Thulasiraj Ravilla: How low-cost eye care can be world-class

譯者: Sean Liu 審譯者: Lin Su-Wei(林書暐)

Good morning.

各位早安

I've come here to share with you an experiment

我來這想跟各位分享一個實驗成果

of how to get rid of one form of human suffering.

如何擺脫一部分的眾生苦難

It really is a story of Dr. Venkataswamy.

這實際上是一位醫生文卡塔斯瓦米的故事.

His mission and his message is about the Aravind Eye Care System.

他要傳達的使命訊息，是這個亞拉文眼科治療系統.

I think first it's important for us to recognize what it is to be blind.

首先我認為大家要先了解失明代表了什麼.

(Music)

(背景音樂)

Woman: Everywhere I went looking for work, they said no,

婦人:所以我去求職的地方,他們都回答不要我.

what use do we have for a blind woman?

不過是一個看不見的女人,我們有什麼用?

I couldn't thread a needle or see the lice in my hair.

我不能在針頭上穿線或是看見我頭髮裡有蝨子

If an ant fell into my rice, I couldn't see that either.

如果有螞蟻掉到我的飯裡,我也不知道

Thulasiraj Ravilla: Becoming blind is a big part of it,

圖拉斯兒賈-朗維拉:失明是很大條的事情

but I think it also deprives the person of their livelihood, their dignity,

但我覺得這奪走了人原有的生活、尊嚴、

their independence, and their status in the family.

自立能力，還有在家庭中的地位

So she is just one amongst the millions who are blind.

她只是數百萬位盲人中的其中一位

And the irony is that they don't need to be.

諷刺的是他們本來不需要失明的

A simple, well-proven surgery can restore sight to millions,

一個簡單,可信賴的手術就能幫這數百萬人恢復視力

and something even simpler, a pair of glasses, can make millions more see.

還有更簡單的,一副眼鏡就能幫數百萬人看得更清楚

If we add to that the many of us here now

如果我們算上在座的各位其中

who are more productive because they have a pair of glasses,

因為戴了眼鏡而能更有產值

then almost one in five Indians will require eye care,

將近五位印度人中就有一位需要眼科治療

a staggering 200 million people.

驚人的2億人口中

Today, we're reaching not even 10 percent of them.

直到今日,我們只能幫不到其中的百分之十

So this is the context in which Aravind came into existence

而這就是亞拉文所存在的環境

about 30 years back

大約是30年前

as a post-retirement project of Dr. V.

文醫生退休後展開的計畫

He started this with no money.

他一無分文的開始這個工作

He had to mortgage all his life savings

他得抵押所有他的畢生積蓄

to make a bank loan.

來拿到銀行貸款

And over time, we have grown into a network of five hospitals,

然後慢慢的我們已經成長到5間醫院的一個體系

predominately in the state of Tamil Nadu and Puducherry,

以泰米爾納德和旁迪切里為主

and then we added several, what we call Vision Centers

然後我們增加了幾個我們稱作視力中心的地方

as a hub-and-spoke model.

作為轉診的集散中心點

And then more recently we started managing hospitals

然後最近我們開始代管醫院

in other parts of the country

在印度其他地區

and also setting up hospitals in other parts of the world as well.

也在世界上不同的角落設立醫院

The last three decades,

這近30年

we have done about three-and-a-half million surgeries,

我們已經完成350萬人次的手術

a vast majority of them for the poor people.

絕大多數都是替窮人做的

Now, each year we perform about 300,000 surgeries.

現在 我們每年執行約30萬次手術

A typical day at Aravind, we would do about a thousand surgeries,

亞拉文中心一天能做約1000次手術

maybe see about 6,000 patients,

約看診6000人次

send out teams into the villages to examine, bring back patients,

派出團隊到鄉村看診然後帶回病人

lots of telemedicine consultations,

許多次的遠距醫療評估

and, on top of that, do a lot of training,

然後更重要的是完成許多的訓練

both for doctors and technicians who will become the future staff of Aravind.

給亞拉文中心未來的員工 醫生或是技術人員

And then doing this day-in and day-out, and doing it well,

而且我們每天不停地做然後做得很好

requires a lot of inspiration and a lot of hard work.

這需要許多的創意還有大量的苦功

And I think this was possible thanks to the building blocks

而我認為能做到這些要歸功於一些重要的根基

put in place by Dr. V.,

由文醫生所建立起來的

a value system, an efficient delivery process,

一個價值體系,一個高效率的配送程序

and fostering the culture of innovation.

