Thulasiraj Ravilla世界品质的平價眼科醫療

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Thulasiraj Ravilla世界品质的平價眼科醫療
早上好。 让我来很你们分享一个 可以让人摆脱苦难的实验。 这是维卡塔丝维敏博士（Dr. Venkataswamy）的故事。 他的目标和他从亚拉文（Aravind）眼保健系统所发出的信号。 我想重要的是，我们首先得意识到失明意味着什么。
（音乐）
女人：当我去找工作得时候，每个人都说不可以， 我们要一个瞎女人有什么用？ 我不能穿针，也看不见我头发里得虱子。 如果一个蚂蚁掉到我得米饭里，我也看不见。
图拉丝内贾 让维拉（Thulasiraj Ravilla）：看不见就是这样的， 但是我想这也剥夺了一个人的生命， 和他们的尊严， 他们的独立性，以及他们在家庭里的地位。 她只是成千上万盲人中的一个。 讽刺的是他们本可以避免失明。
一个简单可行的手术可以让上千万人重见光明， 或者更简单，一副眼镜，可以让更多的人看见。 如果看看在座各位都有谁 因为佩戴了眼镜而使得自己的效率得以提升， 那么五分之一的印度人都会需要视力保健， 这个数字加起来有2亿 现在，我们还照顾不到他们中的10％。
所以这是在亚拉文30年前 面临的挑战。 而这所医院也成为了维博士 （Dr. V.）的退休后的心血工程。 他白手起家。 他用他毕生的积蓄 从银行贷款。 现在，我们已经发展到5个医院的业务网里， 以泰米尔纳德邦和浦度查里邦为主， 然后，我们加入了一些，我们称之为眼科中心的地方， 于是形成了核心加辐射的模式。 最近我们也开始在国家的其他地区 管理医院 同时在世界的其他地方也开始有所涉足。
在上30年里， 我们做了35万例手术， 绝大多数是穷人。 现在，我们每年会做300000例手术。 这是在亚拉文的一天，我们会做到大概近千例手术， 接见大概6000名病人， 发出小队去医院里检查，和带病人回来， 执行很多远程咨询， 最重要的是，做很多培训， 他们中的很多人成为未来亚拉文的员工包括医生的技工。
能每年入一日的保持这样的工作 这需要很多的精力和勤劳的工作。 我想这之所以能够实现，要感谢为这尽心尽力的 维博士。 他建立了一套价值系统，一个高效的手术流程， 并启迪了一种创新的文化
（音乐）
维博士：我通常和一个普通的乡下人坐在一起，因为我就是从乡下来的 然后突然之间你似乎可以和他的内心交流， 你似乎和他是一体的． 这里似乎有着一个拥有一切信心的灵魂． 博士，无论你说什么，我都会接受． 一个暗藏在你身体中的信心 然后你会回应这个信心． 有一个年迈的女士对我有极大的信心，我必须为她做到最好． 当我们在一个有灵性的良知的环境下成长， 我们就会按照这个来定义我们的世界， 所以这里没有剥削． 帮助的是我们自己， 被疗救的也是我们自己。
（掌声）
这帮助我们创建了一个十分道德的和非常以病人为中心的机构 以及一个支持这个机构的系统． 但是在实践过程中．你必须能十分有效的去完成这个服务， 然而，让很多人吃惊的是，灵感来自于麦当劳．
维博士：看，麦当劳的概念很简单． 他们觉得他们可以训练世界各地的人， 无论不同的宗教，文化，和其他所有的事情， 去用一样的方法来创造一个产品 然后以同样的方式 在成百上千个不同地方推出
拉里·布利连（Larry Brilliant）：他一直的谈论这麦当劳和汉堡， 然后这一切都让我们摸不着头脑． 他想创造一个连锁店， 一个拥有麦当劳效率的 视力保健连锁店．
维博士：假设我可以提供视力保健， 技术，方法，都用同一种方法， 使之在世界任何地方都能运作， 失明的问题也就不是问题了．
TR：如果你想想看．我想眼球是一样的， 无论是美国人还是非洲人， 问题都是一样的，疗程也是一样的． 不同的是，质量和服务上则是千变万化的， 这也是我们在设计服务系统中 所遵循的基本条例． 当然，我们的挑战是， 我们谈的是千千万万的病人， 但我们的资源非常非常少 并且很多人是住在偏远地区，也支付不起看病的费用，这就成为巨大的挑战。
