Integral Leadership–M.S. Srinivasan

(Dr. Govindappa Venkataswamy (Dr. V), the founder of Aravind Eye Hospital is an exemplar of integral leadership.  He was able to build an institution where spiritual inspiration, social sensitivity and kindly service blend harmoniously with professional excellence, executive skill and corporate efficiency. This case study is a brief review of the achievement of this remarkable doctor-entrepreneur. ) 

The Sources:

This review is based mainly on the following sources:

  1. A case-study compiled by Dr. C.K. Prahalad from a more detailed case-study of the Indian Institute of Management, Ahmedabad. (1)
  2. Interview with Dr. G. Venkataswamy, founder of Aravind Eye Hospital and R.D. Thulasiraj, Executive Director of Aravind Eye Hospital by Janat Shah and L.S. Murthy of Indian Institute of Management, Bangalore. (2)
  3. Harriet Rubin’s article, “The Perfect Vision of Dr. V” in Fast Company. (3)
  4. Pavithra K. Mehta and Suchitra Shenoy’s book on Aravind Eye Hospital. (4)

The full details of the sources are given in the reference.

The Amazing Performance

Let us begin with some of the institutional and performance land marks of Aravind Eye hospital.  Beginning in 1976 with a modest 11-bed private clinic with a mission to “eradicate needless blindness.”  Dr. V’s institution has grown into the Aravind Eye care System, the largest eye-care provider in the world.  Aravind received the Gates Award for Global Health in 2008 and the Conrad N. Hilton Humanitarian Prize in 2010; it was listed as one of the world’s fifty most innovative companies by the well-known business magazine Fast Company.  The case study on Aravind is required reading for MBA students in Harvard Business School and in many other B-schools in US.

The Aravind Eye Hospital (AEH) in Madurai has grown into a 1500 bed hospital performing nearly 95000 eye surgeries every year.  In addition to Madurai there are eight more AEH’s located in Chennai, Tuticorin, Tirupur, Hyderabad, Tirunelveli, Coimbatore, Theni and Pondicherry.  The Eighthospitals together perform a total of more than 2, 00,000 surgeries every year which is nearly 45 percent of all surgeries performed in the state of TamilNadu and 5 percent of the total in India.  The AEH group is not merely a chain of hospitals but a total eye care system consisting of a centre for manufacturing synthetic lenses, sutures and pharmaceuticals related to eye care; an institution for training in every aspect of eye care; an institution for research; an eye bank; a woman and child care centre; a postgraduate institute of Ophthalmology offering MS degree; and a centre for community outreach programme.

Imagine an organization giving eyesight to 13 million people; an organization performing nearly 1.8 million surgeries in a span of 26 years. It was the single largest cataract surgery provider in the world. While a cataract surgery costs US $1650 in a US hospital, AEH performed the same quality surgery in India, at US $104. The manufacturing division of the hospital, Aurolab, was a leading manufacturer of intraocular lens (IOLs) in the world. In 2003, the division held 10 percent share of global market in IOLs. When other manufacturers such as American Ophthalmic Laboratories, US, IOL, Inc sold these lens at US $100-US $ 150 a piece, Aurolab sold the same quality lens at US$ 4 – US $6 per lens.

The other unique and remarkable feature of Aravind is its financial self-sustainability.  Aravind is not a for-profit commercial hospital for the rich and upper class patients, nor is it a charitable hospital run on donations.  In Aravind, patients are given the choice to pay or not to pay.  70% of Aravind’s patients belong to the lower income group who are treated free.  The other 30% who pay provide the funds for the operations and expansions of Aravind Eye Hospital.  Thus despite having a majority of non-paying patients, Aravind had always been financially self-supporting.  Even from the beginning it did not depend on government grants or private donations except for the support given by the government for eye camp patients.  C. K. Prahalad, a leading management thinker, studied AEH operations over the years. He observed that AEH generated 200 per cent return on capital employed.   Dr. V kept the costs low by building efficient, high-volume, assembly-line process to perform surgeries.

