Insights Series Issue 13: "Sight to the world: How Aravind improves access to care for millions"

How did Aravind give access to care to millions in Southern India and what lessons can be taken from their example?

Insights Series Issue 13 transforming-care-delivery Sight Treal Sight to the world: How Aravind improves access to care for millions A thought leadership paper on how to ‘Improve access to care’ co-authored with Dr. Aravind Srinivasan, MS, MBA SIEMENS Healthineers Preface The Insights Series The Siemens Healthineers Insights Series is our preeminent thought leadership platform, drawing on the knowledge and experience of some of the world’s most respected healthcare leaders and innovators. The Series explores emerging issues and provides you with practical solutions to today’s most pressing healthcare challenges. We believe that increasing value in healthcare – delivering better outcomes at lower cost – rests on four strategies. These four principles serve as the cornerstones of the Insights Series. 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Please visit Executive summary Across the globe, it is estimated that more than Today, the Aravind Eye Care System (AECS) has treated 39 million people suffer from blindness.1 In a large more than 65.5 million patients and performed majority of these cases – up to 80% – the cause of 7.8 million surgeries.a By embracing a model of high the blindness is preventable or treatable.2 In more volume and intense specialization, AECS can perform than half of all cases, blindness is the result of cataract.1 cataract surgery 98% cheaper than in the U.S.4,5 This is a serious medical eye condition, but it can In addition, the outcomes achieved by AECS are as good be treated quickly, effectively, and cost-efficiently to as, or better than, those realized in the U.S. and Europe. restore vision. Improving access to care is a central element of transforming care delivery, one of the How does AECS succeed in a market that many others fundamental challenges facing healthcare providers view as unattractive? And what can other market worldwide. Remarkably innovative and effective segments and more developed markets learn from its approaches exist to tackle this challenge. extraordinary success story? The problem of blindness is particularly evident in India, Dr. Aravind Srinivasan, nephew of the hospital’s founder, where it is estimated that close to five million people describes the success in straightforward terms, highlighting are blind.3 Difficulties in treating these people are largely the mission to “provide care to the poorest of the poor,” the result of poverty. Problems are further compounded and to “do something beautiful.” They achieve this through by poor infrastructure, which makes it difficult to reach the application of clear operating principles based on the patients; poor logistics that reduce access to the necessary three dimensions of access to care: affordability, availability, consumables; a lack of awareness of treatment options; and acceptability. These “Three A’s” – affordability, avail- and a scarcity of qualified workers. ability, and acceptability – are essential for improving access to care. Most of these patients reside at what many regard as the ‘bottom of the pyramid,’ a market segment that is “The way to build economies of scale in India is not by generally considered unattractive by healthcare providers. serving the top 20 or 30 million people. It is by serving Dr. Govindappa Venkataswamy viewed the situation the bottom billion people,” says Dr. Aravind. The traditional differently. For him, this ‘bottom of the pyramid’ was market-driven business model is not effective for serving precisely where he could have the greatest impact. In 1976, this ‘bottom of the pyramid’ segment. For Dr. Aravind, he established the first Aravind Eye Care Hospital in the key to success in such a market is to drive the market, south-east India, dedicated exclusively to eradicating by identifying and building a new market in response to needless blindness caused by cataract. a realistic assessment of existing conditions. a As of March 2020. Siemens Healthineers Insights Series · Issue 13 3 About Aravind Eye Care System Aravind Eye Care System founded 1976 Aravind Eye Care System (AECS) was founded in Key figures (as of 2020) Madurai, India, in 1976 with a modest 11-bed hospital. 