Aravind and Efficiency

If you want to learn about how to make health care more efficient, take a trip to Aravind. Their guiding principle has always been that everyone deserves high quality eye care without regard to their ability to pay. Anyone can choose to go to either the free or paying hospital; it's on the honor system. For every one paying patient, they treat two free patients and still have enough money left over to invest in new hospitals, clinics and treatment camps.

The amount and variety of eye disease here is astonishing. This morning in the cornea clinic in the paying hospital, I saw two cases of an eye disease called macular dystrophy. Two cases is about equal to the number of cases Dr. Zegans (the ophthalmologist from Dartmouth who comes here every year and brought me with him) has seen in fifteen years at Dartmouth. Even though the people at Aravind currently see 2,000,000 patients per year and perform 350,000 surgeries, there is much, much more demand here.

So, back to how Aravind can afford to treat that many people for $20,000,000 per year: they also have an arm which manufactures surgical supplies they have a huge support staff for each ophthalmologist. The surgery they do here most often is cataract surgery. This surgery takes about 10 minutes to do: you cut a slit in the eye and then take out the lens, either by phacoemulsification (breaking the lens up with an ultrasound applicator which also sucks up the pieces) or you take the whole lens out through the slit. Then, you replace the lens with an artificial one. A few years ago (and still in the U.S.), the artificial lenses cost about $150. In a country where per capita annual income is about $1000, you can't charge $600 for a surgery (remember, the paying patients cover themselves and two free patients). So, Aurolab spun off from Aravind.

The Dartmouth contingent at Aurolab:

Aurolab figured out how to make lenses (of approximately the same quality as the $150 lenses) for about $5. Right now they sell them in about 70 countries and are a major supplier for Aravind. Because these lenses exist, the price for the "name-brand" lenses has also come down in India. Some patients still choose the Alcon lens (Aravind allows the paying patients to choose), but those lenses are now less expensive. All the free patients and many of the paying patients get the Aurolab lenses. They also use Aurolab surgical blades, suture and pharmaceuticals here and elsewhere around the world. I've seen the Aurolab facility and it is incredible to me how inexpensively they can produce such high-quality products. About 90% of the workers are young women who have finished high school and live and work at Aurolab for good pay.

A couple of other factors go into the efficient delivery of health care at Aravind: The support staff. Almost all of the non-physician care at Aravind is provided by the "sisters". The sisters are high school senior girls (some of the best at their schools) who choose to come to work for Aravind. They are trained for two years to do preliminary eye exams, screenings, prep patients, assist in procedures, administer some medications, etc. After that two year period (during which they receive housing and a stipend) they come to work for Aravind. They allow work to proceed more efficiently. In cataract surgery, for instance, a surgeon will work two tables simultaneously. A sister will prep one patient while the surgeon works on the other. When the surgeon is finished, a sister takes that patients and preps the next (while the surgeon is working on the patient on the other table). In between surgeries, the surgeon doesn't rescrub or write down notes (not much paperwork for physicians to do here). The surgeon just dips his or her gloves in sterilizing solution and moves on to the next patient. Thanks to the huge number of support staff, a surgeon here can do 6-8 cataract surgeries per hour (in the U.S., an ophthalmologist can do 1-2). The surgeon doesn't need to do paperwork because one catarct surgery is typically much like another and there are fewer regulations here. Even cutting corners that we couldn't in the U.S. (no rescrubbing), their post-surgical complication rate is lower than in the UK. Also, when a surgeon is in the operating theatre (OT), he or she can focus on just doing surgery.

One other observation: everything happens faster here. From a conversation from this morning: "You need a corneal transplant. We can probably do in sometime in the next couple of days."

Because of the way Aravind has innovated, they can treat an unbelievable number of patients (and they give excellent care here) for an extremely small sum of money. If you want to learn about innovation or effect health care delivery, come to Aravind.

I'm going to an Aravind screening camp tomorrow so I'll post about that when I get back.