Not only in financial cost-effectiveness, but also in other managerial parameters like productivity, quality, innovation and process management, Aravind maintains a high-level of efficiency and excellence.  We will discuss this aspect of Aravind’s performance a little later. As we have mentioned earlier, Aravind Eye Hospital is a mandatory case study in Harvard Business School.  Pavithra Mehta and Suchitra Sen, writing about the HBR case study on Aravind, states: “For well over a decade now, each of the 900 or so students who pass through Harvard’s MBA program every year have been handed In Service for Sight.  Since its publication in 1993, the Harvard Business School has distributed more than 150,000 copies to the top 20 business schools in the United States.  When the school started a management course for entrepreneurs, the case study was required reading.”  Kash Raghavan, the HBR professor who prepared the case study states, “It has longevity.  Dr. V’s passion and vision make it timeless.”

The Caring Culture

However this external corporate performance is only one aspect of AEH’s achievement.  The other more important part of the achievement is the inner quality of the AEH culture.  Once an industrialist from Delhi visited AEH and requested Dr. V, “I need to build a hospital, and I’m very much impressed with this one. Could you come to Delhi and start a hospital for me?” Dr V replied, “You have all the money you need. It shouldn’t be hard for you to put up a hospital in Delhi.” “No,” the industrialist said, “I want a hospital with the Aravind culture. People are cordial here. They seem to respect something more than money. There is a certain amount of inner communion or compassion that flows from them. How do you do it?”

A case study on AEH by Indian Institute of Management, Ahmedabad states, “The overall culture at AEH is one of service, humility, kindness and equality.”  We can feel this distinct culture of Aravind from our first contact with it when we ring up to the enquiry.  The female voice answers all your questions with a genuine politeness, courtesy and patience.  And when we enter into an AEH, we can feel the ambience of smiling care, service and compassion in all the levels of Aravind staff¾doctors, paramedics and nurses.

The Eye-care Visionary: Doctor, Entrepreneur and the Yogi

We made a brief review of the achievement of AEH.  Let us now look at the Man behind the success story, Dr. Govindappa Venkataswamy, Dr. V.

Dr. V was born in 1918 in a small village in South India. He received his medical degree from Stanley Medical College, Chennai in 1944. He joined the Indian Army Medical Corps, but had to retire in 1948 after developing severe rheumatoid arthritis – a disease that left his fingers crippled and changed the course of his life. Despite his condition he returned to medical school and earned a Diploma and Master’s Degree in ophthalmology. With hard work and determination, Dr. V. trained himself to hold a scalpel and to perform cataract surgery. In time, he personally performed over one hundred thousand successful eye surgeries.

He joined the faculty at Madurai Medical College as the head of the department of ophthalmology and later served as the Vice Dean. In these capacities he introduced a number of innovative programmes to attack the problem of blindness in India, including the outreach eye camps, the initiation of a training programme for ophthalmic assistants and the world’s first rehabilitation centre   for the blind.

In 1950 Dr. V met Sri Aurobindo- a poet, philosopher, and sage. He was influenced deeply by him. Driven by the compassionate urge of his heart to eliminate needless blindness and inspired by the spiritual vision of Sri Aurobindo, Dr. V. set in motion a 30-year old, and still continuing, crusade against blindness – Aravind Eye Care System. At the age of 55, Dr. V first saw the golden arches of McDonald’s. That was the beginning of his dream to give eyesight to millions. He reasoned when McDonald’s could sell billions of low-cost burgers, he could also sell millions of low-cost sight restoring operations. In 1978, Dr. V started AEH after mortgaging his house. It had 12 beds then. By the end of 2003, this hospital was offering ultra-modem facilities and 3000 beds. Now, Aravind Eye Hospitals are at Madurai, Theni, Tirunelveli, Coimbatore and Puducherry.

Dr. V is a soft and gentle leader who leads not by command and control but by his living example and humility.  Here are some illustrative episodes.  A new guard confronts Dr. V at the entrance to the hospital, “Sit down, old man, you’re blocking people.”  In walks a senior doctor of AEH and asks, “Dr. V, what are you doing here in reception.”  Dr. V replies:  “I was told I can’t go in, so I’m waiting.”  And another one:  a doctor of AEH, returns from a camp with high fever and wants to take a day off.  As she arrives at the hospital late, Dr. V asks, “What are you doing here.”  She says, “I am having high fever.”  Dr. V replies, “My fever is 104, how high is yours.”