99 sites Today it operates 99 eye care centers with a total of 5,000 beds 5,000 beds, providing services that range from >5,000 staff (80% women) primary to advanced tertiary care. On a typical day, AECS performs approximately 14,000 patient Daily examinations and 1,600 surgeries. 14,000 patient examinations These numbers seem staggering by the standards of 1,600 surgeries Western hospitals, but for Dr. Aravind they are the norm. 11,000 manufactured IOLs AECS’s daily activities also include teaching classes for 100 residents and 300 technicians and administrators, Source: Aravind Eye Care System and its in-house manufacturing facility, Aurolab, produces about 11,000 intraocular lenses (IOLs), which supply AECS internally and are exported worldwide. It all adds up to a remarkably efficient model for improving access to care, with more than half a million eye surgeries performed and 700,000 prescriptions for eyeglasses dispensed annually. A further 800,000 surgeries are performed each year by global, independent partner institutions who use the Aravind approach. 4 Issue 13 · Siemens Healthineers Insights Series Tirupati Chennai 99 South-India locations in South-India Salem Puducherry with a service area Coimbatore of 100 million people: Tertiary care centers (7) Secondary care centers (7) Outpatient centers (6) Madurai Primary care centers (79) Tirunelveli What makes AECS so impressive is not only its size, but Cost of cataract surgery (US$)4,5 also its results. Its mission was clearly established by founder, Dr. Venkataswam (Dr.V), and his vision is being U.S. 3,800 applied with extraordinary impact and effectiveness. With its unique, low-cost approach, AECS offers cataract Aravind 88 surgery for approximately US$884 – 98% less than in the U.S., patients are often charged as much as US$ 3,800 per surgery. Even taking into account the adjusted “Patient charges per cataract surgery relative to purchasing power for both countries, it is significantly average income” per year cheaper.b Despite this low price, AECS performs close to half of its surgeries for free or at highly subsidized rates, in keeping with its mission to serve the poor. U.S. 6.1% Nonetheless, it operates profitably, earning a “healthy margin.” Aravind 1.0% b Average income per year (2018): India US$7,763 (purchasing power parity - PPP); USA US$62.7956 Siemens Healthineers Insights Series · Issue 13 5 The challenge 39 million people suffer from blindness1 80% of cases are treatable2 Globally, about 1.3 billion people live with some form Receiving effective and affordable treatment is difficult of visual impairment,7 and 39 million people are in India. With a population of more than 1.3 billion people, considered to be legally blind.1 Blindness is more the country has a low supply of eye care services. It prevalent in developing countries such as India than has 20,000 practicing ophthalmologists, about 15 in wealthier Western countries. ophthalmologists per million people (compared to 81 in Germany and 59 in the U.S.).9 The primary cause of blindness, in India as elsewhere, is cataract – the clouding of the eye’s lens. Most cases The consumables necessary for cataract surgery – of cataract-caused blindness can be treated quickly, lenses and surgical equipment – are often prohibitively effectively, and cheaply. Cataract surgery can be expensive, especially if purchased from abroad. In performed in less than ten minutes. However, access addition, there are barriers related to the patients to proper care is difficult, particularly in many parts themselves. Many poorer people have no familiarity with of India. eye care, are afraid of surgery, or cannot take the time off work for a medical procedure. For many, even the charge In India, it has been said that blindness is “like having a of US$88 is beyond their reach. mouth without hands.”8 This underlines the significant and often devastating effect of visual impairment on quality of life. The health impact of blindness does not stop at loss of vision; it also considerably shortens life expectancy. Its economic impact is also severe as it often directly causes unemployment and poverty. And the impact on families is profound. People over the age of 50 are particularly susceptible to cataract. Specific causes of cataract remain unknown, although ultraviolet sunlight, diabetes, hypertension, smoking, and previous eye injuries are among the main drivers. 