The Flowering of Aravind Eye Care System

Pravir Malik

Introduction

Aravind Eye Care System is a unique system of hospitals and educational insti- tutes based out of Madurai, South India. It seeks to serve humanity through removing needless blindness. From its inception in 1976, it has grown from a small centre to five hospitals and has been recognized as the leading institute in the world for removing needless blindness. The following extract from an interview conducted by the US-based Fast Company (Issue No. 43, February 2001), summarizes some of the unique achievements of Aravind Eye Care System.

....Since its opening day in 1976, Aravind has given sight to more than 1 mil- lion people in India. Dr. Venkataswamy (Dr. V.) may not run a business, but it's important to note that Aravind's surgeons are so productive that the hospital has a gross margin of 40%, despite the fact that 70% of the patients pay nothing or close to nothing, and that the hospital does not depend on donations. Dr. V. has done it by constantly cutting costs, increasing efficiency, and building his market.
It costs Aravind about $10 to conduct a cataract operation. It costs hospi- tals in the United States about $1,650 to perform the same operation. Aravind keeps costs minimal by putting two or more patients in an operating room at the same time. Hospitals in the United States don't allow more than one patient at a time in a surgery, but Aravind hasn't experienced any problems with infections. Aravind's doctors have created equipment that allows a surgeon to perform one 10- to 20-minute operation, then swivel around to work on the next patient – who is already in the room, prepped, ready, and waiting. Post-op patients are wheeled out, and new patients are wheeled in.
Aravind has managed to beat costs in every area of its service: The hos- pital’s own Aurolab, begun in 1992, pioneered the production of high-quality, low-cost intraocular lenses. Aurolab now produces 700,000 lenses per year, a quarter of which are used at Aravind. The rest are exported to countries all over the world–except to the United States. (In order to get its lenses approved for sale in the United States, Aravind would have to pay for both an FDA and a clinical study, which the hospital cannot afford.) Aravind even has its own guest house, and students and physicians from around the world come to teach, study, observe, practice – and boost their training. Poles for stretchers? They’re made from bamboo that grows in Dr. V.’s garden. “We also have the $5 pole, which is bright and shiny,” says Dr. Natchiar, “but we prefer these bamboo poles.”
....When Dr. V. started, there were perhaps no more than eight ophthalmologists in all of India. Dr. V. saw a market in the 20 million blind of India, most of whom suffer from cataracts, which in India are caused mainly by the glare of the tropical sun, poor diet, and genetic factors. Today, Aravind is the largest single provider of eye surgery in the world. In 1998, its hospitals saw 1.2 million outpatients and performed 183,000 cataract surgeries. Dr. V.'s extended family visited 1,488 villages to run diagnostic eye camps. Paying cus- tomers support the free surgeries, and the sale of lenses abroad adds to the bottom line. Aravind accepts no government grants. The hospitals are totally self-sustaining. And Dr. V. lives on his pension. “There is not one rupee that he takes out of Aravind”, says Dr. Natchiar.

Aravind has always been concerned with defining the cutting-edge. It has always sought out innovative ways to serve humanity. In this regard its management was very open to trying out some of the new organizational flowering analyses and meth- odologies being developed by Aurosoorya. This paper is an examination of some of Aurosoorya’s initial findings and recommendations to Aravind Eye Care System. The work between the two organizations is on-going.

Executive Summary

Aravind Eye Care System has a very developed service component (see section on archetypes), which in fact forms its raison-d’être. This is apparent from its continu- ing to want to serve four times as many free patients as paying, in spite of the added weight of managing such a venture, especially as its volume of patients continues to grow. Not only has Aravind set this audacious goal for itself (80:20 free: paying patient ratio), but it wants to do this while providing “perfect patient satisfaction” to all patients.

This implies two important things. First, every activity at each point in the organization has to be elevated to the highest possible level, so that, in accordance with the Degrees of Freedom Model, every unit and employee is able to respond to every situation in the best possible manner. This can be done responsively or proac- tively as explained below.

Second, the organization “institutionalizes” its raison-d’être, in accordance with the Uniqueness Model. Thus, beyond openly recognizing that Aravind is a service- centred organization, all units, workflows, and employees are examined for their commitment to this underlying principle. This necessitates the creation of organi- zational and employee uniqueness stamps. Further, the principle of ‘free progress’ is leveraged in all units, work-flows, and employees, to allow organic development to take place, so that other archetypal components are also allowed to develop. This functions to strengthen Aravind’s goal of providing perfect patient satisfaction or perfect service.

