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GiveWell aims to find the best giving opportunities we can and recommend them to donors (why we recommend so few charities). We tend to put a lot of investigation into the organizations we find most promising, and de-prioritize others based on limited information. When we decide not to prioritize an organization, we try to create a brief writeup of our thoughts on that charity because we want to be as transparent as possible about our reasoning.
The following write-up should be viewed in this context: it explains why we determined that (for the time being), we won't be prioritizing the organization in question as a potential top charity. This write-up should not be taken as a "negative rating" of the charity. Rather, it is our attempt to be as clear as possible about the process by which we came to our top recommendations.
Published: July 2009; Updated: March 2012
Table of Contents
What do they do?
The Aravind Eye Care System's primary focus is directly providing eye care by (a) running a network of five eye hospitals in India1 and (b) holding "eye camps" to screen and identify patients in need of services.2 In addition, Aravind:
- Advises, supports and oversees other hospitals attempting to implement the "Aravind model."3
- Trains clinicians to perform eye care and administrators to manage eye hospitals.4
- The Aravind Eye Care System also includes a medical research institute (the Aravind Medical Research Foundation)5 and AuroLab, a company that produces eye care materials.6
The Aravind Eye Care System primarily focuses on surgery to correct cataracts.7 Aravind supports its operations by charging patients who have the ability to pay for their medical care. Aravind aims to charge 1/3 of clients and provide free care to 2/3 of clients.8 Aravind's website states that in 2006, 2/3 of outpatient visits and 3/4 of surgeries were provided for free.9 In 2008, however, it appears that only 23% of outpatient visits10 and 57% of surgeries11 were provided for free.
The fees Aravind receives from paying patients fully fund the hospitals' operations, and provide Aravind with some additional revenue they use to expand.12 Therefore, Aravind does not require charitable donations to provide (or increase access to) its core activity: providing cataract surgeries to those in need.
Does it work?
Based on (a) the data on complications in surgeries that Aravind has sent us and (b) the improvement in vision that normally results from cataract surgeries, we would guess that Aravind's activities are significantly improving the vision of the individuals they serve.
Monitoring adverse events during and following surgery
Aravind's Clinical Quality Assessment provides data on complications in surgery, showing the total number of surgeries and complications during those surgeries for one of Aravind's hospitals during 2008.13 The Clinical Quality Assessment also provides a comparison of adverse events among Aravind patients (both during surgery and in the 48 hours following surgery) to patients in the United Kingdom, showing that complication rates among Aravind patients are slightly lower than those among U.K. patients.14 While we see no reason to believe that the populations served by Aravind and the U.K. hospitals are strictly comparable, these data do give us confidence that Aravind is competently performing cataract surgeries.
Monitoring vision improvement
Aravind could not provide us with information on patients' pre- and post-operative visual acuity. However, we do believe that they maintain these records. The researcher who completed the Harvard Business School Case Study reports pulling "out six patient records at random to get a sense of the improvement in sight after surgery."15 In these extremely limited cases, patients' vision improved from near blindness to reasonable levels.16
What do you get for your dollar?
Aravind's primary activity of performing cataract surgeries appears to cost very little per significant life change. This activity also brings in revenue from paying patients (see above).
The cost-effectiveness of the activities supported by donations is unclear.
Cost per surgery performed
In addition to surgeries, Aravind also trains eye doctors. In 2007-08, Aravind trained more than 500 individuals.19 Among graduates, we do not know what portion ultimately work in eye care and perform eye surgeries.
Role of donations
Aravind raises funds through a United States tax-exempt charitable entity, Aravind Eye Foundation.20 According to the Aravind Eye Foundation representative with whom we spoke, Aravind uses donations for purposes other than cataract surgery.21
Room for more funds?
As discussed immediately above, it is clear that donor-funded activities are quite different from Aravind's primary activity of performing cataract surgeries. We are not sure how additional funds will be prioritized between the discussed activities.
- Pre- and post-operative visual acuity. We have relatively little information about the improvement in vision among Aravind's patients. We have based our view that their vision improves on (a) "normal" results for cataract surgeries, (b) comparable rates of adverse events between Aravind patients and patients in the U.K., and (c) an extremely small (though likely random) selection of records of individual patients whose vision significantly improved. More data on Aravind patients' pre- and post-operative vision could offer a more compelling answer to this question.
- What are Aravind's plans for the future? Donors may support Aravind even though it does not need donations to support its operations because they believe that Aravind will use their money wisely to improve eye care in India. We are especially interested in Aravind's plans for testing new methods of providing care.
- Aravind Eye Foundation. Aravind Eye Foundation. http://www.aravindeyefoundation.org/ (accessed March 23, 2012). Archived by WebCite® at http://www.webcitation.org/66OAiSLKF.
- Aravind Eye Care System. Aravind course offerings (PDF).