所以，我们必须不断的创新． 一个早期的创新，也是一个沿用至今的 就是在一个社区内对问题创造一个所有权， 然后让他们像伙伴一样参与进来， 这里有这样一个事件， 这里一个被社区自己所规划的 一个社区营地， 在那里，他们自己找到用地，组织志愿者， 然后我们就做我们该做的，就是检查他们的视力， 医生会找到问题在哪里 并决定有必要执行进一步的测试， 然后这些测试有医疗技术人员完成， 他们会检查镜片， 或检查青光眼．
然后，综合所有的结果，医生会做出最终的诊断， 然后开出处方， 如果他们需要一副眼镜，在营地里就可以拿到， 通常在树下面． 但是他们可以自己选择镜框， 那是很重要的，因为我想镜片 可以帮人们看见， 但是同时也是一个时尚的宣言，他们愿意为这付款． 所以，他们可以在20分钟内得到眼镜 然而对于那些需要手术的，在跟病人知会的前提下， 会坐巴士， 去到我们的医院接受手术。
如果不是有这样的运输和支持， 很多像这样的人就不会得到这样的服务， 当然也不会在他们需要的时候得到． 他们会在接下来的几天里得到手术， 然后他们会留院一两天， 然后他们会搭乘巴士 返回他们来的地方， 那里会有他们的家人等待领走他们．
（掌声）
这每年会发生上千次． 也许我们接待很多病人是很让人惊叹的， 一个十分有效的过程， 但是我们看的是，我们在解决问题吗？ 我们做了一个设计得非常好的调查， 结果令我们十分沮丧， 我们发现我们只覆盖到了那些需要帮助的7%， 我们不能充分的解决更大的问题。
所以我们尝试了一些不同的事情， 所以我们架设起了我们叫做初级视力保健中心以及眼科中心。 这是一个真正的无纸办公室 全部使用的都是电子医学设备。 他们会收到一个全面的医学检查。 我们把一个简单的数码照相机做成了一个视网膜照相机， 然后每一位病人都会和一个医生做一次远程咨询。
在第一年的效率是， 我们的服务群体达至40% 多达50000人。 然后第二年是75%。 我想我们得到了一个 通过渗透到市场 来给有需要的人提供服务的过程， 然后在这个过程中使用科技，来保证 大多数人不用去医院。
然而，他们需要为此支付多少？ 每次诊疗的费用都是固定的 病人也省去了坐巴士去城市的价格， 他们只需支付20印度卢比，那可以支付3次咨询。
（掌声）
另一个挑战是，我们如何能让高科技 给予治疗更多的便利？ 我们在车里设计了透过卫星的网络连线 可以将病人的图片送到医院里 在那里得出诊断， 然后在病人等待的同时，报告就会及时送到病人身边， 打印出来，然后病人可以拿到， 然后得到他们该做什么的咨询， 过去，病人去看一次医生要花半年的时间 现在有了这样的科技， 他们可以迅速的获取他们所需的信息。
所以这些所有的影响是市场增长的基本因素之一， 因为这注重于非用户， 然后触及到了所没有触及的市场， 我们可以显著的让市场成长。
另一方面就是当医院的眼科医生很少的时候 如何提高做手术的效率？ 所以这个视频显示的是一个外科手术， 你可以看到在另外一个桌上， 另外一个病人已经准备好了。 这样，当他们完成手术后， 他们就会把显微镜移到另一边 桌子放的距离恰到好处， 我们必须这样做，因为，这样做的话 我们才有能力做到有效的手术。
因此，为了支持手术， 我买也雇佣了劳动力。 我们雇佣的都是乡下女孩， 她们给整个机构带来了底气。 它们几乎做着所有技术为主的日程工作。 她们一心一意。完成的十分出色。 结果就是，我们的花费十分低， 但质量和效率都十分高。 所以，总而言之，事实是 我们员工的生产效率比 任何人都要高出很多。
（掌声）
这是一个十分忙碌的办公桌， 但是这所传达的是， 当要保证质量的时候，我们有一个 能保障质量的系统。 结果就是，我们的并发症 要远比伦敦的低， 这样的数字你是很少会看到的。
（掌声）
