The story of Aravind Eye Care System’s (AECS) external capacity building legacy is more than just about management, systems and processes. Understanding much of what makes AECS unique can be gleaned from the many narratives and personal experiences of the physicians and staff who, through their passion and commitment, have contributed to preventing unnecessary blindness in disadvantaged areas throughout the world. Just as Dr. Venkataswamy’s (Dr. V) own story so strongly reflects the soul and mission of Aravind, so too do the stories of AECS’ dedicated trainers and mentors serve as a lens into the motivations, struggles and benefits that AECS itself derives as an organization committed to serving others.

Dr. Venkataswamy’s (Dr. V)
 

As Pavithra Mehta, author and documentary filmmaker who chronicled the life of Dr. V. and the history of Aravind in ‘Infinite Vision’ has said,’ “Stories in a very humbling way can help the world see a little bit better, and the story of Aravind is one such illuminating example.”

In our upcoming series of articles we will examine the story of AECS’ capacity building through the eyes of those who shaped and influenced AECS’ mission, and those who are carrying it forward to this day.

Engineering to Eye Care

 

Thulasiraj Ravilla, Executive Director of Aravind Eye Care System giving a TED Talk

“I said to Thulsi (Thulasiraj Ravilla, Executive Director of Aravind Eye Care System), why don’t you come with me and visit these hospitals? I’ll cover the costs.” — Doraiswamy Nagarajan
 
 
Doraiswamy Nagarajan working with Divino Nino Jesus Eye Hospital (located in Lima, Peru) at Aravind in 2015Doraiswamy Nagarajan working with Divino Nino Jesus Eye Hospital (located in Lima, Peru) at Aravind in 2015

It is not hard to think of Doraiswamy Nagarajan as a multi-faceted personality. Nagarajan trained as an engineer, and spent the bulk of his professional career with Indian Railways. In 1966, Nagarajan suffered an on the job accident resulting in the amputation of his left arm. This injury served as motivation for Nagarajan to search out opportunities to ‘pay back’ society for helping him achieve his success despite the injury.

In 1988 Nagarajan joined Sightsavers International, an international charity that works with partners in developing countries to treat and prevent avoidable blindness as its Regional Director for India. During this period Sight Savers was working through as many as 1500 local partners to provide low-cost eye care to poor patients across India as grants for camp surgeries.

“Sightsavers’ clients were, through the partner organization, the poor patients who couldn’t afford to pay. That was their only measure. What the organization did with paying patients was not even captured. When I came in to Sightsavers I started to think, how can I make organizations contribute to eye care services better and be more accountable?”
“As a former senior executive for Indian National Railways, I had an understanding of how to maximize return on investment, but had little knowledge about eye care delivery, or even how charities worked.”

Nagarajan uncovered three critical weaknesses in Sightsavers’ operations. One was quality; because of a set fee on per capita surgical rate, partners tried to package the service within that amount hoping to make a profit, all at the expense of good quality cataract surgical care. Another issue was lack of sustainability. Most eye care providers in the charity sector delivered eye care services only as long as funding was there to support it. Once funding dried up, services were curtailed. To Nagarajan this demonstrated that organizational partners were either not genuinely passionate about eye care, or did not know how to build sustainability eye care away from dependence on external funding for charity work.

 
 
Family transporting their family members after cataract surgery
 

“One major thing I found in northern India was… clinical output was 10–15% of the installed capacity. To me it was not acceptable. The output should be at least 70% of the capacity. In northern India, they’d start the clinical surgical work sometime in September-October and close by March. There was almost no major clinic in the summer months. So, I went and asked them: “I am not a medical guy, but what happens if a baby wants to come out, do you ask it to wait until October?” You have to make revisions in the way service is provided to even out seasonality.”

“I became familiar with Aravind and their more structured approach of screening and bringing patients to a fixed facility to conduct surgery. I was also impressed with their process of and investment in physician and staff training. I recognized that training and building capacity were the keys to ensuring quality and sustainability of services. I wanted to infuse what I saw at Aravind into the Sightsavers ecosystem.”

‘To ensure that these hospitals were meeting expectations, I personally visited each site on a monthly basis. Thulsi agreed to accompany me to these sites to see for himself what progress was being made, and where improvements might be implemented. At this stage, Aravind had no idea how physicians/hospitals performed once they left Aravind, having never conducted any offsite training or follow up with trainees.”