6 Issue 13 · Siemens Healthineers Insights Series The solution The model of the Aravind Eye Care System successfully improves access by addressing the following three barriers: 1. Affordability 2. Availability 3. Acceptability Retaining a sharp focus on these three dimensions brings coherence and discipline to AECS’s efforts, and keeps its day-to-day work in line with the overall mission. Aravind Eye Care System increases access to care by making care affordable, available and acceptable 1. Affordability: 3. Acceptability: offering health services helping populations to that do not cause understand and utilize financial hardship their care options $ V ...... 2. Availability: ensuring that healthcare services are there when and where they are needed Siemens Healthineers Insights Series · Issue 13 7 1. Affordability Providing affordable care in India demands a fundamentally This ‘assembly line’ approach in no way compromises the different and more frugal approach than that applied surgeons’ accuracy or concentration; in fact, it has the by Western care providers. Drawing an analogy to the opposite effect, removing distractions and allowing them hospitality and travel industries, Dr. Aravind asks, “Imagine to focus their full attention on the surgical procedure. As if India had only five-star hotels. How many people could with an elite athlete who invests countless hours in afford to stay there? How many people could travel if perfecting a certain skill, there is a direct correlation India only had first class sections in trains and airplanes?” between repetition and excellence. As Dr. Aravind notes, “when you build a certain level of efficiency, people become To meet this affordability challenge, AECS developed a very, very good at what they’re doing.” Almost all business model that drastically lowers costs through non-surgical tasks including patient preparation, cleaning, a combination of increasing workforce productivity and and sterilization are handled by nurses. This frees up stripping out costs by manufacturing consumables additional time for surgeons to concentrate on surgery, in-house. These efforts are supported by rigorous allowing them to perform between six and eight surgeries benchmarking. an hour. Increasing workforce productivity Stripping out costs In order to get maximum value from surgeons’ time, The essence of cataract surgery consists of removing a AECS’s practice model enables surgeons to perform five patient’s clouded lens and implanting an intraocular lens times more cataract surgeries than the Indian average (IOL). These IOLs are a costly part of cataract surgery. and up to eight times more cataract surgeries than the Until the early 1990s, AECS purchased them abroad at a U.S. average. Each operating theater is equipped with cost of approximately US$200 each, as there were no two fully functional tables. While a surgeon is operating local manufacturers in India. This led to two classes of on a patient at table 1, nurses are preparing a second treatment for patients: paying patients would receive an patient at table 2. As soon as the surgery at table 1 is IOL, while non-paying patients unable to cover the costs complete, the surgeon simply turns to the other side to of the artificial lens were forced to go without and were operate on the second patient who has already been required to wear thick corrective eyeglasses. However, fully prepared. that was not in keeping with Dr. V’s original mission. He asked himself: “If our mission is to give eye care to all in the same way, why are we differentiating?” 8 Issue 13 · Siemens Healthineers Insights Series “In 2019 about 60% of the people can afford to pay for surgery. But in 1976 it was only 20%.” Dr. Aravind Srinivasan In order to make IOLs available to all patients, irrespective In addition to producing IOLs for use at AECS facilities, of their ability to pay, AECS decided to manufacture its Aurolab has become a leading global supplier to the eye own – a bold step for a hospital with no previous experience care industry, offering more than 200 products including in this area. In 1992, AECS established a not-for-profit pharmaceuticals (retinal products, eye drops, antiseptics), manufacturing facility named Aurolab. Today, Aurolab ophthalmic equipment (phacoemulsification machines, manufactures 11,000 IOLs daily. The lenses meet the slit lamps, retinoscopes), suture needles, and surgical highest quality standards, they are ISO certified, and blades. Aurolab exports its consumables to more than several products have CE certification. Most remarkably, 160 countries worldwide and it is estimated that more Aurolab produces these IOLs for a sale price of about than 30 million people worldwide see through Aurolab US$2 per piece10 