Thus, for example, even though a doctor may exist to provide service, avenues for allowing the development of the archetype of knowledge, in the form of research, say, must be allowed. It is to be noted, that challenges that seem to emerge spontane- ously should also be interpreted in this light. That is, occasional conflicts may be used to prompt the organization to develop capacities of the corresponding archetypal component that at present may be lacking in development.

Aravind Eye Care System is already a great and unique organization. Adoption of the Degrees of Freedom Model and the Uniqueness Model into its planning and every day functioning is likely to make it greater.

Degrees of Freedom Model

Broadly speaking there are several levels at which an organization may operate:

If an organization operates at a “material” level, then it is tied in to the past and to what may have once made it successful. Its world consists of known custom- ers, known products, known markets, known processes and structure, and known strategies. Innovation is about “tweaking” and about moving within the boundaries that have already established what it is. An organization centered at this level has a limited number of options to choose from when confronted with change. Change itself is engineered as though the world is fixed, and therefore any efforts are only incremental, within the confines of the described world. To the degree that an organization centered at this level can call on attitudes and strategies from higher levels, it will, in all likelihood, be able to function more successfully than an organization that perceives and acts in the world solely from a material perspective.

An organization operating at the “financial” level has more degrees of freedom. Being centered in financial results, whether return on investment, sales, or market share, it is not necessarily bound to the world that has made it successful. It is not necessarily bound by past markets, customers, products, processes, structures or strategies. It has the added flexibility of changing any of these to ensure that it meets its specified financial goals. Yet, if it were required to go through a quantum change, as is being required from many organizations today, it runs the risk of becoming extinct when it remains focused on meeting its self-imposed financial goals. It is to be noted that organizations operating at this level do embody all the positive capacities of the previous, material, level. At the same time, to the degree that an organization centered at this level can call on attitudes and strategies from the conceptual level, it will be able to function far more successfully than an organization that perceives and acts in the world solely from a financial or a financial-material perspective.

An organization operating at the “conceptual” level is not bound by its past. It has more degrees of freedom and is in essence more fluid and adaptive than any form that precedes it. It seizes on ideas and will change its customers, products, markets, processes, structures and/or strategies to ensure that these ideas can be fulfilled. It too, has the know-how and capability of all the previous levels embed- ded into it. Thus, material and financial capabilities are deeply embedded or easily available to it.

An organization operating at the “intuitional” level is fulfilling some deep need, possibly far beyond what it might even imagine. As such, it has opened to deep forces of formation, and is bound only by its ability to give the receiving intuition a form. At such a level of operation, old, accepted ways of organizing may prove inadequate or incomplete and the organization may have to conduct its operations in new, virgin forms. Such an organization is deeply creative and perhaps becomes the model by which many other organizations develop.

Examples of organizations at each of these levels follow:

  • An example of material-level operation, to the point where it becomes restric- tive, is that of the US Rail Industry. They tried to continue providing only rail services, even though others had begun to provide comprehensive transport services, and therefore signed their own death warrant.
  • Another example of the material-level operation is that of a company in the “typewriter” business. Computers now provide all the capabilities provided by a typewriter, and many more. Any company that insisted on providing typewriters has been wiped out.
  • An example of financial-level operations is that of Barnes & Nobles. When Amazon.com actually began following through on its vision of becoming the largest bookstore on the planet, Barnes & Nobles, threatened by its diminishing market share, spun off barnesandnobles.com. Their motivation was simply to gain back lost market share. If instead, they had moved to an ambition at the concept-based level, they may have been able to reinvent the retailing industry by being the first truly click-and-mortar type company.
  • Another example of an enterprise operating at the financial level is Covisint, the e-marketplace joint effort between GM, Ford, and Daimler Chrysler. While Covisint had the possibility of being a concept-led play, in reality it has been motivated by a vision that is at a less empowering financial level. Thus, to avoid the continuing costs of ongoing battles and pains associated with continu- ing to support their own auto-parts marketplaces against the efforts of other

