Efficient high-volume cataract services: the Aravind model

THULASIRAJ RAVILLA: In 1976, when Aravind started, 1.5% of India’s 650 million people were blind, 80% due to cataract. This translated to about 8 million people being blind due to cataract. This required a high-volume approach to make a dent. Aravind, when it started, had its mission of eliminating needless blindness. And for it to achieve it, the high-volume approach was a necessity and not an option. The effective service delivery, in any organisation, requires a strong and equal focus, both on demand and supply. In a high-volume operation, it mandates that there is a steady and a large flow of patients into the system and matching processes, which deal with that volume that’s coming in, in an efficient manner.

On the demand front, Aravind’s focus was on those affected by cataract but were not accessing care, and they constituted a larger proportion. The approach included– awareness creation, diagnosis, service delivery, and follow up. This took the form of outreach screening camps, organised by local communities. At these camps, comprehensive eye examinations were carried out, glasses and medicines were prescribed, and those requiring cataract surgery were transported immediately to one of the base hospitals.

Further investigations were then carried out, and patients were operated on the following day and transported back the day after. After five weeks, Aravind team went back to the campsite for follow up. In recent years, Aravind has been setting up a network of vision centres to provide primary care. And currently, they are in over 50 locations. Through outreach and vision centres, Aravind admits and does about 100,000 cataract surgeries each year. Additionally, about 100,000 come directly to the paying section and 50,000 to the subsidised section of the hospital, taking the total to 250,000 cataract surgeries being done annually. This requires Aravind to perform 750 to 1,500 surgeries each day.

This is achieved through the detailed, daily micro-planning, to ensure adequate staffing, supplies, and equipment, including sterilised surgical instruments. Each surgeon operates on two tables, supported by two scrub nurses and a circulating nurse, thus minimising the wait for patients or equipment. This process, combined with a highly motivated workforce, has ensured a high output.

Such high volume is enabled when quality is integral to it. Higher productivity is possible by eliminating unnecessary remedial work. And quality has got to be consistent, since services are offered day after day. This means that robust systems have to be in place, and quality cannot be left to chance. At Aravind, quality systems are built on the foundation of standardised protocols, good medical records and, more importantly, an organisational DNA that fosters a culture of continuous improvement. There are close to 400 doctors in the system, with about half of them in training. Thus, it becomes vital for everyone to follow a common protocol in patient treatment.

Standardisation is enforced using simple techniques, like checklists, that are an integral part of the medical records. This allows complications and outcomes to be more directly attributed to processes.

The scheduling of patients matches the complexity of the case to the surgeon’s skills and experience, trainees and junior doctors handing the simple ones and the more skilled surgeons handling the challenging cases. The robust outcome and complications monitoring system captures data on every surgery. Every day, a sample of patients give feedback on their experience and satisfaction through a structured questionnaire or focus group discussions. This provides a better insight into what drives satisfaction and areas needing improvement. Staff members collect and record data relating to quality. In addition, they also do the analysis and review. This results not only in continuous quality improvements, but more importantly, in strengthening quality consciousness and patient-centricity across the hospital.

The business model of any organisation is largely governed by its purpose and philosophy. Aravind’s purpose of eliminating needless blindness resulted in policies such as– no one will be turned away for want of money; reaching out proactively those who are not accessing care. Equity– that is the core aspects of care around safety, outcome, and maintaining patient dignity are the same, regardless of the patient’s paying capacity. The hospital has to be self-reliant in providing patient care. So these formed the non-negotiables policies. Financial sustainability is essentially maintained by a simple formula of keeping the costs to be less than the revenues. Aravind chose its income to come predominantly from patient services to ensure sustainability.

Reflecting the paying capabilities, the Aravind pricing covered the full range from market rates for the paying patients to a negative price for the rural poor. Negative price means that Aravind spent money on patients in the community to enable access by transporting them. Zero was also a legitimate price point. The pricing structure was transparent and easier to comprehend, which built patient trust. The patients coming to the hospital could self-select to be seen at the paying or free facility. Ambiance and facilities, like air conditioning, was what the paying patients paid for. Some same clinical quality was insured by rotating the staff within the two facilities.

The focus on equity also gave birth to Aurolab, which made available good quality IOLs at low costs. On the cost front, they were kept to a minimum by focusing on productivity, eliminating waste, and efficiently managing bottlenecks. This was also helped by viewing cost from the patient’s perspective. They were reduced through a leveraging scale, completing the entire care cycle, including surgery in a single visit and rationalising the number of follow-up visits. This approach helped Aravind’s financials to become robust, not only covering the costs of free care and subsidised care, but also financing the building of new hospitals and purchase of equipment.

This comprehensive approach of focusing on demand, supply side in terms of building capacity, quality, and ensuring financial viability has helped to provide cataract services consistently and sustainably in large volumes.