Many of you are aware of how I spent my free time this summer in India. Some are even aware of what work I did while in India. Fewer are cognizant of The Aravind Eye Care System (AECS) that I worked for, and my impetus for coming to India. AECS is the single largest surgical eye care provider in the world. Hindu mythology affirms a triumvirate of cosmic gods controlling the universe: Brahma, the creator, Vishnu, the preserver, and Shiva, the destroyer. Their forces work in harmony, complementing one another and each force capable of dominating when necessary. In a way, Aravind is driven by three forces of its own — volume, quality, and affordability. Aravind’s founder, Dr. Govindappa Venkataswamy (“Dr. V”), found his inspiration in the assembly line model of fast food franchises like McDonald’s. He applied this mentality to the hospital healthcare and as a result appeals to all socioeconomic classes. The synergy between these forces and patient demand is what drives Aravind’s business model forward and demands our admiration.
Understanding Aravind’s largest asset, access to astoundingly high volumes, is the first facet to analyze. By 2010, AECS was seeing more than 2.5 million patients and conducting 300,000 surgeries a year. Compare this to the entire United Kingdom National Health Service that did a little over a half million eye surgeries in the same time period. A doctor at Aravind performs over 2,000 surgeries yearly; the average in India is 400. My supervisor is considered a high-volume surgeon at Aravind; performing up to 100 cataract procedures in the span of a single day is not uncommon for him. When speaking with a US based ophthalmologist about looking at glaucoma risk factors to study, it was suggested I try to collect data from at least 20 patients a day over a two-week duration to garner solid stats. Glaucoma is a leading cause of irreversible blindness on a global scale. Aravind is dedicated to eradicating treatable causes of blindness including glaucoma. On my first day collecting data, in a matter of 5 hours, I was able to assess 67 patients for the study. The huge sample size available through Aravind is incredibly helpful for research and understanding disease processes.
A typical operating theater in Aravind will have 2 surgeons operating simultaneously with 2 patients each. The surgery day starts at around 7am and finishes up at around 1pm, with each cataract surgery taking anywhere from 5-10 minutes.
The registration counter is constantly flowing with people regardless of the time of day.
Aravind is heavily focused on delivering high quality care in an efficient manner. They are constantly doing data collection to make sure patients are not waiting long periods of time, and will analyze work flow issues to find solutions. These screens are up in all the general and speciality clinics, updated real time, so there is constant focus on improving the system.
The high quality of healthcare Aravind delivers to patients is consistent across all pay scales, whether a patient pays $0 or $1,000 for their procedure. The same surgeons who operate on the highest-paying patients, including politicians and celebrities, are the same ones who operate on nonpaying camp-sponsored patients. The differentiation between paying and free patients comes in the form of accommodation add-ons. For example, patients pay for provisions such as an extra bed for a family member, air conditioning, or private rooms. There is a differentiation in surgical procedure and lens implant as well. Charity cases are done without utilizing costly automated machines, excimer laser or phacoemulsifiers, depending solely on physician dexterity which is a nonchargable service here. Aravind offers locally made intraocular lenses and medications instead of costly branded ones to free patients. Affording patients pay a $1 consultation fee for either up to three visits or 90 days, whichever comes first. The consultation fee includes individual tests such as refraction, ocular pressure, and slit lamp biomicroscopy. Obviously, this fee is waived for free patients, but they receive the same quality of care. Outcomes between paying and nonpaying patients are statistically the same. Quality analyses of outcomes over many years have shown parity between the groups and even stand up higher than international standards!
The free patient unit waiting area
A free patient ward, where patients stay overnight the day before their surgeries. A paying patient will get their own room with amenities.
Camp patients receiving counseling for their cataract surgery, which will take place the next day at the base hospital by one of the doctors. These patients will receive care for free and get a standard intra-ocular lens.
Meeting with the leaders and workers immediately after a weekend camp to discuss how it went and any recommendations for future camps. 
The “examination room” at a camp where the doctors will perform a quick flashlight test to check for cataracts.
The final element of the trinity, cost, is a source of inspiration and a beacon of hope for American healthcare. The US, while known for quality, is infamous for its skyrocketing medical costs. Over 17% of US GDP spending goes toward healthcare. In fact, if our $3 trillion health care sector were its own country, it would be the world’s fifth-largest economy. Despite this, hospitals and physicians find it very difficult to collect reimbursements from insurance companies including the government. Even a recent Time Magazine cover story explored the exorbitant, not to mention often arbitrary, inflated, unfair, and often erroneous, bills patients receive for routine healthcare. The American system favors insured patients, often leaving the uninsured with inequitable to no options. The Aravind system sets up a new reality. There, patients are split into three categories: free, minimal, and paying, where patients self-identify themselves without any burden of proof required. “Those who elect to pay, the consultation fee is roughly $1, and the various surgery prices are capped at local market rates…patients who decide to pay for cataract surgery choose from a tiered range of packages. Midrange prices start at about $110, while high-end packages can go up to $1,000.” (Infinite Vision, p.19) A free or minimal patient will pay anywhere from $0-$17 for cataract surgery. The government reimburses them $15 for every free patient surgery performed. Some paying patients are covered by insurance and have most of if not all of their costs covered, save the consultation fee or “co-pay”. People choose Aravind regardless of their ability to pay because of their strong reputation and efficiency.
An MLOP performing a test encompassed in the consultation fee.
Aravind manufacturers their own standard lenses in order to keep costs low. This is the packaging of an “Aurolab” IOL.
The combination of high volume, which reduces unit cost, as well as manufacturing many things on site helps Aravind keep overall total costs very low.
Often, we hear of people undergoing hardship to come to America for access to and for high quality care. When people talk of going to the third world, it is often implied that it is to change something there and westernize them with our philosophy. In Aravind, I have experienced the exact opposite. I have learned so much over the course of my time here that I believe it is in fact the western world that has something to learn. I have true admiration for the work done, the people served, and the results gained. Dr. V’s mission to end needless blindness is the mantra that inspires everyone from the orderlies to the CEO. Seeing the forces of volume, quality, and cost work together to that keep Aravind in balance, makes me wonder if there is a way the Aravind model can be applied to healthcare in the United States.
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