還有鼓勵創新的養成文化

(Music)

(音樂)

Dr. V: I used to sit with the ordinary village man because I am from a village,

文醫生:我常跟鄉村老百姓在一起,因為我同樣來自鄉村

and suddenly you turn around and seem to be in contact with his inner being,

而當你環顧四周,突然間你跟他的內心有所共鳴

you seem to be one with him.

好像你跟他合為一體

Here is a soul which has got all the simplicity of confidence.

有一個完全信任你的靈魂

Doctor, whatever you say, I accept it.

醫生,無論你怎麼說我都接受

An implicit faith in you

對你無瑕的信任

and then you respond to it.

然後你有所回應

Here is an old lady who has got so much faith in me, I must do my best for her.

這裡有一個老婦人對我有這麼大的信心,我一定要給她最好的

When we grow in spiritual consciousness,

當你增長靈智的時候

we identify ourselves with all that is in the world,

我們認同世上所有事物

so there is no exploitation.

所以不存在剝削,

It is ourselves we are helping.

我們所幫助的正是自己

It is ourselves we are healing.

我們所醫治的也是自己

(Applause)

(掌聲)

This helped us build a very ethical and very highly patient-centric organization

這讓我們建立了一個非常有原則而且高度以病人為核心的組織

and systems that support it.

還有支持這樣的各種機制

But on a practical level, you also have to deliver services efficiently,

但是在實務上,你還必須有效率地提供服務

and, odd as it may seem, the inspiration came from McDonald's.

而乍看之下很奇特,這樣的靈感來自於麥當勞

Dr. V: See, McDonald's' concept is simple.

文醫生:麥當勞的概念是很簡單的

They feel they can train people all over the world,

他們覺得他們能訓練世界上所有的人

irrespective of different religions, cultures, all those things,

無論是不同的宗教,文化,各種不同的差異

to produce a product in the same way

用同樣的方式來製造同樣的產品

and deliver it in the same manner

並且用同樣的態度提供服務

in hundreds of places.

在數百個不同的地方

Larry Brilliant: He kept talking about McDonalds and hamburgers,

賴瑞-布里安特:他不斷的提到麥當勞與漢堡

and none of it made any sense to us.

而那些我們一點都不懂

He wanted to create a franchise,

他想要創造一種加盟

a mechanism of delivery of eye care

一個提供眼科醫療的機制

with the efficiency of McDonald's.

有如麥當勞的運作效率

Dr. V: Supposing I'm able to produce eye care,

文醫生:如果我能生產眼科醫療

techniques, methods, all in the same way,

技術方法,都是用同樣的方式

and make it available in every corner of the world.

同時能提供給世界上不同角落

The problem of blindness is gone.

失明的問題就沒了

TR: If you think about it, I think the eyeball is the same,

圖拉斯兒賈-朗維拉:想一下,人的眼球都是一樣的

as American or African,

美國人的或是非洲人的

the problem is the same, the treatment is the same.

問題都是一樣的,治療方法也是一樣的

And yet, why should there be so much variation in quality and in service,

所以那為何有有這麼多不同的服務方式與醫療品質呢

and that was the fundamental principle that we followed

這個就是我們在追求的根本主軸

when we designed the delivery systems.

當我們在規劃配送系統的時候

And, of course, the challenge was that it's a huge problem,

當然,考驗的是這確實是很大的問題

we are talking of millions of people,

我們在考慮的是數百萬人

very little resource to deal with it,

而只有一點點資源來完成目標

and then lots of logistics and affordability issues.

還有許多物流,定價問題要考慮

And then so, one had to constantly innovate.

也就是因為如此,我們必須不斷的創新

And one of the early innovations, which still continues,

而其中一個初期的創新,仍然沿用的

is to create ownership in the community to the problem,

就是設立社區裡的針對問題的所有權

and then engage with them as a partner,

然後對待他們如同夥伴

and here is one such event.

這邊就有一個例子

Here a community camp just organized

有一個社區營地剛成立

by the community themselves,

由這個社區自己組的

where they find a place, organize volunteers,

他們自己找場地,組織義工

and then we'll do our part. You know, check their vision,

然後我們來做我們的事情,也就是 檢查他們的視力

and then you have doctors who you find out what the problem is

然後你讓醫生去發現問題是什麼

and then determine what further testing should be done,

然後決定那些進一步的檢查該去處理

and then those tests are done by technicians

然後由技術人員去做這些檢查

who check for glasses,

有的是檢查眼鏡

or check for glaucoma.

