Lecture: COVID-19 Second Wave: Building upon First Wave Lessons and Preparing for Managing Future Uncertainty

[Phanindra] Good evening, everybody, I’m Phanindra from Vision 2020 The Right to Sight India. I welcome you to this webinar on Building Upon the First COVID Wave Lessons and Preparing for Managing the Uncertainty in the Coming Time. This webinar is essentially a follow up webinar that we have conducted a couple of weeks ago. We will run this session for an hour and a half. I’m now requesting Aaron to take over and start the proceedings of this webinar, please. Thank you so much.

[Aaron] Thank you so much, Mr. Phanindra, for the introduction. So to get things started, we have five topics that are lined up for today. And for the first topic we will having Dr. Venkatesh from the Aravind Eye Care System Group, who will be speaking about managing capacity and productivity.

The goal of these topics, as suggested, was to go ahead and identify how hospitals can actually manage uncertainty in this course of the second wave. And even prepare themself in the likely event that there was a third wave that would be coming. We all know that COVID-19 has actually raced across the country and has left a lot of glaring gaps and exposed the issues that are there and are prevalent in the healthcare system. And we do feel that it is important for all of us to work together to try and see what we can learn from each other in these trying times.

I request Dr. R. Venkatesh to kindly start the presentation for managing capacity and productivity. Thank you so much, sir.

[Venkatesh] Thank you. Thank you, Aaron, and thank you, Phanindra, for organizing this on behalf of Vision 2020. This is a very important part of how do you take care of the capacity which you have built up? And also a high, productive organization in a pandemic. I’ll be touching upon some of our learnings.

I’m sure most of you who are attending will know about Aravind which started 45 years back. Now we’ve got seven tertiary care centers, seven secondary care centers, community centers, and of course, a chain of primary eye care centers, visions centers, in 91 places now. And on average, we see close to 13 to almost 15,000 outpatients every day and do more than 1,500 surgeries. Through outreach we bring lots of patients and a training center for a lot of residents, fellows and also people who undergo short-term training and administration and things like that. It’s a highly productive organization.

Last year the end of March-April, when the outbreak happened, we all had to put safety as the first priority. We all had to do all these things which we have discussed, about social distancing, hygiene, masking. And how do you make sure you change the behavior of not only the patients, but also your staff? We had to do a lot of things to work around it. What you see here, we had to even remove the central seating so that now you couldn’t tie or something like that. Finally they keep a patient sheet or X-ray or bags, that also has to be cleaned up. We had to do a lot of things and processes around this so that we can function smoothly and also get the patients into the system who really need care during those periods.

I’m just going to share with you an interesting date which we just submitted for WHO journal, which shows between 2019 and 2020 what’s happening. Now when you had total lockdown, the last week of April to May 3rd, the tertiary care centers were seeing 5% and secondary care 10%. And when the lockdown phase two, when your own vehicle was opened up from 4th of May to 17th of May, if you see the vision centers opened. The vision centers were closed during this period because the staff couldn’t come. Immediately the volume jumped to 50%. And if you see phase three, when own vehicles and taxis and autos started running, the OP went to 60% for vision centers but the base hospital it was just 18 and 30%. That showed the primary care centers are accessible to people and this we really learned during the pandemic. Following the unlock, if you see the hospitals had 50-70%, whereas the secondary and tertiary were almost touching 90%.

And then you know what happened in November, December, January, February, there was a significant increase in the volume. I think we saw this across the country. In the lockdown, 5% gradually increased unlock. And during November, December and post lockdown here in south of India, we were doing 140% work. It was terrific to manage some of the daily load, both in the outpatient and surgery. And now in the second lockdown, we are back to 18% of our normal volume. The point we have to keep in mind is this can go up and down like this, we have to be prepared for another 140 or 150% once the second wave eases and before we get the third wave. I think, unfortunately, I’m sure we have to pray that we don’t get another wave.

This is just to show you what happened in these couple of weeks when Tirunelveli and Pondicherry went to lockdown. This is the three centers where vision centers are all actively running. If you see the vision center volume is almost more than your paying. And significantly more than your free outpatient. This includes both new and review. If you see Tirunelveli, it’s almost there. In Pondicherry, also, it’s slightly less because we are still not able to run all of our centers because of lack of transport to some of our staff. This again shows that accessibility is so important in a condition like this where people are really easy to go or walk or go in an Uber or in a cycle to a center.