所以最后的迷题是， 我们如何保证资金运转正常？ 要知道我们大部分病人都无法支付看病的费用！ 我们的做法是，很多都是免费的， 对于那些有能力支付的病人，我们收取当地市场的价格 不多于这个，通常是少于这个的， 我们被市场的低效率性所帮助了。 我想这是我们的救星，直到现在。 当然了，一个人必须有一个能 放弃的的盈余的思维。
结果就是，在近几年里， 我们的支出显著增长， 我们的收入则是以更高速度在增长 这样一来，我们可以保证有健康的盈余 因为我们需要免费为很多病人提供治疗 从绝对数字来说， 去年，我们挣了大概2000万美元， 用了1300万美元，超过税前利润40％。
（掌声）
但是这意味着我们要超越我们现在所做的， 或着我们已经做的， 如果你真的想去解决失明的问题。 所以我们做了一些反直觉的事情。 我们为我们自己创造了竞争对手， 这样使得眼保健的价格降得更低 让更多人可以享受到这样的服务 我们主动的，系统化的 在印度的很多医院里宣传这个实践， 很多是在我们自己的地盘，也有世界其他地方。 结果是， 那些我们提供咨询的医院 他们的手术数量翻了一番 也使得收益得以改善
另一个部分就是你这样对待 科技消费上的增长？ 我们后来没能谈下来一个 可以接受的内眼镜片的价格， 于是我们干脆就设立了自己的流水线。 这样，一段时间后，我们就有能力将支出显著的降低 到我们开始的2个百分点。 现在，我们相信我们占有了全球市场的7％， 在大概120的国家里。
总而言之，我要提出的是，我们是要将这个模式推广出去， 还是只是将它保留在印度或其他发展中国家？ 为了能说明这，我们比较了一下英国的眼科治疗和亚拉文。 这显示了，我们做的是英国 的60倍大小， 整个国家的手术有50万例。 而我们的300000。 而且我们训练大概50个眼科医生 他们要训练70个， 训练和病人护理的质量都是同等级别的 我们真的是用苹果来比较苹果。 我们看看消费上。 （笑）
（鼓掌）
所以，我想这要说的是 因为这在英国没成功但印度成功了。 我想还有更多的可以做。 我的意思是，我想也要看看其他的方面。 也许 降低成本的方法就在生产效率里， 也许在高效里，在诊所的过程里， 或者在他们能支付多贵的镜片里， 或条例里，或者在实践里。 所以，我想破解这些也许可以 给大多数发达国家 包括美国带来答案，或许 奥巴马的支持率会再度升高。
（笑）
另外一个观点，就是，我想留给你们， 当问题十分大的时候， 当问题是在这个经济阶层的时候， 当我们有一个好的方法， 我想我刚才已经描述了过程， 你找到，生产率，质量，病人中心的护理， 可以给出答案， 有很多都很适合这个范例。 你可以用到牙科，助听器，产假等。 有很多这个范例都可以做到， 但是我想最有挑战力的事情 是在“软件”上。
现在，你们怎样创造关怀？ 现在你怎样让群众拥有问题， 让他们想对此做点什么？ 这样就是更难一点的问题。 我肯定在座的会有人找到答案。
所以我想我用这个问题和挑战来结束这个演讲。
维博士：当你是在一个有灵性良心的环境下的时候， 你会认为世界充满了这些 所以就没有了压迫。 我们帮助的最终是我们自己 我们疗救的最终也是我们自己。
主持人：十分感谢你。
（掌声）
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Thulasiraj Ravilla: How low-cost eye care can be world-class
Good morning. I've come here to share with you an experiment of how to get rid of one form of human suffering. It really is a a story of Dr. Venkataswamy. His mission and his message is about the Aravind Eye Care System. I think first it's important for us to recognize what it is to be blind.