    competitors in the same space, the Covisint principals decided to join forces to come up with a joint auto-parts marketplace. Since their motivation has been driven by the financial level, they have been unable to step up to the broader concept-led leadership required to bring such a venture to successful fruition. Thus, from the word ‘go’, they have been dogged by a host of problems start- ing from the inability to come up with a mutually acceptable name for the project, furthered by an on-going difficulty in selecting the right technology platform, to the potentially crippling inability to really bring their suppliers along. These leadership problems had been compounded moreover by the Federal Trade Commission’s concern that the combined purchasing power of the auto-makers could be anti-competitive for suppliers.
  • An example of a concept-led company is that of Amazon.com. At its incep- tion it sought to create the world’s largest virtual bookstore. It sought to allow the user to browse titles in the comfort of their home, while allowing users to view online reviews by other readers. They shipped books to buyers at prices compatible with or less than those available at its competitors. Its concept for selling books was so different from existing sellers of books, that investors allowed it to continue in operation for 5 years before it even began to show a profit. Further, it drew investors to its unique concepts, and through the funds that became available to them was able to quickly mobilize capabilities at the previous level — material and financial.
  • An example of an organization somewhere between the conceptual and the intuitive level is that of Aravind Eye Care System. Note that this is not a busi- ness organization, and therefore its inclusion on this scale is tenuous, but done nonetheless, to provide a rough indication of what the different levels of operation may mean. Aravind Eye Care System has grown organically, without upfront planning, and has assumed a unique practical shape, with a reach into the village level unparalleled by any other organization. This reach has assisted it in creating a unique culture through the young village girls who join Aravind to become its nurses, and the backbone of the organization. This reach also allows Aravind to provide service to numerous blind throughout Southern India. It is driven by the vision and idea of its founder, and there is an adhe- sion to this vision, even though circumstance and time go on. In this sense it remains at least concept-led.
  • To the best of the author’s knowledge companies that function fully at the Intuitive level do not exist, though several may be in formation, driven by the vision of their leaders. One such organization is the World Wide Web (WWW) which because of its open structure is being pulled towards the financial level. However, its core continues to withstand this pressure. Something of the core may be understood by reading the following words of Tim Berner-Lee, consid- ered to be its inventor: “The dream behind the Web is of a common informa- tion space in which we communicate by sharing information. Its universality is essential: the fact that a hypertext link can point to anything, be it personal, local or global, be it draft or highly polished. There was a second part of the dream, too, dependent on the Web being so generally used that it became a realistic mirror (or in fact the primary embodiment) of the ways in which we work and play and socialize. That was that once the state of our interactions was on line, we could then use computers to help us analyse it, make sense of what we are doing, where we individually fit in, and how we can better work together.”

An organization should be centered at the higher levels. This then provides it with the flexibility and living-quality to become an effective organization constantly fulfill- ing real needs. It thus becomes imperative to create a culture whereby there is always a push to the higher levels. As such, proactive actions and responsive measures need to be taken at every instance to ensure that every part of the organization is operating with the highest degrees of freedom available to it.

Proactively, work should be designed in such a manner that each individu- al’s uniqueness is tapped, and allowed to flower. In an ideal world work should be designed so that the full personality around the uniqueness of an individual is allowed to take shape and express itself. This leads to the Uniqueness Model, to be discussed shortly. It is to be noted that it is in such a fulfilment of each employee that patient fulfilment can best be achieved. In reality there will often be a trade-off between the fulfilment of each employee and the needs of the moment. Over time, however, perhaps these two can truly bolster one another. A motivated, constantly advancing employee, after all, will naturally interact with patients in a more positive way than the non-motivated, stagnant employee.

Responsively, every occasion/incident in the organization, such as a planning session, meeting, or unexpected incident should become the occasion to push the employee to a higher level of thinking and acting--through meetings conducted in a different way, for example. Individual challenges need to be met with the same approach so that every decision made becomes the occasion to exercise a conscious choice from a higher as opposed to a lower consciousness. The following mobilizing techniques when used repeatedly will assist in shifting the organization to a higher level of operation:

TechniqueBrief Description
Contribution question Contribution question is about creating an underlying sense of questioning to do with individual level of contribution to the company. While “contribution question” is an aspiration for peak performance, it is based on a foundation of self- questioning insufficiency. In this respect it always pushes the subject(s) toward self-exceeding.
Hard talkHard talk requires a shift in the mutual understanding of the nature of “conflict”. Conflict needs to be viewed as a means to surface difference of opinions, and to work through them to create a more robust business foundation.
Learning from adversityLearning from adversity is about learning from adverse situations to create a more robust system.
Instilling situational understandingThis is about creating a widespread understanding of those variables that really drive the business.
Managing from the futureManaging from the future requires participants to stand in the future and to remove any obstacles that remain in the way of being there fully.
Creating a holistic employee-employer contractThe employer and employee have to enter into a holistic contract that nurtures the employee and provides the employee with a stimulating and rewarding work environment.
Building collaborative competencyTechnique for being able to collaborate with others through focusing on what is unique and best about them.
Cultivating macro-perspectiveParticipants need to ‘see’ differently, so that the corporation, the entire business environment, along with all stakeholders, is seen as one unified complex adaptive system.
Appreciative inquiryAppreciative inquiry is about mobilizing and leveraging the positive patterns and energy that exists in all people, all organizations, and all situations.
Cultivating self-awareness A series of introspective techniques to create greater self- awareness, leading to increased levels of calm, concentration, and creativity.

It is to be noted that organizations or parts of organizations at the material end of the spectrum will literally need to be shaken out of their inertia. These units have become complacent and have reached a state of stagnation. They have lost their coping mechanisms. Thus, “hard” or even “adversarial” techniques will usually be required to literally shock them out of an outdated worldview.

Companies at the conceptual end of the spectrum are usually more present and alive. Given that they are not locked in to their present worlds, the energy that sustains them tends to be dynamic and opportunistic. Techniques to ensure that they continue to live in the present moment and with the same output of positive energy are, therefore, required.

The following diagram depicts this variation in application of techniques. Note that techniques further up the slope will have a greater range of applicability in that they may successfully be applied to organizations or parts of organizations that corre- spond to circumstances further down the slope. Techniques further down the slope, on the other hand, cannot be applied to organizations or parts of organizations that correspond to circumstances further up the slope:

Uniqueness model

The premise of this model is that any successful creation must be, and in fact in its secret or inmost heart, is unique. This applies to (1) organizations, (2) to individuals, and (3) has an important corollary around the relationship between an organization and its employees.

Generally speaking, there are four archetypes that stand behind the formation of an individual’s personality, or that drive the development of a successful organi- zation. These archetypes are Knowledge, Power, Mutuality, and Service. While one aspect will always prevail in any individual or successful organization, individual or organizational uniqueness may be due to a unique combination of the various capaci- ties underlying each of the archetypes.

(1) On the organizational front, organizations that do not achieve a distinct uniqueness soon become redundant and decay. In fact, a successful organization is a unique organization, and further, has developed its uniqueness along one of the four archetypal directions as illustrated in chart below:

Thus, in the chart above, the service component leads, while at the same time there is maturity along each of the other dimensions, though to a lesser extent. The above chart depicts a unique and fairly well-developed organization, like Aravind, whose raison-d’être is service. There is need for the mutuality component to develop further, however.

(2) On the individual front, there is uniqueness at the heart of each individual. The fulfilment of the person lies in recognizing this uniqueness, and further allowing it to flower by creating the right organizational and work circumstances. Individual uniqueness would be depicted in a similar manner to organizational uniqueness (see the following chart).

(3) On the relationship front, in order for the organization to continue to develop along its line of uniqueness, it is imperative that individuals who join the organization have a strong development along the same archetype as that of the organization, or at the very least have an opening to it, and a desire or will to develop it. This is illustrated in the following diagram:

The above illustration depicts an organization with a strong service component. Two employee stamps are shown. The aligned employee has the service component in one of three states – strong and dominant, mature, or undeveloped with a desire to develop. The unaligned employee has no service or potential service component. It will be to the organization’s advantage to cultivate aligned employees.

It is to be noted that an organization that begins to flower around its raison-d’etre will successively be led to develop more aspects of itself through the development of capacities belonging to components other than its prime component. Thus, an organization that successfully develops around its service component, for example, will be led, by circumstance, to develop each of the other components, if it is to con- tinue to prosper. This will in turn assist it to more completely fulfill its raison-d’être (svadharma).

The Four Archetypes

Every thought, word, and act, already is a means for the vaster powers of harmony and mutuality, of knowledge and wisdom, of service and perfection, of power and energy and courage, to manifest themselves. It is indeed these powers – harmony and mutuality, knowledge and wisdom, service and perfection, power and energy–that stand behind all that we see manifest around us.