有的是檢查青光眼

And then, with all these results, the doctor makes a final diagnosis,

然後根據這些檢查結果醫生做出最後的診斷

and then prescribes a line of treatment,

然後列出治療的處方

and if they need a pair of glasses, they are available right there at the camp site,

如果需要一副眼鏡,在營地現場就有提供

usually under a tree.

通常是在樹下

But they get glasses in the frames of their choice,

還有他們自己選好鏡框

and that's very important because I think glasses,

這點非常重要 因為我認為眼鏡

in addition to helping people see,

除了幫助人看見

is also a fashion statement, and they're willing to pay for it.

同時也是一種品味的表示,而他們願意為此付費

So they get it in about 20 minutes

這樣他們在20分鐘左右拿到眼鏡

and those who require surgery, are counseled,

那些需要手術的則給予建議

and then there are buses waiting,

然後有巴士在那等著

which will transport them to the base hospital.

會載他們去基地醫院

And if it was not for this kind of logistics and support,

如果不是使用這樣的物流跟協助

many people like this would probably never get services,

許多人可能根本無法得到服務

and certainly not when they most need it.

尤其是在他們最需要的時候

They receive surgery the following day,

他們在隔天接受手術

and then they will stay for a day or two,

然後他們會住院一兩天

and then they are put back on the buses

然後送他們上巴士

to be taken back to where they came from,

帶他們回到他們來的地方

and where their families will be waiting to take them back home.

那裏他們的家人會在那等著接他們回家

(Applause)

(掌聲)

And this happens several thousand times each year.

這樣的方式每年發生數千次

It may sound impressive that we're seeing lots of patients,

乍聽之下會覺得很驚人 我們看了這麼多的病人

very efficient process,

非常有效率的程序

but we looked at, are we solving the problem?

但是我們仔細看.我們解決問題了嗎?

We did a study, a scientifically designed process,

我們做過一個研究,一個科學規劃過的程序

and then, to our dismay,

但是讓我們失望的是

we found this was only reaching seven percent of those in need,

我們發現這樣只接觸到百分之七的有需要的人

and we're not adequately addressing more, bigger problems.

我們並沒有針對到更大的問題

So we had to do something different,

所以我們必須做些不同的事情

so we set up what we call primary eye care centers, vision centers.

因此我們設立了稱作初級眼科治療中心,視力中心

These are truly paperless offices

那是完全無紙化中心

with completely electronic medical records and so on.

完全使用電子醫療紀錄等等

They receive comprehensive eye exams.

他們能記錄複雜的眼科檢查

We kind of changed the simple digital camera into a retinal camera,

我們可說是把簡單的數位相機改成眼底攝影相機

and then every patient gets their teleconsultation with a doctor.

然後每個病人透過遠端看診面對醫生

The effect of this has been that, within the first year,

這樣的效果是,在第一年

we really had a 40 percent penetration in the market that it served,

我們就拿下市場上百分之四十的比例

which is over 50,000 people.

也就是超過了五萬人

And the second year went up to 75 percent.

第二年就達到了百分之七十五

So I think we have a process by which

所以我覺得我們有一個系統真的能

we can really penetrate into the market

滲透進入市場

and reach everyone who needs it,

並且服務到每一個需要的人

and in this process of using technology, make sure

在這個使用科技的過程

that most don't need to come to the base hospital.

找出大多數人不需要去基地醫院

And how much will they pay for this?

究竟他們需要付多少錢呢?

We fixed the pricing, taking into account

我們固定收費,並且以

what they would save in bus fare in coming to a city,

他們能省到的往來城市的巴士開銷為準

so they pay about 20 rupees, and that's good for three consultations.

因此他們付大約15元台幣,而且包含三次看診.

(Applause)

(掌聲)

The other challenge was, how do you give high-tech

另一個挑戰則是,如何提供高科技

or more advanced treatment and care?

或是更先進的醫療與照護?

We designed a van with a VSAT,

我們設計了一個裝有碟型衛星天線的箱型車

which sends out images of patients to the base hospital

能夠發送病人的影像給基地醫院

where it is diagnosed,

在那邊完成診斷

and then as the patient is waiting, the report goes back to the patient,

然後當病人在等待的時候,報告就能傳送回給病人

it gets printed out, the patient gets it,

列印出來,病人就拿到了

and then gets a consultation about what they should be doing --

然後他們會從諮詢中知道他們該做什麼

I mean, go see a doctor or come back after six months,

我的意思是,去看個醫生或是六個月後再過來這樣的建議

and then this happens as a way of

所以這樣的方式

bridging the technology competence.