(Music)

Woman: Everywhere I went looking for work, they said no, what use do we have for a blind woman? I couldn't thread a needle or see the lice in my hair. If an ant fell into my rice, I couldn't see that either.

Thulasiraj Ravilla: Becoming blind is a big part of it, but I think it also deprives the person of their livelihood, their dignity, their independence, and their status in the family. So she is just one amongst the millions who are blind. And the irony is that they don't need to be.

A simple, well-proven surgery can restore sight to millions, and something even simpler, a pair of glasses, can make millions more see. If we add to that the many of us here now who are more productive because they have a pair of glasses, then almost one in five Indians will require eye care, a staggering 200 million people. Today, we're reaching not even 10 percent of them.

So this is the context in which Aravind came into existence about 30 years back as a post-retirement project of Dr. V. He started this with no money. He had to mortgage all his life savings to make a bank loan. And over time, we have grown into a network of five hospitals, predominately in the state of Tamil Nadu and Puducherry, and then we added several, what we call Vision Centers as a hub-and-spoke model. And then more recently we started managing hospitals in other parts of the country and also setting up hospitals in other parts of the world as well.

The last three decades, we have done about three-and-a-half million surgeries, a vast majority of them for the poor people. Now, each year we perform about 300,000 surgeries. A typical day at Aravind, we would do about a thousand surgeries, maybe see about 6,000 patients, send out teams into the villages to examine, bring back patients, lots of telemedicine consultations, and, on top of that, do a lot of training, both for doctors and technicians who will become the future staff of Aravind.

And then doing this day-in and day-out, and doing it well, requires a lot of inspiration and a lot of hard work. And I think this was possible thanks to the building blocks put in place by Dr. V., a value system, an efficient delivery process, and fostering the culture of innovation.

(Music)

Dr. V: I used to sit with the ordinary village man because I am from a village and suddenly you turn around and seem to be in contact with his inner being, you seem to be one with him. Here is a soul which has got all the simplicity of confidence. Doctor, whatever you say, I accept it. An implicit faith in you and then you respond to it. Here is an old lady who has got so much faith in me, I must do my best for her. When we grow in spiritual consciousness, we identify ourselves with all that is in the world, so there is no exploitation. It is ourselves we are helping. It is ourselves we are healing.

(Applause)

This helped us build a very ethical and very highly patient-centric organization and systems that support it. But on a practical level, you also have to deliver services efficiently, and, odd as it may seem, the inspiration came from McDonald's.

Dr. V: See, McDonald's' concept is simple. They feel they can train people all over the world, irrespective of different religions, cultures, all those things, to produce a product in the same way and deliver it in the same manner in hundreds of places.

Larry Brilliant: He kept talking about McDonalds and hamburgers, and none of it made any sense to us. He wanted to create a franchise, a mechanism of delivery of eye care with the efficiency of McDonald's.

Dr. V: Supposing I'm able to produce eye care, techniques, methods, all in the same way, and make it available in every corner of the world. The problem of blindness is gone.

TR: If you think about it, I think the eyeball is the same, as American or African, the problem is the same, the treatment is the same. And yet, why should there be so much variation in quality and in service, and that was the fundamental principle that we followed when we designed the delivery systems. And, of course, the challenge was that it's a huge problem, we are talking of millions of people, very little resource to deal with it, and then lots of logistics and affordability issues.

And then so, one had to constantly innovate. And one of the early innovations, which still continues, is to create ownership in the community to the problem, and then engage with them as a partner, and here is one such event, here a community camp just organized by the community themselves, where they find a place, organize volunteers, and then we'll do our part, you know, check their vision, and then you have doctors who you find out what the problem is and then determine what further testing should be done, and then those tests are done by technicians who check for glasses, or check for glaucoma.

And then, with all these results, the doctor makes a final diagnosis, and then prescribes a line of treatment, and if they need a pair of glasses, they are available right there at the camp site, usually under a tree. But they get glasses in the frames of their choice, and that's very important because I think glasses, in addition to helping people see, is also a fashion statement, and they're willing to pay for it. So they get it in about 20 minutes and those who require surgery, are counseled, and then there are buses waiting, which will transport them to the base hospital.

And if it was not for this kind of logistics and support, many people like this would probably never get services, and certainly not when they most need it. They receive surgery the following day, and then they will stay for a day or two, and then they are put back on the buses to be taken back to where they came from, and where their families will be waiting to take them back home.

(Applause)

And this happens several thousand times each year. It may sound impressive that we're seeing lots of patients, very efficient process, but we looked at, are we solving the problem? We did a study, a scientifically designed process, and then, to our dismay, we found this was only reaching seven percent of those in need, and we're not adequately addressing more bigger problems.

So we had to do something different, so we set up what we call primary eye care centers, vision centers. These are truly paperless offices with completely electronic medical records and so on. They receive comprehensive eye exams. We kind of changed the simple digital camera into a retinal camera, and then every patient gets their teleconsultation with a doctor.

The effect of this has been that, within the first year, we really had a 40-percent penetration in the market that it served, which is over 50,000 people. And the second year went up to 75 percent. So I think we have a process by which we can really penetrate into the market and reach everyone who needs it, and in this process of using technology, make sure that most don't need to come to the base hospital.

And how much will they pay for this? We fixed the pricing, taking into account what they would save in bus fare in coming to a city, so they pay about 20 rupees, and that's good for three consultations.