One thing we started, even when we had the lockdown is, we were preparing for the big drought. Our IT team did a lot of work to bring up the scheduling software which really helped when we had that 100%, 120-140% coming back into the system in November, December. This is not basically appointment, it is basically you have to schedule for that day the particular time. So 9-10 will allow 15 patients for one unit. Three units will have 45 patients slot. This helped us to reduce the overcrowding in the hospital and in the clinic. This is one thing which we did immediately.

The other thing which I want to stress is some of the high risk patients, when they went to vision centers, they were not able to get an entry into Pondicherry. From Kumbakonam to Pondicherry you need an E pass when the lockdown was happening. What we did was we facilitated by giving them a letter which were printed in the vision center. Somebody with a phacolytic glaucoma, a corneal ulcer, something which needs emergency care, so we would send them a letter like this. And now also we are doing it, see this letter is dated from May 19, 2021. So even in this lockdown, this system is helping us to get the high risk patients comfortably into the system.

This is one thing, again, we learned during the lockdown, the previous lockdown which we still follow now. Usually patients who are referred from vision centers for cataract surgery, they come the previous day, have their tests done, next day surgery, third day follow up. What we did was we tried to do all the investigations in the vision center except biometry. We went for a additional premium they had taken. And then they come for surgery only on the day of surgery, they go back the same afternoon because they’ve hired a taxi, they’ve taken an auto rickshaw to come, or on a bike. They go back next day to review there. This learning is really helping us now and this is significantly reducing the carbon footprint also, which we are interested in.

Day one follow up, we were doing a few day one follow ups in vision centers, but during the pandemic we learned that why should they come back to the base hospital? Why can’t they follow up there? Doctors are doing telemedicine to all the vision centers. What can we miss? We can’t miss anything unless there are significant problems. Any complications we made them wait in the hospital. If they were a noncomplicated surgery, then we ask them to go to the vision center the next day. Almost 60% of them were able to go to vision centers because around Pondicherry we had these 14 centers which were covered in most of the geographical area. This also, again, helped to reduce the crowd coming back to the hospital and during the peak crowd it also helped a lot.

This is one example, I’m just sharing with you, because we had done a lot of incremental changes when the crowd came back into the system. This is one idea which we did. Again, this idea came from a biometry nurse. She said the volume is really high, normally they do 100-120, it was going beyond 200. Because daily we had to do more than 150 surgeries. She said mature cataracts when they come, I put them on an IOL master, then I have to again repeat an immersion biometry. Why can’t we separate for mature cataract? I think it’s a great idea, you try it. And then two or three days they tried, the feedback was so good that almost 40-50 of them had mature cataract which was segregated. And this simple change made a big difference in the life of patients and the staff.

There are so many things like that, which incrementally I think many organizations would have changed and from that learning we should take on to how to tackle the second wave of patients which is going to come.

Tele consultancy it’s happening through vision centers but we tried, it wasn’t very successful for somebody as now from home connecting and things like that. But they always went to vision centers. So we thought, why don’t we do from shared medical appointment for high risk patients who couldn’t come back for follow up.

(people in video speaking in foreign language)

Here you’re seeing a glaucoma doctor interacting with three to five glaucoma patients with the help of vision centers. If they go back there, they have their pressure checked, they have their medicines in hand, and then the vision center staff helps in interacting with the glaucoma specialist. This is one thing which we tried and it really helped us and we’ve done several high risk patients follow up through this.

This is one thing which is interesting which piloted, I’m just sharing with you quickly. We wanted to call it an uberisation of eyecare. Now in this pandemic everything come home, so we thought why don’t we take a vaccinated and all of the PPE technician to the home of some of the patients. Like this patient was not able to follow up, again a high risk patient, a glaucoma patient, a diabetic retinopathy patient, you can see him doing eye care. And then we have developed this portable virtual reality perimetry. So his perimetry is also done. And then he takes the brilliant fundus images with the Remedio Fundus on Phone. And then the images are shared with the base hospital and the report is done by the doctor, and the opinion is given.