However, Dr. V’s inspiration is not entirely moral and social but mainly spiritual.  Dr. V is primarily a yogi who happens to be a doctor and a social entrepreneur.  He wrote in his diary, “I have been doing yoga since 1936, from the age of 18 years consciously or unconsciously.” Behind the moral and social vision of eradicating blindness, Dr. V has a spiritual vision based on Sri Aurobindo’s teachings.  Here are some statements from Dr. V’s talks, interviews and journal entries, which give an indication of the spiritual faith and vision behind his works and achievements.

“I ask God that I be a better tool, a receptacle for the divine force.”

 “Our effort is to make Aravind an instrument of the Divine Will. We strive to forget our limitations and work with the direction of the Divine Will, not in a vain superficial way but with a deep commitment and faith that guidance comes from a higher level of consciousness. Then one is able to work with the great confidence that comes only with that faith and realization that we are all part of a spiritual capacity or spiritual power. It is then that all of nature works with you. You don’t feel that you are a superior being but you are an instrument in the hands of a higher force and it is in that spirit that we meet our day to day struggles and successes.”

 “We believe that the higher consciousness is trying to gradually give us a system.  We are all aware of the parts of the human body as they work.  We take in food; we like the taste of it; part of it is absorbed here, part of it there.  But we are not aware of it.  The higher consciousness works in the same way.  Slowly, your system is built around it but not according to human notions.  At the hospital we are slowly building an organisation that seems to be linked to higher consciousness.”

“To some of us, bringing divine consciousness to our daily activities is the Goal.  The Hospital work gives an opportunity for this spiritual growth.  In your growth you widen your consciousness and feel the suffering of others.”

Dr. David F. Chang, regarded as one of the best among cataract surgeons in US, recall what he felt when he first met Dr. V, “He has an amazing aura.  It was like being in the presence of a living legend.  He brings a lot of energy and purpose to everyone he comes into contact with.  I really think Dr. V’s spirituality is an important driving force at Aravind.”  Similarly, Dr. Kash Raghavan, who prepared the cast study on Aravind for Harvard Business Schools, observes, “Everything revolved around the thing Dr. V was talking about—-this man’s spirituality wasn’t incidental to the story.  It was what everything else hinged on.”

Most of the corporate studies tend to ignore or underplay this spiritual dimension behind Aravind’s success.  But Aravind’s success cannot be fully understood without this higher inspiration behind it.  As Pavithra Mehta and Suchitra Shenoy rightly point out:

“Every organization operates with a set of reference points that re­flect its ultimate motivation. Aravind too, through Dr. V, has a touch­ stone. If left unexamined, explanations of Aravind’s work and what it offers the world will always be incomplete. Dr. V believes Aravind’s work is a manifestation of Sri Aurobindo and the Mother’s influence. Whether or not this is true is irrelevant. The objectives, systems, and culture of Aravind certainly do not demand belief in spirituality. But the fact remains that they were created and distinctly shaped by one man’s sense of an inner reality. This is why you cannot give short shrift to Dr. V’s spirituality when tracing the path of Aravind’s evolution. It threads through everything: his priorities and perspectives, his vision for Aravind, his leadership practices, and the unique impact he has on the people who work with him. It is what linked this man’s individual quest to the evolution of the largest eye care facility in the world.”

Culture of Dedication and Excellence

But Dr. V’s spirituality is not merely an in draw personal seeking for lonely spiritual salvation or ecstasy.  It is a dynamic spirituality which is translated into a strategic action leading to exemplary corporate performance.  This brings us to the question what are the strategic factors behind the success of AEH?  There are two major elements: first is the dedication to a higher purpose.  As Pavithra Mehta and Suchitra Shenoy describe this deeper, moral factor behind Aravind’s success: “There is a gradual, catalytic force unleashed when people put aside personal gain in service to a higher vision, day after day, month after month, year after year. That is why money cannot explain Aravind’s success. What the hospital has accomplished today is not by virtue of its bank balance but by, in some sense, its virtue-period.”  In Dr. V’s perspectivethis moral factor is not just saintliness but a strategic action which brings material results.  Dr. V believed that when you do your work dedicated to a higher ideal and without seeking for personal gain, whatever that is needed to materialise the ideal will come.  “You must do your work” said Dr. V “money will follow—-it comes—the ideas, the money, people.”