- Aravind Eye Care System. Clinical quality assessment at Aravind eye hospitals (DOC).
- Aravind Eye Care System. Consolidated income and expenditure account. Aravind has asked us not to publish this document online.
- Aravind Eye Care System. Overview of Aravind Educational Programs (PDF).
- Aravind Eye Care System. Website:
- About us. http://www.aravind.org/aboutus/index.asp (accessed April 21, 2010). Archived by WebCite® at http://www.webcitation.org/5pA0p7Ber.
- Aravind Eye Hospitals: Performance (2007-2008). http://www.aravind.org/annualreport08/performance.htm (accessed April 21, 2010). Archived by WebCite® at http://www.webcitation.org/5pA1vQ1tf.
- Aravind Medical Research Foundation. http://aravind.org/amrf/index.asp (accessed April 21, 2010). Archived by WebCite® at http://www.webcitation.org/5pA15dxZC.
- Aurolab. http://aravind.org/aurolab/index.asp (accessed April 21, 2010). Archived by WebCite® at http://www.webcitation.org/5pA1DgKd6.
- Community outreach. http://www.aravind.org/community/index.asp (accessed April 21, 2010). Archived by WebCite® at http://www.webcitation.org/5pA0rHtuh.
- Education and Training Programmes. http://www.aravind.org/annualreport08/displayreport.aspx?qstring=Educat… (accessed April 21, 2010). Archived by WebCite® at http://www.webcitation.org/5pA2tZxjK.
- Our Hospitals. http://www.aravind.org/hospitals/ourhospitals.asp (accessed April 21, 2010). Archived by WebCite® at http://www.webcitation.org/5pA29fWnw.
- Campbell, Donna. Executive director, Aravind Eye Foundation. Phone conversation with GiveWell (DOC), February 10, 2012.
- Desaia, Parul, D.C. Minassianb, and Angela Reidya. 1999. National cataract surgery survey 1997-8: A report of the results of the clinical outcomes. British Journal of Ophthalmology 83:1336-1340. Abstract available at http://bjo.bmj.com/content/83/12/1336.abstract (accessed April 21, 2010). Archived by WebCite® at http://www.webcitation.org/5pA021fnb.
- John Morgan Eye Center, University of Utah. Visual acuity. http://webvision.med.utah.edu/KallSpatial.html (accessed April 21, 2010). Archived by WebCite® at http://www.webcitation.org/5pA2d224S.
- Prasad, Chitra. Aravind Representative. Email to GiveWell, June 29, 2009.
- Prasad, Chitra. Aravind Representative. Phone conversation with GiveWell, May 7, 2009.
- Rangan, V. Kasturi. 1993. The Aravind Eye Hospital, Madurai, India: In service of sight. Harvard Business School Case Study. Summary available at http://hbr.org/product/aravind-eye-hospital-madurai-india-in-service-fo… (accessed April 21, 2010). Archived by WebCite® at http://www.webcitation.org/5pA0SsEtP.
"Founded in 1976 by Dr. G. Venkataswamy, Aravind Eye Care System today is the largest and most productive eye care facility in the world. From April 2007 to March 2008, about 2.4 million persons have received outpatient eye care and over 285,000 have undergone eye surgeries at the Aravind Eye Hospitals at Madurai, Theni, Tirunelveli, Coimbatore and Puducherry." Aravind Eye Care System, "About Us."
"Through free eye camps, medical teams from each hospital reach patients in rural areas. The teams work closely with local community leaders and service groups to organise the camps. Eye camps are conducted every day of the week. During the year 2006, a total of 1,793 camps were conducted, at which 2,313,398 patients were examined and 270,444 site restoration surgeries have been performed." Aravind Eye Care System, "Community Outreach."
Chitra Prasad, phone call with GiveWell, May 7, 2009.
Chitra Prasad, phone call with GiveWell, May 7, 2009.
"The Aravind Eye Research Institute is run by the Aravind Medical Research Foundation (AMRF). AMRF was formed to investigate issues concerned with causes and treatment of various eye diseases and problems related to delivery of eye care." Aravind Eye Care System, "Aravind Medical Research Foundation."
"Aurolab, the manufacturing division of Aravind Eye Hospital, supplies high quality ophthalmic consumables at affordable prices to developing countries." Aravind Eye Care System, "Aurolab."
In the year ending in March 2008, cataract surgeries accounted for 200,123 of a total of 285,745 surgeries performed at Aravind hospitals (both direct and managed). Aravind Eye Care System, "Aravind Eye Hospitals: Performance (2007-2008)."
Chitra Prasad, phone call with GiveWell, May 7, 2009.
"2,313,398 outpatient visits were handled and 270,444 surgeries were performed at the Aravind Eye Hospitals in 2006. Two-third of the outpatient visits and three-fourth of the surgeries were serviced to the poor, free of cost." Aravind Eye Care System, "Our Hospitals."