Like this we did a lot of things in patient care, but the point is only a minimal number of people are involved in patient care in pandemic. We didn’t want this good crisis to go to waste. So we had a lot of other activities for our doctors, in the form of writeathons where they had to take their thesis into publication. For the first time, Pondicherry crossed 100 publications in 2019. And of course, across the Aravind system we did very well in publication. We did a lot of hackathons, like three or four hackathons with problems of COVID and then how to solve it. Then all this was shared across social media and publications across India. And many of them, like the eye opener, slit lamp shield, became very popular among ophthalmologists. We did video editing workshops for people to make award-winning movies and we had a lot of activities for our NMPs also. Like this we had to use our human resource also very actively and usefully so that now we always take this dream long, thank you.

[Aaron] Thank you so much, sir, for that beautifully summarized presentation. And I think just by going across some of the points that you’ve highlighted, I think there will be a lot of learning to everybody present here. Now we have some set of questions that were already asked by our members, which I will be addressing to you, sir.

The first question is, what were some of the major hurdles for switching to an appointment-based system? And what would you advise for medium and smaller hospitals in switching to an appointment-based system?

[Venkatesh] The main hurdle was everybody knows that Aravind is a non-appointment system. So anybody walks in, they can come into the clinic and register from morning to evening. When we said that you had to schedule, it was a real shock for some people. So they had to go and wait in another line where they had to schedule a time. Because we had to publicize this through social media, through our patient network, people who are coming back for review, we sent the messages. But still the IT is still something, we said, “Go to your app, do all this.” But it’s not easy for somebody like a layman who comes into a system like Aravind. So we have to facilitate them. That was a challenge to begin with.

What we did was we said we’ll try a really challenging population, we tried first the free hospital patient, even in Pondicherry and other hospitals. We were able to schedule but the only thing, there was another line waiting outside so that they get a time slot and then they have to wait for the time slot to enter into the hospital. Which was not the normal way, so it’s basically not appointment, but like a time schedule where you’ll enter. You would come at 7:30, but you’ll get a schedule only at 9:30. But this really helped us to manage throughout inside hospital. So we were able to maintain a lot of social distancing, and the hygiene, and all these practices. And also we were able to comfortably see that other than the 40% jump, which we had. And I’m sure many of the hospitals also had that.

Again, if we’re going to have a second wave of patients, after the second wave of COVID comes down, scheduling is going to really help us. We are still building on that, seeing how to do it comfortably. Even in this low volume, we are continuing to do that scheduling.

[Aaron] All right, sir, thank you so much. The next question would be, have you tried incorporating this scheduling system at the vision center level? And if yes, how did you go about the same, sir?

[Venkatesh] Not for vision center, but vision center is normally they see 20-25 patients, they’re doing comfortably as they walk in at different front time points. But people who come from vision center to base hospital, we are asking them to schedule. They are now helping them to schedule the times so that they get a printout tied to the vision center that your time schedule is 9:15 to 9:30 you can enter. Like your passport thing, you get a small printout. That printout is facilitated by the vision center staff.

[Aaron] All right, sir. And there’s one more question that had come from one of our members. Who’s question, do you feel testing for COVID-19 should be mandatory for all IPD cases?

[Venkatesh] This question has been there from the first wave, or no prompting, last March-April. And IJO or AIOS came up with a very good guidelines that for regular cataract surgery, where there’s minimal time with the patients, we don’t have to do a COVID testing. But this is kind of challenging even now. Even now when we do a COVID test for somebody, like a retinal surgery, orbital surgery. Almost 2-3% are positive, so they are already in the OPD, you’re examining them, so you’re doing all these things. Any major surgeries we still recommend to have a COVID testing. Wherever there is longer duration of surgery, whether it’s involved and things like that, a lot of aerosols involved. But normally for a cataract surgery we’re not doing a COVID test.

[Aaron] All right, sir, thank you so much. And so the last question from the pre-panel questions are, if testing for COVID-19 is not available as a service within a hospital, how would you recommend an eye hospital go about requesting patients scheduled for surgery to get tested for COVID, as hospital-based infections would also be a concern? Lot of patients would have a lot of hesitancy to go to a general hospital at this point in time to get tested. How would you address that concern, sir?

[Venkatesh] That’s a challenge from day one. Now people are saying they are totally COVID-free and you make them do a COVID test and they can get COVID during the testing. That is what is happening. That is why the government now wants us coming with regulation to say how we can avoid unnecessary testing. Or for applying or for regular elective surgeries. Because all this has added burden to already the testing authorities for patients who are symptomatic now who really need the testing, you don’t have a kit now. So there will be a crisis for testing kits tomorrow. Because that’s where we’re already saying how are you going to look into all these aspects, even for lab investigations there is going to be a crisis. We have to keep all that in mind. In fact, we don’t have a testing center. We are sending them to the nearest medical college where our paying patients have to pay a certain amount and the free patients, depending on the government charges, they charge and then they test them and give us a report in 24 hours.