Interestingly, this deeper spirit behind Aravind is perceived even by some observers who have no spiritual inclinations.  For example, David Roes, an American lawyer, who helped Aravind in legal matters, states, “At Aravind, I learned its an attitude, more than just the techniques or the business model, its a spirit that needs to pervade everything that we do¾a sense that we’re all doing this together and will each do whatever needs to be done.  I’ve become convinced that the kind of attitude that Aravind epitomizes is the secret.  Set up the environment for it, model it, and let it pervade.  The rewards are built-in.”    The second factor is a culture of excellence in every activity of corporate life, especially in those vital domains or parameters which lead to sustained organisational effectiveness like for example, human resource development, productivity, quality, innovation, customer service.  Let us briefly examine some of these factors behind Aravind’s phenomenal success in delivering eye-care to the masses.

Human Development

The HR strategy of AEH has two aspects: professional development of doctors and training of paramedics.  For the development of doctors, AEH management encourages its medical professionals to pursue research and publish papers in reputed professional journals.  Best practices, improvements or discoveries in surgical techniques, medical knowledge or equipment that happen all over the world are collected, disseminated and shared among medical professional.   For example, if a doctor in Boston or Germany discovers a new technique, Aravind doctors go there to learn it or the expert comes to teach the doctors at Aravind.  The doctors also have the opportunity to specialize in a specific field in ophthalmology and to acquire professional reputation in the field.

AEH is developing centers of excellence in various specialized domains of ophthalmology.  For example in Coimbatore, Aravind is trying to develop a centre for treating eye-cancer and it has sent its doctors for training to Newyork.  Similarly there are specialized centers of excellence in Tirunelveli for Glaucoma and in Madurai for paediatric ophthalmology.  Dr. V admits that retaining doctors is a problem because when a doctor gets sufficient experience and reputation he or she leaves for better money.  But the management of AEH is trying to tackle the problem, like for example, by paying market rates and having discussions with younger doctors on how to make the job more attractive in term of career growth, working conditions and compensation.

The other aspect of HR management in AEH is the recruitment, training and development of paramedics.  Here, a great emphasis is laid on inner attitude and commitment.  As R.D. Thulasiraj, Executive Directors, Aravind Eye Hospital explains:

“In our selection process, we recruit young girls from the village, who have a certain amount of curiosity and a capacity for hardwork.  We interview the parents also and look for commitment, so that we can be sure they will stay on.  Most of them continue with us even after they get married because they are respected in the community.”

The training given to paramedical staff and nurses is something unique and different from that of other hospitals.  Apart from professional skills, girls are also trained in cooking, housekeeping, tailoring and other life-skills.  This helps prepare them to become good housewives in the future.  Voluntary devotional songs and yoga sessions are also organised in the evening.  The nurses are encouraged to be kind to the patients at all times and approach them with thankfulness for providing them with an opportunity to serve.  The nurses are also asked to save a part of their salary in bank account in their name, so that they have a sizable sum saved for their marriage.  And the result is a quality of customer experience which is very different from that of other hospitals.  In other hospitals, customer experience is either indifferent or apathetic, with callous nurses and arrogant doctors or at the best, impersonal, efficient and fast service.  But in AEH the customer, whether she is paying or, not paying, feels an atmosphere which is caring, kindly and benevolent.

Productivity of Surgeons

The productivity of AEH’s surgeon’s is astonishingly high in comparison with other eye-care centers.  While the industry average for a surgeon is around 400 surgeries per year, the productivity of a surgeon at AEH is around 4500.  What are the main factors behind the phenomenal productivity of Aravind’s surgeons?  The first factor is a higher and noble purpose which provides the motivation.  The second factor is the long working hours from 6.00 a. m to 6 p.m.  The third factor is a supportive system which leads to the optimum utilization of a surgeon’s skill.  Those activities which don’t require the surgeon’s skill are done by the junior or paramedical staff.  Two or more patients were kept in an operation theatre at the same time. A doctor performed a cataract operation in 10 to 20 minutes and then moved on to another patient who was ready to be operated by the time he completed operating on the first patient.  As Dr. V explains the system:

 “At Aravind Eye Hospital each surgeon works on two operation tables alternatively.  We don’t need to do everything ourselves.  There is a team of paramedical and junior doctors to wash the eye, put the suture, give the injections and so on.  The surgeon does his part and moves on to the next table.”