1,239,978 for-pay and 372,940 free. Aravind Eye Care System, "Aravind Eye Hospitals: Performance (2007-2008)."
122,900 for-pay and 162,845 free. Aravind Eye Care System, "Aravind Eye Hospitals: Performance (2007-2008)."
In 2007-08, Aravind had total revenues of $17.0 million and expenses of $10.1m. Revenues came primarily from sureries ($10.9m); donations and other awards added up to $1.6m. These figures are from Aravind Eye Care System, "Consolidated Income and Expenditure Account."
Aravind Eye Care System, "Clinical Quality Assessment," Pg 1, Table 1.
Aravind Eye Care System, "Clinical Quality Assessment," Pg 2, Table 3. Data for U.K. patients comes from Desaia, Minassianb, and Reidya 1999, Pg 1339, Tables 6 and 7.
Rangan 1993, Pg 13.
Rangan 1993, Pg 13. For more information on the visual acuity scales below, see John Morgan Eye Center, University of Utah, "Visual Acuity."
- 5 of the 6 patients had no vision pre-surgery. Of these 5, 1 patient's vision improved to 20/20 vision (6/6 on the metric scale), 2 patients improved to 20/40 (6/12), 1 patient to 20/60 (6/18), and 1 patient to 20/120 (6/36).
- 1 patient had 20/400 vision. That individual improved to 20/40 (6/12).
Aravind Eye Care System, "Aravind Eye Hospitals: Performance (2007-2008)."
The hospitals for which Aravind reports costs are Madurai, Coimbatore, Tirunelveli, Theni, Pondy, Laico, and Govel, according to Aravind Eye Care System, "Consolidated Income and Expenditure Account." The hospitals for which Aravind reports completed surgeries are Madurai Theni, Tirunelveli, Coimbatore, Puducherry as well as Aravind Managed Eye hospitals. Madurai, Coimbatore, Tirunelveli, and Theni account for 226,022 surgeries at a cost of $8.2m, or $36 per surgery. We therefore believe that $35 is a reasonable estimate of Aravind's cost per surgery performed.
Aravind Eye Care Systems, "Education and Training Programmes." It's unclear to us whether this figure represents the number of individuals who completed training or were enrolled in training.
"The Aravind Eye Foundation, formerly the Friends of Aravind, was founded in 2000 to support Aravind by networking, building partnerships with academic institutions and sharing best practices with other eye care facilities. Through targeted investment in capacity building, community outreach, medical research, and patient support, Aravind Eye Foundation’s Board works towards realizing Dr. V’s vision of eliminating needless blindness.
Aravind Eye Foundation is a 501 (c) (3) non-profit organization." Aravind Eye Foundation, "Aravind Eye Foundation."
These activities include:
- “Capacity-building. We've trained 270 hospitals in India and the rest of the developing world to help them increase surgical output and deliver more efficient, high quality, patient-centric care. Most hospitals are set up to treat certain ailments in the community, but they don’t use scientific methods to estimate the need for their services, as well as their own capacity. Over time, this results in underutilization of existing resources. The World Health Organization estimates that only 25% of the world's eye care resources are utilized. Through LAICO, Aravind’s healthcare management arm, we have developed processes and tools to address this problem... To date we estimate that we’ve added about 750K cataract surgeries worldwide. They have been funded historically by the International Association for the Prevention of Blindness, the World Health Organization (WHO), the Seva Foundation, and the Lavelle Fund for the Blind. Each of those training segments cost roughly $50,000.
- Giving access to people in rural areas. As part of WHO’s Vision 2020 initiative, Aravind committed to build 100 rural vision centers, which cover 50,000-70,000 people each... Typically, a center costs $25,000 to establish and operate for the first two years. But after that, most are self-sustaining from examination fees and sales of spectacles. To date, we have built 40 centers with contributions from Standard Chartered Bank, the Seva Foundation, the Lavelle Fund for the Blind and private donors.
- Medical research. India is a particularly rich environment for ophthalmological research because of a unique combination of environmental and genetic factors -- plus it’s a very large population. While a US researcher might see a few dozen cases of a particular disease, in India you could see hundreds of examples. Aravind works with some of the leading universities and NGOs in the world -- Johns Hopkins, University of California, Cole Eye Institute, National Eye Institute, University of Paris, London School of Hygiene and Tropical Medicine to name just a few -- on basic and clinical research.
- Patient Support. Some types of eye disease require extensive, long-term treatment that our patients could not afford without support. One complete cycle of treatment -- including surgery, radiation, and chemotherapy -- for a child with retinoblastoma (eye cancer) is about $1,000. We also pay for travel and food for patients traveling to the hospital, and provide free spectacles to school children.”
Donna Campbell, phone conversation with GiveWell, February 10, 2012.