連結科技的能力

So the impact of all this has been essentially one of growing the market,

這些影響是其中一個原因帶動市場的成長

because it focused on the non-customer,

因為我們專注在非付費客戶上

and then by reaching the unreached,

然後接觸到原本接觸不到的人

we're able to significantly grow the market.

我們能夠明顯的成長整個市場

The other aspect is how do you deal with this efficiently

另一方面就是你如何有效率的對應事情

when you have very few ophthalmologists?

當你只有很少的眼科專科醫師的時候?

So what is in this video is a surgeon operating,

這影片裡是一個外科醫生手術的畫面

and then you see on the other side,

你會看到另一邊

another patient is getting ready.

另一個病人已經準備好

So, as they finish the surgery,

所以 當他們完成手術時

they just swing the microscope over,

他們直接把顯微鏡換過去

the tables are placed so that their distance is just right,

手術台擺放的正好距離是剛好的

and then we need to do this, because, by doing this kind of process,

我們需要這樣做,因為這樣的流程

we're able to more than quadruple the productivity of the surgeon.

我們能提高外科醫生四倍以上的產能

And then to support the surgeon,

為了能協助外科醫生

we require a certain workforce.

我們需要一群人協助

And then we focused on village girls that we recruited,

然後我們專門招募鄉村女孩

and then they really are the backbone of the organization.

他們是整個組織的骨幹

They do almost all of the skill-based routine tasks.

他們執行幾乎所有需要技巧的例行工作

They do one thing at a time. They do it extremely well.

他們一次做一件事情,他們做的相當的好

With the result we have very high productivity,

這樣的結果我們得到了非常高的產能

very high quality at very, very low cost.

非常好的醫療品質同時成本非常的低

So, putting all this together, what really happened was

所以整個來說,真正的結果是

the productivity of our staff was

我們的員工的生產力

significantly higher than anyone else.

遠高於其他任何人

(Applause)

(掌聲)

This is a very busy table,

這是一個非常忙碌的檯子

but what this really is conveying is that,

但是實際上傳遞的

when it comes to quality, we have put in

就醫療品質來說,我們放入了

very good quality-assurance systems.

一個非常好的品質管理系統

As a result, our complications are significantly lower

因此我們這手術的併發症是相當的低的

than what has been reported in the United Kingdom,

比在英國手術的併發症報告還低

and you don't see those kind of numbers very often.

而你不容易看到這樣的數據

(Applause)

(掌聲)

So the final part of the puzzle is,

這個謎題的最後一部份是

how do you make all this work financially,

該如何讓這樣的工作收支平衡

especially when the people can't pay for it?

尤其是當這些人無法付錢的時候

So what we did was, we gave away a lot of it for free,

我們所做的其實是我們提供許多免費服務

and then those who pay, I mean, they paid local market rates,

然後那些付錢的人,我指的是,他們以當地市價支付

nothing more, and often much less.

不會比較高,而且通常是便宜很多

And we were helped by the market inefficiency.

然後我們得到市場低效的幫助

I think that has been a big savior, even now.

我想即使至今都是超級省錢王

And, of course, one needs the mindset to be wanting to give away

當然我們需要保持樂於付出的心態

what you have as a surplus.

我們所擁有的只是額外的

The result has been, over the years,

多年來這樣的成果是

the expenditure has increased with volumes.

開銷與客流量一同增加

The revenues increase at a higher level,

收益增加到更高的比例

giving us a healthy margin

給了我們很棒的利差

while you're treating a large number of people for free.

當你免費治療大量的人的時候

I think in absolute terms,

我指的是絕對的價值

last year we earned about 20-odd million dollars,

去年我們賺了約2千萬美金

spent about 13 million, with over a 40 percent EBITA.

花了1千3百萬美金,這樣大約是百分之40的淨利加上孳息

(Applause)

(掌聲)

But this really requires going beyond what we do,

要做到這樣需要我們超越極限

or what we have done,

或是挑戰我們自己

if you really want to achieve solving this problem of blindness.

如果你真的想解決失明這種問題

And what we did was a couple of very counter-intuitive things.

我們所做的不過是一些違反直覺的事

We created competition for ourselves,

我們給自己帶來競爭

and then we made eye care affordable

然後我們讓眼科治療平價化

by making low-cost consumables.

透過製作低成本的消費品

We proactively and systematically

我們自發的有系統的

promoted these practices to many hospitals in India,

在印度的許多醫院推廣這些實務經驗

many in our own backyards and then in other parts of the world as well.