Dr. V, Nagarajan and Thulsi at Aravind

There were, however, some difficulties at the outset.

“Some people were motivated to participate and so some of them tried to replicate some pieces they learned from Aravind. However, it was hard for them to replicate much of what they learned and saw from these trainings because there was no formal history of training at their own institutions. Also, the decision makers were not exposed to Aravind’s system of delivering high-quality high-volume care in a cross subsidy mode.”

What Nagarajan found most troubling was a lack of investment (e.g. training, education) in the different groups of people providing these services.

“In pursuing this training strategy, I experienced push back from organizational leadership who claimed that donors would only give money for direct service and not for training…I refused to give up, and independently searched out donors who would support clinical skills training. I found such donors and by moving more (money) into training, I worked collaboratively with AECS to build capacity with partner sites over a 5–6 year period from 1992–1997.

Thulsi and I agreed that for partners to recognize and implement necessary training at their facilities, they first had to modify organizational behavior, as well as employ an incentivizing approach.

To build support and buy-in, Thulsi and I agreed concurred that it would be more beneficial to form a team of 4–5 people from each institution (physicians, administrators, other staff, etc.) to travel to Aravind to observe their methods and processes.

With the help of seed funding from Seva, I provided funding and incentives for four hospitals in India, each experiencing a low number of cataract surgeries, to send physicians and staff to Aravind for training. My expectation was that in addition to increasing cataract surgeries, each hospital would provide good quality service with respect to a patient’s ability to pay, meaning providing service to paying patients as well as free patients, applying a cost subsidizing method similar to Aravind’s, and limiting any seasonality.

At that time, Aravind was the first institution in India conducting onsite training in intraocular lens (IOL) surgical procedures.

I allocated Sightsavers International (SSI) funding and equipment support to the partners only if they had an ophthalmologist that underwent the related training. I used to call it ‘graded support’ — equipment support commensurate to training and performance. “Where do I get the microscope? they’d ask, and I would tell them “I’ll give you the microscope if you show me the certificate you earned from Aravind.” Once I verified they’re competent I gave them the microscope. I also bought the supplies and equipment for them to use it. I also stipulated that it (IOLs) should be used in all patients and not only those that could afford them. It took considerable persuasion in the beginning but as they realized the benefits this move gained momentum.

In addition to quality issues, many of these facilities in northern India were not operating at full capacity. Physicians were only treating patients directly coming to their facility, and were not actively searching out other patients who might benefit from screening and treatment.”

These early external capacity building visits by AECS staff helped shape and refine their external capacity building operations, leading to the formal establishment of Lions Aravind Institute of Community Ophthalmology (LAICO) in 1996. As external site visits by AECS increased, so did the number of AECS’ physicians participating as faculty in these activities. Nagarajan, with Seva support, participated in one of AECS’ first external engagements outside of India at the Lumbini Eye Hospital in Nepal in 1998.

 
Patient trying on glasses at Lumbini Eye Institute                              

“Since they have been doing vision building for others, LAICO has started doing vision building for themselves. Their work with others and with themselves defines their destination and influences target setting and action planning. They don’t need someone else to emulate. With whatever is available be it experience or knowledge they set their own course. That’s the developmental benefit. Through this process AECS learns how to innovate, how to be cutting edge. It’s easy to replicate what someone else has done but it’s difficult to develop things for others to replicate.”

Today, Mr. Nagarajan is a treasured and cherished member of the Seva Foundation Board of Directors, is an Honorary Advisor Visiting Faculty at LAICO/Aravind and L.V. Prasad Eye Institute in Hyderabad and assists as a volunteer resource person in Program and Partner Development for rural eye care in South Asia. Mr. Nagarajan is a valued advisor and mentor to LAICO/AECS, Seva Foundation, and to the many young physicians and administrators who participate in AECS’ capacity building workshops and activities.

Through his work with Sightsavers and as a professional volunteer, Mr. Nagarajan helped to form the foundation for AECS’ work in capacity building not only In India but across Asia and Africa. His story provides another example of how, like Dr. V., AECS strives to learn and adapt from others.

Mr. & Mrs. Nagarajan
                                              Mr. & Mrs. Nagarajan

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