compared to US$97 in the U.S. – again, lenses.11 98% cheaper. Benchmarking sites and surgeons For the cost of 1 IOL from the U.S., Aurolab manufactures 50 In order to maintain its high efficiency and its ability to perform surgery at low cost, AECS constantly tracks KPIs at a staff, site, and enterprise level. Data is collected in U.S. import Aurolab manufacturing a range of areas, including the number and type of surgeries performed, complications, revisions/re-surgeries 1 IOL 50 IOL and the reasons for these, and recovery processes. The data, which is aggregated to KPIs, makes it possible to compare and evaluate different sites and individual surgeons. If performance gaps are identified, measures can be taken to close them and thereby maintain the high quality of AECS’s outcomes. Siemens Healthineers Insights Series · Issue 13 9 2. Availability In addition to making its care affordable, AECS also faced Expanding primary eye care centers a challenge in making its services available, both physically and in terms of the time a patient must invest. Many Outreach camps alone are not sufficient to guarantee the patients could not travel to an AECS hospital because of physical availability of care to all people in rural areas. the cost, a lack of time due to absence of work, the need Despite the high number of camps, AECS was only able to be accompanied by someone who could see, or their to reach less than 10% within its catchment areas.12 own visual impairment. To address these barriers, AECS It has therefore expanded its network with 79 primary implemented a hub-and-spoke model. care centers covering a population of 5 million people in remote areas. These primary care centers handle more than 500,000 patient visits per year. After working with Reaching out to patients primary care centers for two years, AECS has been able to expand its reach to 75% of the people living in its rural One way in which AECS seeks to make its care available catchment areas. is through mobile outreach camps that literally bring eye care to the doorstep of patients in rural areas. AECS operates seven to eight of these mobile camps every Sharing the model worldwide day, with doctors and nurses travelling to rural communities to offer eye examinations, refraction AECS’s mission is not limited to India; its goal is to tests, and diagnosis. Camps are set up in community eradicate blindness worldwide. In many African countries, halls, schools, on the street, or in village squares. Each the ratio of ophthalmologists to people is far lower than camp sees approximately 200 patients daily. Most can in India. To help combat this problem, AECS has founded be treated on-site with spectacles, their lenses and Lions Aravind Institute of Community Ophthalmology frames fitted directly at the camp. About 29% of (LAICO). The idea is to share AECS’s approach, methods, patients are identified as needing cataract surgery. and best practices with hospitals around the world These patients are transported to the nearest Aravind through teaching, training, research, and consultancy. hospital by an AECS bus service, and provided with More than 350 hospitals and clinics in 29 countries now meals and accommodation. follow the AECS approach. The effectiveness of the LAICO training is clear: ophthalmologists participating in the training increase the number of surgeries they are able to perform by an average of 45%.13 Besides physical availability, the Aravind model also provides availability in terms of time – with flexibility designed to accommodate patients, and by ensuring that visits and treatment are quick and efficient. This is achieved by taking all necessary steps to ensure that resources are in adequate supply and are utilized and allocated as efficiently as possible. c In Ethiopia, Kenya, Mozambique, Rwanda, Tanzania, and Zimbabwe, the ratio of ophtomologist to inhabitants is less than 2 per million. 