在我們自家後院然後也在世界上不同的角落

The impact of this has been that these hospitals,

這樣的效果是這那些醫院

in the second year after our consultation,

在我們輔導的第二年

are double their output

就提高產能兩倍

and then achieve financial recovery as well.

然後同樣財務上回收了那些投資

The other part was how do you address

另一部分則是你如何面對

this increase in cost of technology?

技術設備成本的增加

There was a time when we failed to negotiate

曾有一次我們沒辦法

the [intra-ocular lens] prices to be at affordable levels,

讓人工水晶體的價格談到可以接受的低

so we set up a manufacturing unit.

所以我們成立製造部門

And then, over time, we were able to bring down the cost significantly

然後沒多久我們就開始把成本降得更低

to about two percent of what it used to be when we started out.

比一開始我們的成本還低百分之二

Today, we believe we have about seven percent of the global market,

今天我們相信我們佔了全球市場的百分之七

and they're used in about 120-odd countries.

然後在120多個國家中使用

To conclude, I mean, what we do, does it have a broader relevance,

總結來說,我們所做的究竟有更廣的影響

or is it just India or developing countries?

或僅只在印度或是一些開發中國家?

So to address this, we studied UK versus Aravind.

為了解答這個問題我們研究了英國跟亞拉文的差別

What it shows is that we do roughly about 60 percent

顯示出來我們所做大約是百分之六十

of the volume of what the UK does,

的全英國所做的量

near a half-million surgeries as a whole country.

英國全境作了將近50萬次手術

And we do about 300,000.

而我們做大約30萬次

And then we train about 50 ophthalmologists

然後我們有大約50位眼科專科醫生

against the 70 trained by them,

英國則有70位眼科專科醫生

comparable quality, both in training and in patient care.

差不多相等的醫療品質就訓練跟病人照護上來比

So we're really comparing apples to apples.

所以可以說我們是差不多的

We looked at cost.

我們來看看成本

(Laughter)

(笑聲)

(Applause)

(掌聲)

So, I think it is simple to say

我想簡單的說

just because the U.K. isn't India the difference is happening.

只因為英國不是印度 所以我們做到了

I think there is more to it.

我看不只是這樣

I mean, I think one has to look at other aspects as well.

我認為你該去看其他面

Maybe there is --

或許像是

the solution to the cost could be in productivity,

達成這樣低成本的方案是可以複製的

maybe in efficiency, in the clinical process,

在效率上在臨床流程上

or in how much they pay for the lenses or consumables,

或是在病人買的眼鏡或是其他東西的價格上

or regulations, their defensive practice.

或是法規,他們的防衛方式

So, I think decoding this can probably bring

所以我認為把這些徹底學會了或許能

answers to most developed countries

讓許多已開發國家

including the U.S., and maybe

包含美國,還有

Obama's ratings can go up again.

讓美國總統歐巴馬的支持度再提升一次

(Laughter)

(笑聲)

Another insight, which, again, I want to leave with you,

另一個心得我想帶給你們的是

in conditions where the problem is very large,

當這問題考驗著非常多人的時候

which cuts across all economic strata,

包含了從窮人到有錢人

where we have a good solution,

我們找到了很棒的解答

I think the process I described,

我認為我描述的流程

you know, productivity, quality, patient-centered care,

你們看到的產能,品質,以病人為核心的照護

can give an answer,

已經提出了解答

and there are many which fit this paradigm.

而且還有許多符合這樣的類型

You take dentistry, hearing aid, maternity and so on.

你可以拿牙科,助聽器,育兒等等來看

There are many where this paradigm can now play,

許多都能運用這個典範

but I think probably one of the most challenging things

而我認為應該是其中最難的

is on the softer side.

是在內心深處

Now, how do you create compassion?

如今你怎要找到熱情?

Now, how do you make people own the problem,

如今你要如何讓人扛起這個問題

want to do something about it?

讓他們覺得,這是他們想要做的東西?

There are a bit harder issues.

那是比較難的部分

And I'm sure people in this crowd can probably find the solutions to these.

我相信TED的各位應該找的到這問題的解答

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

在結束演說的同時,我用這段話,勉勵各位

Dr. V: When you grow in spiritual consciousness,

V醫生:當你增長靈智的時候

we identify with all that is in the world

我們認同世上所有事物

so there is no exploitation.

所以不存在剝削,

It is ourselves we are helping.

我們所幫助的正是自己

It is ourselves we are healing.

我們所醫治的也是自己

TR: Thank you very much.

圖拉斯兒賈 朗維拉:非常感謝

(Applause)

(掌聲)