The third factor which provides the quantitative base for maintaining high productivity is AEH’s community outreach programmes.  Aravind doesn’t wait for the patients to come; it goes out into the community and brings patients to the hospital.  This approach ensures a steady, constant and uninterrupted flow of patients for the surgeons.

Sustaining High Quality

Aravind’s achievement in quality can be viewed interms of three factors: service, products and competence.  First is the quality of service.  Aravind has a reputation for quality and fareness in treating the patient.  The poor patient who is treated free of cost and the richer patient who pays are given the same quality of care and treatment.  As Dr. V points out:

“Whether the patient is from the village or a big man from a metro, we tell them honestly what their problem is, what can be or cannot be done to treat and what the fixed rates.  Over the years we have built an image that we respect them and we don’t treat them badly because they are poor.  Now, even when there is a choice of three or four camps, they prefer the Aravind camp.”

What are the main factors behind this reputation for quality?  The first factor is a rigorous and thorough follow up and review system which ensures every patient attains complete care.  For example, while screening children, AEH staffs have found children are not wearing the glasses prescribed for them.  So to make sure they wear the glasses, the teachers are first trained in screening.  Then AEH staffs go back to the schools to check if the children are wearing the glasses.  The second aspect of quality is that each patient, paying or not paying, is treated according to the nature of his or her problem.  As Thulasiraj, Executive Director of Aravind Eye Hospital points out:

“We don’t take chances whether a patient is paying or free patient.  All complicated surgeries are done only by senior doctors.  If a patient has permanently lost vision in one eye even a simple cataract will go to a senior doctor because the risk is greater.”

The second factor is the quality of products.  The Aurolab, the manufacturing wing of Aravind which makes IOL lenses is the first Indian company to achieve IOL certification for IOL in India.  One of the world renowned researchers in IOL wrote in a noted ophthalmology journal, “[Aurolab lenses] clearly meet and often exceed world standards of many lenses manufactured in the United States and European countries.”

The third factor is the quality of clinical competence.  Aravind’s surgeons are regarded as some of the best in the world. “When doctors from the United States see what surgeons from Aravind do, they are blown away,” says Dr. Christine Melton, a Manhattan-based ophthalmologist. “I had Prajna (a senior surgeon at Aravind) give a presenta­tion at the New York Eye and Ear Infirmary on corneal ulcers one year. After his talk, the faculty advisor told his residents, ‘The amaz­ing stuff you just saw-don’t try it here. We don’t have that kind of expertise.'”

Flexibility, Adaptation and Innovation

Flexibility and adaptation are important aspects of organisational effectiveness.  AEH has displayed remarkable flexibility and adaptive skills in steering the institution towards its goals.

Backward integration into manufacturing contact lens is an example of flexibility and adaptation.  Initially IOL surgeries with contact lenses, which have to be imported, are done only for the paying patients because it was costly.  But AEH has found that IOL surgery will benefit the poor patient more than the rich patient.  So, keeping its mission of providing equal quality of service to the paying as well as the non-paying patients AEH decided to manufacture the contact lenses in house and do the IOL surgery for the poorer patients.  AEH took up the challenge and set up a separate manufacturing felicity with imported technology.  AEH was able to manufacture the lenses at a much less cost than the imported price and IOL surgery was made affordable to poorer patients.

Constant improvement and innovation in process and surgical techniques are integral part of AEH culture.  AEH has made many improvements and refinements to the existing surgical techniques.  There is also a constant mutual sharing of best practices between AEH and other leading eye care centers all over the world.  Similarly in organisational systems and processes, as R.D. Thulasiraj states, “We try to find out if there is something we can do differently to improve the system.  So that is our mindset to keep on improving process.”

References:

  1. C.K. Prahalad, The Fortune at the Bottom of the Pyramid, Wharton School Publishing, Wharton, 2003, p. 265-85.
  2. Janat and L.S. Murthy, ‘Compassionate High Quality, Health Care at Low Cost: The Aravind Model’ In Conversation with Dr. G. Venkataswamy and R.D. Thulasiraj, IMB Management Review, September 2004.
  3. Harriet Rubin, ‘The Perfect Vision of Dr. V’, Fast Company, January 2001.
  4. Pavithra K. Mehta and Suchitra Shenoy, (2011) ‘Infinite Vision,’ Bernett-Koehler Publishers, Inc., p. 26,27, 52, 74-75, 107, 123.
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