9 10 Issue 13 · Siemens Healthineers Insights Series Maximizing scarce resources Optimizing clinical operations The single most valuable resource of any eye clinic is the Another element of ensuring the timely availability time of its ophthalmologists. This must be used to achieve of necessary resources is efficient administration. the greatest possible impact. The processes and task- A system as large as AECS requires highly professional shifting (to nurses) discussed above are an important part and capable management. Cataract surgery, particularly of this effort, allowing ophthalmologists to devote their in the Aravind model, has become fairly routine. However, time and energy to their principal task: surgery. the administrative challenges of managing an organization of this size and complexity are immense. As Dr. Aravind Ensuring that adequate support staff are available when readily admits, “the biggest challenge in running this needed can be a challenge. Every year, AECS recruits organization is logistics, not surgery.” around a thousand young women from village high schools, who would otherwise have little access to the One important step toward optimizing clinical operations labor market and vocational training in rural India. AECS is that AECS does not work on an appointment system. trains them to perform nursing tasks and their role is Instead, it is committed to making sure that every patient vital to AECS’s overall performance. “Trust me, Aravind’s who arrives at a clinic is seen by a doctor that same day. backbone is these young women,” says Dr. Aravind. Patients can expect short waiting times and adequate levels of staff, with electronic medical record systems tracking and displaying the current and estimated wait times. Operations are also streamlined through efforts to engage and motivate the workforce. All employees are continually informed of how their own work contributes to AECS’s overall mission. Each department displays its objective on a notice board. For example, the notice in the medical records department reads: “To contribute to Aravind’s mission of eliminating needless blindness by recording all relevant patient information accurately without any delay and providing timely reports to support effective decisions.” This clarity about goals helps to create a sense of identity and purpose among all employees. Siemens Healthineers Insights Series · Issue 13 11 3. Acceptability Patient outcomes The standard test to measure clarity of vision after cataract Acceptability is the third dimension of access to care. In surgery is known as “Corrected distance visual acuity” many of AECS’s service areas, acceptance of eye surgery (CDVA). A CDVA score of 6/12 is regarded as an indicator of among the general population is poor. This is often the successful surgery. result of several factors: a lack of awareness among rural populations that many of their cases are curable; concerns Aravind* 97.20%14 about the costs of the surgery; and a more general fear of surgical interventions and possible complications. EU 97.20%15 Benchmark EUREQUO** 97.00%15 Increasing awareness UK 89.60%16 An essential part of the challenge that AECS must overcome is raising awareness of the services it offers. Steps to address this include making vigorous efforts to bring its services directly to their target population, for example through the outreach camps. This eliminates the need for patients to travel to unfamiliar surroundings – a journey that could be prohibitively expensive as well as confusing and intimidating for many. In addition, mobile vans * with injection of intracameral moxifloxacin disseminate information about AECS services using ** European Registry of Quality Outcomes brochures, public announcements, videos, and simple for Cataract and Refractive Surgery presentations. Mobile communication also plays an increasingly important role. Accordingly, AECS has been sending SMS messages to its target population for several years now, and is raising its profile on social media. 12 Issue 13 · Siemens Healthineers Insights Series “Offering cataract surgery at low cost does not mean that we compromise on quality.” Dr. Aravind Srinivasan Achieving superior outcomes Complication rates Posterior capsular rupture, zonular dehiscence By delivering superior outcomes and demonstrating this w/ and w/o vitreous disturbance to prospective patients, AECS reduces patients’ fears KPI for one of the most common surgical complications and anxieties. A simple and straightforward message – “What we do works, and the risks are very, very low” – helps Aravind* 0.56%17‒1.37%18 to reassure patients and their families, thereby boosting acceptability. Medical evidence supports this message. UK 1.95%16 Among AECS patients, outcomes are as good as in the EU and better than in the UK.14–16 Their complication rates are below the rates in the U.S. and UK.16–19 Postoperative Endophthalmitis Rate KPI for one of the most common inflammations subsequent to surgery Aravind* 0.04%17‒0.09%18 IRIS Registry 0.08%19 Medicare 0.14%19 Siemens Healthineers Insights Series · Issue 13 13 Conclusion The Aravind