[Aaron] All right, sir, thank you so much for the preset of questions. I would be following up with Q&A that would be coming from all the attendees, post all the five presentations once it’s done. Thank you so much for your valuable learning and advice. And we definitely hope that the entire Aravind team is doing a fantastic job in these difficult, trying times.

With that we come to an end to the first topic which was managing capacity and productivity. We’d now go into a very critical function that would be discussed, which is critical to every hospital for inventory, supplies, and consumables. How do hospitals go ahead and work and balance the act of maintaining their financial liquidity, at the same time make sure they’re not overstocked or understocked. And for that, would requisition Mr. Anjaneyulu from LV Prasad Eye Network to kindly come and make a presentation.

[Anjaneyulu] Good evening, everyone. Thank you, Aaron, for the nice introduction. What I would say is, what we have learned from this first wave pandemic, the healthcare organizations are not ready for the massive wave of demand and supply. Actually, we would not know about the pandemic beforehand and then would not know how we can deal with this kind of emergency. And then we start here, at LV Prasad, the supply chain is a support function. We called all the people, the stakeholders, particularly when we are dealing with patients, we have to take care of all the stakeholders into account. And then we called for a meeting and discussed how we go about it. How you want to run your hospital, what precautions you are to take, and we have developed the SOPs, Standard Operating Procedures, and what to do and what not to do. And how we deal with the emergency and all. 35% of the hospital expenses are for the supplies through supplies in any hospital expenses. Supply chain is also a very important function. It has to work in coordination with all other stakeholders, particularly in patient care.

What we had started in the beginning is we called all the stakeholders and then see how we want to run the hospital. You want to run the hospital in full capacity and based on the numbers. Initially in all our centers when the pre pandemic situation, we see 2,000 patients all around network. We have 20 secondary care locations, three tertiary care locations, one center of excellence, and 200 primary care vision centers. How we want to function, that is the main focus. And then we formed three groups, actually A, B, C, the initial stages, where two days each team will work. And all six days, three teams will work. And if there is any problem with one team, the other team will take over and start working.

During the pandemic, there is national lockdown, all over the nation there is a lockdown. And there is no, as Dr. Venkatesh told, there is only 18%, 20% foot fall. So based on the foot fall only, we had to work. And then how much inventory is required for our operations? So based on that we had to plan and what would be our consumption and then who are the people? Regularly our operations, we do not have any problem with supplies. The more important thing is the COVID supplies. COVID supplies are very new to any of the organization, so we do not know where to get and what kind of PPE kits and what kind of N95 masks we need to use in the initial stages.

Later on, a lot of people came into the business, in general. And then more and more people came into the business and then we see a lot of change in the behavior of the suppliers. And then we get, for real, a surprise. Initially we have got for inflated prices, 400%, 200% inflated prices of the PPE kits as well as the N95 masks. Slowly, once we developed our inside resources in India, more and more people start producing the N95 mask and PPE kits. And now we have a very good situation where we are stabilized and now we are getting for a reasonable cost. So that is very important.

And what we have learned is how to reduce the cost and efficient operations. First of all, operation efficiency and cost reduction is two important steps to what we have to do. How we can reduce the cost? Because we have a network of hospitals, for regular supplies we have a decentralized procurement system. But for COVID materials we have a centralized procurement system where we can better bargain with the suppliers. And then get a better price. Because we, actually, maintain dashboards, weekly consumption statements, and get requirements from different hospitals. And how much they require for entire day and then based on that we negotiate with the suppliers and get the supplies in a reasonable cost.

On a daily basis, we ask everyone of all our hospitals to share with us our dashboards. Like how many numbers you have opening balance, how many you got that day, and how many you consume, and then what is the closing balance? This way we constantly monitor for some time until we stabilize in regard to all the supplies in place without any hurdle. That is what we have done in the initial stages.