Consider a simple example of a chair. For centuries perhaps, people sat on the ground, or on boulders. Then one fine day somebody had a flash of insight and the concept of sitting on a moveable, comfortable chair became manifest. The concept itself was the result of the power of knowledge. Having had a concrete vision of the thing to be done, the force and energy to do it became manifest. This is the result of the power of energy. Next, of course, was the issue of making the concept manifest. Elaborate plans were then drawn out, specifying materials to be used, implements to be used, alternative end-designs, and even the process of production. This was the result of the power of harmony and mutuality. Finally, the blueprints needed to be executed. The skill and workmanship and overseeing of the project had to be embarked upon. This was the result of the power of service and perfection.

These four powers must be allowed to express themselves in their purity. Currently, and in accordance with the unrefined vital tendency of the age, all the sub-powers of the four powers have submitted themselves to the dynamics of commer- cialization, itself an unrefined power of mutuality and harmony. Thus, Art is created and valued for its ability to generate monetary wealth. Sports too has become big business. Knowledge is valued only for its ability to generate monetary gains. And so on. When we say that everything must express itself in its purity, therefore, we mean that knowledge must be pursued for the sake of knowledge, art to express beauty, sport to perfect the body, enhance organization skills, and develop many other noble qualities, and so on. But it also means that the myriad capacities contained within these four powers will more easily exercise themselves in our functioning.

Thus the development of the archetype of knowledge within oneself will per- haps imply not only the seeking of knowledge in areas related to one’s immediate work, but even seeking of knowledge in other areas, of a need to research and create new knowledge, of a temperament that is calm and turned to introspection and even meditation, of a tendency to want to dominate all emergence of passion and vital tendencies by reason, by the urge of wanting to spread knowledge amongst all, and by the seeking after truths too profound to perhaps even be contemplated.

The development of the archetype of mutuality and harmony within oneself will perhaps imply the understanding of rhythms of all kinds, the understanding and even mastery of the great laws of interchange by which organizations are built, of the need of amassing in order to throw out in even larger measure in order to create an even greater return, of even the ability of compelling others to unite through harmony, and the insights into practicalities – of making even abstract thoughts and ideas manifest practically.

The development of the archetype of power, leadership and energy within oneself will perhaps imply the development of an unflinching courage, of the abil- ity and need to be a leader in noble causes, the need to protect the down-trodden, the ability to muster and possess great energy for any new endeavours, the ability to see the new and needed, and the ability to convince others of the worthiness of new adventures.

The development of the archetype of service and perfection within oneself will perhaps imply an extraordinary attention to detail, a need to labour at any discipline in order to achieve perfection, a giving of oneself to that which one loves without concern of the self, a sense that nothing is too small to be the object of attention, and a sense of what has already been accomplished and what remains yet to be accomplished.

Once each power is developed and expressed in purity then only will multiple motive forces become the engine of development. When this happens, then truly robust organizations, flowering organizations, can begin to come into being.

6. Recommendations

In summary, the following recommendations are made to assist in the flowering of Aravind Eye Care System’s:

  1. Identify a part of the organization that has planning sessions or important meetings and begin to introduce the appropriate mobilizing technique to push that part of the organization up the Degrees of Freedom slope. An immediate possibility is Aurolab.
  2. Examine challenges being faced by Aravind to understand what correspond- ing archetypal capacity is being pointed at for development. Subsequently, call a meeting(s) of appropriate employees, conducted using some Degrees of Freedom mobilization technique(s), to begin to address the challenge. An immediate challenge could be Aravind’s need to generate more revenues to meet its service goals.
  3. Identify the archetypal stamp of employees, and determine what their develop- ment needs might be. This too could be started immediately by focusing on some part of the organization. Perhaps the doctors-unit, since the turnover of doctors tends to push the average turnover higher. Subsequently, examine workflows around this unit to determine in what manner these can be altered/ augmented to allow the employee to develop further.
  4. Create Aravind’s organizational stamp to understand what further capabilities need to be developed, and thus what further challenges Aravind may face as an organization. This could be done in a “training” session of some kind.
  5. Identify the archetypal stamp of prospective employees to insure that the ser- vice component is aligned with Aravind’s organizational stamp.
  6. Conduct training sessions with appropriate employees to introduce the Degrees of Freedom Model and Uniqueness Model with the aim of incorporating these into the appropriate place in the organization.