model, with its focus on affordability, The future availability, and acceptability, delivers better outcomes at lower costs, and provides access to high quality Aravind Eye Care System is aware that its care eye care – even surgery – to patients who would model is not immune to competition; cataract otherwise be unable to obtain it. AECS not only is a relatively easy to treat disease and the outperforms Western countries in vision outcomes AECS model has attracted attention from after cataract surgery, it also achieves lower would-be challengers. In addition, to pursue complication rates. its mission of eradicating needless blindness, it must also treat eye diseases other than Can this model be replicated elsewhere? cataract. Some of the elements of the Aravind approach are unique AECS has, therefore, identified three goals for to the Indian market and cannot be exported in their the coming years: entirety. Yet some of the basic elements do have broader applicability and can serve as useful operational principles 1. Increase volume: By 2030, AECS aims in other settings. to perform one million surgeries and see 10 million outpatients per year. The ‘three A’s’ – affordability, availability, and acceptability – are central guiding principles that can serve as useful 2. Improve efficiency: AECS aims to increase elements to a wide range of healthcare initiatives. While its operational efficiency by an additional all three appear straightforward, perhaps even simple, 25% by eliminating idle time and further applying them consistently can be challenging. optimizing clinical operations. Affordability is difficult to evaluate outside of a particular 3. Broaden the portfolio: AECS aims to context; the definition of ‘affordable’ varies greatly from expand its services to treat other rare eye Atlanta to Bangalore to Copenhagen. Nevertheless, the diseases such as eye cancer (a type of basic elements for improving affordability are common to cancer with very low incidence) and facial all health systems. Regularly evaluating processes makes and orbito-cranial deformities. it possible to define measures such as streamlining, reducing input factors, eliminating unnecessary steps, and insourcing to reduce costs and make care affordable to a broader population. 14 Issue 13 · Siemens Healthineers Insights Series Availability is a challenge in every part of the world. Underserviced populations exist even in the wealthiest countries. AECS overcomes distance and physically reaches its patients with a carefully designed network of care centers that cover primary to tertiary care. Such hub-and-spoke models achieve proximity to patients and guide them efficiently through the network. In addition, healthcare providers can now reach their patients with telemedicine services, overcoming many of the availability barriers that previously existed. Timely availability depends heavily on resources. Therefore, it is critical to support the single most scarce resource: the healthcare workforce. Identifying and removing wasteful activities and automating or re-assigning tasks allows all employees to work at the top of their license. Acceptability is the final piece. Even when care is affordable and available, patients need to be willing to accept the care that is offered. Creating awareness that healthcare services exist and that they are effective and safe are important elements of achieving the necessary level of acceptability. In addition to the ‘three A’s,’ the Aravind approach also vividly illustrates the importance of an overarching vision or goal. The dedication with which the entire AECS team embraces their founding mission – eliminating unnecessary blindness especially among the poor – demonstrates the power of a central, guiding philosophy against which operational elements and decisions can be measured. Dr. Aravind refers to this as “emotional infrastructure”, which their founder Dr. V called, “the joy of doing something beautiful”. A purpose like this is invaluable. Siemens Healthineers Insights Series · Issue 13 15 Suggested follow-up on care-delivery • Insights Series Issue 7: Do one thing and do it better than anyone else • Insights Series Issue 4: Achieve twice as much but only work half as hard • Insights Series Issue 2: Culture of diversity, respect, and inclusion • Harvard Business Review: Transforming care delivery to increase value Information The Siemens Healthineers Insights Series is our preeminent thought leadership platform, drawing on the H. knowledge and experience of some of the world’s most respected healthcare leaders and innovators. It explores emerging issues and provides practical solutions to today’s most pressing healthcare challenges. All issues of the Insights Series can be found here: Contact If you have further questions or would like to reach out to us, please do not hesitate to contact our expert directly: Dr. Herbert Staehr Vice President Global Head of Transforming Care Delivery at Siemens Healthineers [email protected] 16 Issue 13 · Siemens Healthineers Insights Series References 1. World Health Organization. Global Data on 10. Vickers T, Rosen E. Driving down the cost of Visual Impairment 2010 [Internet]. 