And the other thing is, we have done regular consumables. We have cataract consumables like Gravity cases, Laret cases, and Infiniti cases. And I was also, we constantly monitor how the consumption patterns are. And based on the consumption patterns we slowly increased the consumptions. And then supplies also, we increased. And after a few days, what happened, slowly the foot fall increased from 18% to 20%, then 35%, 40%. And during October through December, we start seeing more number of patients and based on our consumption levels, we started increasing all our inventories.

And another important thing is evaluating the vendor performance is one of the most important aspect. Where we regularly identify the reliable vendors and get commitment for faster supplies. Some people they say they will supply the coats, and then they ask for an advance payment. And after some time, they say that we cannot supply because we don’t have the supplies available with us. So we should be very careful whether these vendors are regular vendors, or they came for the purpose and then they leave. We have to be very careful and we have to manage the vendors in such a way that they value the business and then they give a faster supply. As well as, this will only happen when you have a good relationship with the vendors.

And then we have almost 10-15 years old vendors available in our vendors list. This will be only possible when you make the payments on time and then we’ll have a good vendor relationship so that this will help us in finding a way during the difficult times. That is one thing.

And one more thing is maintaining stocks. More than economic are the quantity, particularly for the critical consumables like surgery consumables as well as COVID-19 consumables. Stocks, you have different types of stocks. You have stockable items, you have regular items, you have stocks on consignment basis and all. Stockable items are those items which you can stock and based on your consumption patterns. And then you will see, you have a reorder level and based on the reorder level, so you keep the stocks in your operations. And usually the ideal stockable item would be one month consumption as a stock. And then some buffer, 15-20% buffer, in case of lockdowns when we have lockdown. And all the things will be closed and then it’s very difficult for you to get the stocks. When you know that there is going to be a lockdown, then immediately you get the supplies and then you keep in your stocks.

Another thing is regular stocks. You have a housekeeping consumable, stationary items and all these things. Usually that will happen in your town or city where you can just order and the next day or third day, you will get within a few distant time in the earlier days. But now, because of uncertainty and lockdowns and then very few hours of time is open for them to distribute the things. So what will happen is it will be better if you have 15 days stock of these regular consumable items.

And then one more critical thing is most of the IOLs and then cataract consumables are on consignment basis. Consignment basis is where the vendor will keep the stocks in your place and after consumption, they will write the bill and then you need to pay. So you need not keep any stock with you and then the vendor himself will keep all the consumed stock, replace the consumed stock, and will keep the initial stocks with us and then suppose the 50 IOLs are now put in the initial stocks. So if you consume 30 stocks over a period of 15 days, then they will write bill for the 15 consumed lenses and then again they’ll replace those 15 lenses. If 50 lenses are intact at any point of time. The same way for all cataract consumables, we maintain stocks on a consignment basis. This will help in keeping all the money, to keep the entire stocks, we do not know which IOL is required for you for what patient. What will happen, it is very difficult for you to keep all the diopter lenses in your stock and then you have to unnecessarily make the payments. That is a thing.

And one more important thing is transportation. Particularly you have different locations and usually in the pre-COVID conditions we have a GST in place, where the supplies are from the local base hospital. Now what is happening is we have a central procurement system, particularly for COVID materials. Because unless you have a good quantity, they will not give you a good price. Particularly for the COVID consumables. What we have done is we have taken the requirement from all the centers and then we negotiated with the supplier centrally from Hyderabad. And then we have moved all the supplies to all the locations as per their requirements.

There are two other important things is we have speed of data and reporting, accurate data and inventory is very critical. Having the right systems that provide accurate inventory is critical to our supply, so we have a SAP system in place. We know what stock is available in different places. We have how much stock we have in different locations. So it is easy to move the stocks from one place to another when there is a shortage in a particular place. And another important thing is build your own capabilities where possible. Our innovation engineering team, they came up with an open source design advisor we use for the COVID consumable. What we have done is we have procured for a very lesser price and we have distributed for all our staff in our network. And we have distributed the police as well as the municipal staff also. This is how we can manage inventory in all the difficult times.

We don’t know how long we’ll have to continue like this and how the pandemic will not wait for us and then patients need and we have to make limited steps to maintain financial as well as operational stability. With this, I will conclude my presentation and will open for questions and answers now.

[Aaron] Yes, sir, thank you so much. We know there’s so much more that is to be said in such a vast topic. In the interest of time we try to see whatever is possible so that it can be of benefit to all our members.