(Applause)

The other challenge was, how do you give high-tech or more advanced treatment and care? We designed a van with a VSAT, which sends out images of patients to the base hospital where it is diagnosed, and then as the patient is waiting, the report goes back to the patient, it gets printed out, the patient gets it, and then gets a consultation about what they should be doing, I mean, go see a doctor or come back after six months, and then this happens as a way of bridging the technology competence.

So the impact of all this has been essentially one of growing the market, because it focused on the non-customer, and then by reaching the unreached, we're able to significantly grow the market.

The other aspect is how do you deal with this efficiently when you have very few ophthalmologists? So what is in this video is a surgeon operating, and then you see on the other side, another patient is getting ready. So, as they finish the surgery, they just swing the microscope over, the tables are placed so that their distance is just right, and then we need to do this, because, by doing this kind of process, we're able to more than quadruple the productivity of the surgeon.

And then to support the surgeon, we require a certain workforce. And then we focused on village girls that we recruited, and then they really are the backbone of the organization. They do almost all of the skill-based routine tasks. They do one thing at a time. They do it extremely well. With the result we have very high productivity, very high quality at very, very low cost. So, putting all this together, what really happened was the productivity of our staff was significantly higher than anyone else.

(Applause)

This is a very busy table, but what this really is conveying is that, when it comes to quality, we have put in very good quality-assurance systems. As a result, our complications are significantly lower than what has been reported in the United Kingdom, and you don't see those kind of numbers very often.

(Applause)

So the final part of the puzzle is, how do you make all this work financially, especially when the people can't pay for it? So what we did was, we gave away a lot of it for free, and then those who pay, I mean, they paid local market rates, nothing more, and often much less, And we were helped by the market inefficiency. I think that has been a big savior, even now. And, of course, one needs the mindset to be wanting to give away what you have as a surplus.

The result has been, over the years, the expenditure has increased with volumes. The revenues increase at a higher level, giving us a healthy margin while you're treating a large number of people for free. I think in absolute terms, last year we earned about 20-odd million dollars, spent about 13 million, with over a 40 percent EBITA.

(Applause)

But this really requires going beyond what we do, or what we have done, if you really want to achieve solving this problem of blindness. And what we did was a couple of very counter-intuitive things. We created competition for ourselves, and then we made eye care affordable by making low-cost consumables. We proactively, and systematically, promoted these practices to many hospitals in India, many in our own backyards and then in other parts of the world as well. The impact of this has been that these hospitals, in the second year after our consultation, are double their output and then achieve financial recovery as well.

The other part was how do you address this increase in cost of technology? There was a time when we failed to negotiate the [intra-ocular lens] prices to be at affordable levels, so we set up a manufacturing unit. And then, over time, we were able to bring down the cost significantly to about two percent of what it used to be when we started out. Today, we believe we have about seven percent of the global market, and they're used in about 120-odd countries.

To conclude, I mean, what we do, does it have a broader relevance, or is it just India or developing countries? So to address this, we studied UK versus Aravind. What it shows is that we do roughly about 60 percent of the volume of what the UK does, near a half-million surgeries as a whole country. And we do about 300,000. And then we train about 50 ophthalmologists against the 70 trained by them, comparable quality, both in training and in patient care. So we're really comparing apples to apples. We looked at cost. (Laughter)

(Applause)

So, I think it is simple to say just because the UK isn't India this is happening. I think there is more to it. I mean, I think one has to look at other aspects as well. Maybe there is -- the solution to the cost could be in productivity, maybe in efficiency, in the clinical process, or in how much they pay for the lenses or consumables, or regulations, their defensive practice. So, I think decoding this can probably bring answers to most developed countries including the U.S., and maybe Obama's ratings can go up again.

(Laughter)

Another insight, which, again, I want to leave with you, in conditions where the problem is very large, which cuts across all economic strata, where we have a good solution, I think the process I described, you know, productivity, quality, patient-centered care, can give an answer, and there are many which fit this paradigm. You take dentistry, hearing aid, maternity and so on. There are many where this paradigm can now play, but I think probably one of the most challenging things is on the softer side.

Now, how do you create compassion? Now, how do you make people own the problem, [make them feel that they] want to do something about it? There are a bit harder issues. And I'm sure people in this crowd can probably find the solutions to these.

So I want to end my talk leaving this thought and challenge to you.

Dr. V: When you grow in spiritual consciousness, we identify with all that is in the world so there is no exploitation. It is ourselves we are helping. It is ourselves we are healing.

TR: Thank you very much.

(Applause)