been
key for Aravind’s success. Based on
training hundreds of potential replica-
tors, the greatest challenge Aravind has
seen to others successfully replicating
their model is the new teams’ also not
taking enough time to build and com-
mit to shared values that identify why
they are adopting and contextualizing
this new eyecare model.
“Until now,” Dr. Devendra describes,
“people have tried to copy the systems but
they have not been able to copy all of the
elements in the new local context. There
are three parts of an organization:
1) the why - values and why they are
doing it 2) the what - what they do,
and 3) how - the operations. Organi-
zations have not necessarily taken
the ethos - and that doesn’t work.”
For this reason, Aravind builds
specific trainings for, and is looking
for new ways, to help new hospitals
identify their value system and
help them to build their value
systems. For Aravind, core values
have included treating every pa-
tient with respect and compassion
regardless of ability to pay, turning
no patients away, and relentlessly
finding new partners and businesses
to be self-sustainable. For example,
at Aravind, Dr. Devendra describes,
“Patient centricity is
needed for any decision.
Say an equipment or
process does not help
the patients, or software,
then we don’t go for it.”
 Acknowledgements

❏ Authored by Reem Rahman, Olga Shirobokova, Odin Mühlenbein, Nadine Freeman and Mark Cheng for Ashoka Globalizer

❏ Interviews by Ken Banks (FrontlineSMS), Michael Feerick (Alison), Steve Song (VillageTelco), Dr. Devendra (Aaravid Eye Care Systems), and
Tristram Stuart (Toast Ale)

Creative Commons creativecommons.org/licenses/by-sa/4.0

Licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.