Two questions for you, the first question is in case of lockdowns, how should we go about stocking medicines, spectacles, and lenses at the vision center as well as base hospital? What do you think is the right approach for this?

[Anjaneyulu] Usually the general concept is if you can stock one month for your drugs and medicines. Preferably you’re to ask the vendor to supply the long expiry date medicines. Because if you don’t consume in a particular time, then it would get expired and it is a loss of money. What we can ask is the vendor, if you can supply the long expiry drugs, particularly drugs and medicines.

And then spectacles and lenses. Spectacles powers you know you have spectacle frames as well as lenses. All the regular ready-made lenses you can keep in the vision center. In the base hospital it will be more cylinders and then other lenses which you can immediately get and fix it. If your consumption is handled and then you can put a 50 days buffer. 150 you keep, it will be easy for us run the operations smoothly without any problem.

[Aaron] All right, sir, thank you so much. And so the next question is what approach or parameters do we need to follow to keep a specific number of IOLs of each power at the base hospital in times like these?

[Anjaneyulu] Actually if there is a stock on consignment basis, most of the hospitals, we have most of the vendors have agreed to keep the stocks on consignment for IOLs. Because we do not know which power get consumed. And we do not know what patient requests which power. Ideally it would be regular power from 18 diopter to 26 with fine for diopter range in all the centers, 33 each if you don’t have a consignment stock in place. That will be an ideal situation. And if there is any customer’s lens or in any low IOP lenses, you can always ask the supplier to supply on demand.

Patients also, you can inform that this particular diopter lens is not available, you have to wait for some days until you get this particular lens. You are to wait and then get the surgery done.

[Aaron] Thank you so much, sir, we’ll be following up with more Q&A once all the sessions are completed. Thank you so much for your valuable input and learning for managing inventory in these difficult times. Thank you, sir.

[Anjaneylul] Thank you. Thank you.

[Aaron] With that we come to a close to the second topic. Now we would be going to the next topic which is one of the most critical functions in any eye hospital. And it constitutes the largest expense on the balance sheet of every organization, which is the human resource component. In these difficult times, we would look forward to speaking to Dr. Madhu who’s truly a pioneer in this field and had made a complete turn around as mentioned by Dr. Phanindra earlier for Sitapur Eye Hospital. We are privileged to have her learning here. And she will be discussing about retaining of HR and HR management practices in the time of COVID. With a lot of people having so many questions and how to go about it, we will get some tips of wisdom which we could go ahead and incorporate now in our own institutions. With not delaying further, I request Dr. Madhu to kindly take over. Thank you, ma’am.

[Madhu] Thank you, Aaron, and thank you, Vision 2020. It’s really a pleasure being with you all. It’s impossible to define value of an invaluable resource. “Achievements of any organization are the result of combined efforts of each individual.” This thing in hospitals, it’s a unique place that HR doesn’t consist of only the employees. It also means trainees, patients. It’s a big set up. And each category has got different kinds of needs. In difficult times, these needs require more exceptions because of the challenged times. And being an army person, I might refer once and awhile to war and peace, because that’s what it feels to me.

First and foremost, it becomes easier to deal with the problem if you have a value-based team. And in most difficult times, what works best is a trust of team and you and your team. Your trust in your team. Other than that, honestly, integrity, discipline, and spirituality, with that I mean is compassion. If any organization has its value, times are difficult or not difficult, doesn’t really make a difference. And if you weave all these qualities with good communication, it becomes a beautiful fabric. What we really need is a highly motivated team and a fearless leader.

And this is the most underutilized thing in most of the organizations, but believe me it not only increases productivity but long term loyalty. And what we say in the army, people who face war together stay together. The best thing is to keep them stimulated and alive because so many people in this world don’t really die, but they die within themselves, something of themselves dies. This is where the crux lies in managing any organization or a hospital.

Leadership has to be pretty good in the sense that they’ve got to be role modeling everything and not only preaching. And really important is to foresee what’s coming ahead. If you can foresee then you can plan everything in the mind. And you can start with the end in mind first. How will I make my timeline? And then, make them understand with clarity, and standby in time of need. There isn’t another way but to stand. If somebody has to die, the leader has to die first.

I’ll give an example, simple example. When I joined Sitapur Hospital there was an OT list of three or four patients, because it was a post-endotheliitis epidemic. Finally once until that worked for me was that each one of the employee gets one patient also a month for surgery. We can pay salary every month and I don’t need to tell what step it was.