2012. high-quality care: Lessons from the Aravind Eye Available from: Care System. Health International, McKinsey. GLOBALDATAFINALforweb.pdf 2011. 2. World Health Organization. Universal eye 11. Aurolab. Aurolab facts. Madurai; 2019. health – A global action plan 2014-2019. 12. Fletcher AE, Donoghue M, Devavaram J, 2013. Thulasiraj RD, Scott S, Abdalla M, et al. Low 3. Press Trust of India. Blindness In India Uptake of Eye Services in Rural India: A Reduced By 47 Per Cent Since 2007: Report Challenge for Programs of Blindness Prevention. [Internet]. New Delhi Television ltd (NDTV). Arch Ophthalmol. 1999;117(10):1393–9. 2019 [cited 2019 Dec 12]. Available from: 13. Lions Aravind Institute of Community reduced-by-47-per-cent-since-2007- Ophthalmology (LAICO). About LAICO [Internet]. [cited 2019 Dec 11]. Available from: report-2114833 index.php/who-we-are/about-us/ 4. Le HG, Ehrlich JR, Venkatesh R, Srinivasan A, Kolli A, Haripriya A, et al. 14. Haripriya A, Chang DF, Namburar S, Smita A, A Sustainable Model for Delivering High- Ravindran RD. Efficacy of Intracameral Quality, Efficient Cataract Surgery in Moxifloxacin Endophthalmitis Prophylaxis at Aravind Eye Hospital. Ophthalmology. Southern India. Health Aff. 2016;123(2):302–8. 2016;35(10):1783–90. 5. Segre L. What does cataract surgery cost? 15. Lundström M, Barry P, Henry Y, Rosen P, Stenevi Check our price guide [Internet]. All about U. Evidence-based guidelines for cataract surgery: Guidelines based on data in the vision. 2019 [cited 2019 Dec 11]. Available European Registry of Quality Outcomes for from: surgery-cost.htm Cataract and Refractive Surgery database. J Cataract Refract Surg. 2012;38(6):1086–93. 6. The World Bank. GDP per capita, PPP (current international $) - India, Middle income, 16. Day AC, Donachie PHJ, Sparrow JM, Johnston RL. The Royal College of Ophthalmologists’ National United States [Internet]. 2018 [cited 2020 Feb 10]. Available from: Ophthalmology Database study of cataract surgery: report 1, visual outcomes and indicator/NY.GDP.PCAP.PP.CD?locations=IN- complications. Eye. 2015;29(4):552–60. XP-US 7. World Health Organization. Blindness and 17. Haripriya A, Chang DF, Reena M, Shekhar M. vision impairment [Internet]. Complication rates of phacoemulsification and manual small-incision cataract surgery at 2018 [cited 2018 Oct 11]. Available from: Aravind Eye Hospital. J Cataract Refract Surg. 2012;38(8):1360–9. blindness-and-visual-impairment 8. Mehta PK, Shenoy S. Infinite vision: 18. Haripriya A, Chang DF, Ravindran RD. How Aravind became the world’s greatest Endophthalmitis reduction with intracameral business case for compassion. San Francisco, moxifloxacin in eyes with and without surgical complications: Results from 2 million California: Berrett-Koehler Publishers; 2011. consecutive cataract surgeries. J Cataract Refract 9. International Council of Ophthalmologists. Surg. 2019;45(9):1226–33. Number of Ophthalmologists in Practice and Training Worldwide [Internet]. 2012 [cited 19. Coleman AL. How Big Data Informs Us About 2019 Oct 4]. Available from: Cataract Surgery: The LXXII Edward Jackson ophthalmologists-worldwide.html Memorial Lecture. Am J Ophthalmol. 2015;160(6):1091-1103.e3. Siemens Healthineers Insights Series · Issue 13 17 About the authors Dr. Aravind Srinivasan, MS, MBA Director - Projects, Aravind Eye Care System Dr. Ralf Meinhardt Chief Medical Officer (CMO), Senior Global Marketing Manager Aravind Eye Hospital, Chennai at Siemens Healthineers Dr. Aravind Srinivasan graduated in medicine from PSG Institute of Ralf Meinhardt engages in thought leadership activities for Medical Sciences, Coimbatore, South India in 1992 and completed Transforming Care Delivery. Prior to his role at Siemens Healthineers his residency in ophthalmology leading to Masters in Ophthalmology he spent several years in the pharmaceutical industry, consulting from Aravind Eye Hospital and Postgraduate Institute of and scientific research. Ralf holds a Doctor of Economics and Social Ophthalmology, Madurai, South India in 1996. Sciences degree from the University of Erlangen-Nuremberg. In addition, he holds a Master of Science degree in Management and Having worked in the medical field, he had a passion for management. Bachelor of Arts degree in Business Administration. He studied at the In 2000 he did his MBA with specialization in strategy from the University of Erlangen-Nuremberg and Indian Institute of University of Michigan, Ann Arbor, USA. After MBA, he took over Management, Bangalore (IIMB). His scientific background is in the as the Administrator of Aravind Eye Care System and was instrumental field of corporate strategy where he has authored several in bringing changes to the various facets of the organization. From publications. 2011, he is serving the organization in the role of Director-Projects of Aravind Eye Care System. He is on the Board of Govel Trust that runs the Aravind Eye Hospitals. From September 2017, he is leading the Aravind Eye Hospital Chennai as Chief Medical Officer. On the clinical front, Dr. Aravind is a high volume cataract surgeon. And in Non-Clinical aspects, he is innovating, executing and working with all stake holders in the respective branches to ensure harmony in work, mentoring staff to invent and implement innovations in areas of need to ensure better patient centred care towards. Dr. Herbert Staehr He is involved in teaching eye health management courses. He is Vice President also a resource person for Indian Institute of Management and Global Head of Transforming Care Mentor for the MBA students of Wharton School of Business and Delivery at Siemens Healthineers University of Michigan. Dr. Aravind’s area of specialization concentrates on overall evaluation and interpretation of performance of each Division and to track progress of performance so as to facilitate Herbert Staehr is passionate about healthcare and, as global head benchmarking both internally and externally to achieve patient of Transforming Care Delivery, drives activities to equip healthcare centred care across the system. Besides administration of the hospitals providers to deliver higher-value care. Prior to this position, he led and grooming managers, Dr. Aravind also evaluates new projects Portfolio Development and Marketing within the Enterprise Services and ensures replication of the “ARAVIND Way” – As a Trainer and and Solutions business of Siemens Healthineers. Before joining Mentor at Management courses, he contributes in extending the Siemens Healthineers, Herbert Staehr worked with a major private Aravind Model of high volume, high quality, affordable cost eye care hospital group in Germany in senior leadership roles including to developing nation. serving as managing director of an acute care and a post-acute care hospital. Earlier, he led the group’s Corporate Development department. He was employed for several years in the Healthcare Consulting practice of McKinsey & Company on various European and international assignments. Herbert Staehr holds a PhD in Healthcare Economics from the University of Hohenheim, Germany. He obtained a dual degree (Bachelor of Arts and Diplom-Betriebswirt) in International Business and Finance from the European School of Business, Germany, and Dublin City University, Republic of Ireland. 18 Issue 13 · Siemens Healthineers Insights Series At Siemens Healthineers, our purpose is to enable healthcare providers to increase value by empowering them on their journey towards expanding precision medicine, transforming care delivery, and improving patient experience, all enabled by digitalizing healthcare. An estimated five million patients worldwide benefit every day from our innovative technologies and services in the areas of diagnostic and therapeutic imaging, laboratory diagnostics and molecular medicine as well as digital health and enterprise services. We are a leading medical technology company with over 120 years of experience and 18,500 patents globally. With about 50,000 dedicated colleagues in over 70 countries, we will continue to innovate and shape the future of healthcare. Siemens Healthineers Headquarters Siemens Healthcare GmbH Henkestr. 127 91052 Erlangen, Germany Phone: +49 9131 84-0 Published by Siemens Healthcare GmbH · Printed in Germany · 0920 · ©Siemens Healthcare GmbH, 2020

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