And then standby, I’m talking of the peacetime now. One guy got a blunt injury, the state hospital was not able to really take the seriousness of the injury and this took the gravity. Shifted him, got him treated, and the most nasty employee became a promoted for making other employees in a bigger situation. However, every nasty employee doesn’t turn out good, that doesn’t matter. Even if out of hundred, even if 10-20 also can convert into good employees it’s really good. Sometimes we lost some employees in the service and we looked after their families. And why I’m saying, this is the prelude to in difficult times how people get motivated by. Right?

These are standard practices we use for team building. Then come the transfer of your strategy that you have studied with the end in mind. Then philosophy and transfer of power also in advance. The man who’s sitting for a door-to-door screening will not come back to you every moment. This is what I need to decide. And listen, until there’s a clarity of heart and people with high esteem, because they got the power to deal with. And minded modifications may be required. If there are any innovations, always promote them because if anybody comes with an idea, say the person will go ahead and do it, I am with you. And we’ll see, it may not work so well, something will work. And then many time we require the younger ones who have a little difficulty of the decision making. Help them in the decision making and they are yours forever.

Then comes, in difficult times, there is no other way but protocol-based system and these protocols cannot be the same protocols that were used earlier. The protocols had to be changed completely for the COVID. We didn’t have all these at the gate and all this. So all the COVID-related protocols, they had to based in the system, practiced again and again. And also the people have to feel that this is being done for my safety. They must feel positive about it. So that is what the multiple ways we did these little things, but we did these things.

Now come to HR planning. As I said, foresee the most important thing is the COVID peaks and there is lull. When there is a peak, more people will fall sick, we will lose more people, but we will have less number of patients as well. We don’t have so many. So our thing has been between wave one and wave two, like one, two, whatever you call it. ⅓ to ¼ of patients come during the highest of the peak. And if you look at this peak, also the peaks are in three. Patients first drop and then they become very little and then again they start rising, they don’t rise together.

⅓, ⅓ who works, give ⅓ to people for leave for looking after family, for COVID positive emergency leave, any kind of leave. Divide the rest ⅔ into ⅓, ⅓ into two halves. One working for a week, another one resting for a week. The rest doesn’t mean really rest, that is the time used for the productivity. That means people are managing the OT, making the protocols, making the equipment maintenance. Or the doctors and all they are doing thesis, they are doing their research papers, they are doing webinars, so many things.

Then we come to retention, very, very important. Retention is something that is possible only when we have a team ready who’s willing to change at a drop of a hat. Change in anything is not difficult to manage at any time. But the communication for any change has to be direct, directly from the policy maker or those who are heading the team. And with arrival of COVID was good introduction and re-assurance of COVID was what really helped us. That we gave them all the possible COVID knowledge and safety measures. And as I said, again, trust in leadership is a single tool to manage any change. The head should be able to lead them, that’s it.

We come down to what we really need in difficult times. This is the Maslow’s hierarchy which I’m sure people must be knowing better than me. But in the most difficult times of life, whether it’s a war, it’s COVID, that bottom most three become the most important needs and if you can take care of them. Then there is no way the employees will not be motivated to work no matter where they’re required to work.

How we went about it is that the first thing is the fear of COVID itself. I showed between the first and second wave, vaccination for all, medication free of cost for everybody, extraordinary sick leave for the people who had COVID. Look after leave for the families, a space in hospital for isolation for the people who needed it, arrangement of oxygen, and transport to COVID facility that was required. All these people were pretty comfortable.

Then personal safety. This is where it comes to that you can die. Then what becomes most important is me and my family and for that, most important is that what will save me from my enemy, that is COVID? What are my resources? The resources were best possible PPEs, training at multiple levels, multiple times, because everybody needs a different kind of training. It’s not about donning/doffing but actually what is the role, why they should wear it, and why they should commit to it? The reinforcement, monitoring and if it’s not followed, punishment. This is one place where punishment is absolutely justified. Then supply everything adequately. There should not be a want. Money is less important at this time, if you have more inventory of COVID items, there is really no challenge. I feel human life is worth thousand times more than any amount of money spent or money lost for that matter. But in this time discipline is the key, you can’t afford anything. The T has to be crossed and the I has to be dotted.

In the first wave putting the mask on people’s faces with the patients or employees and making them follow was a challenge. Second wave I didn’t need to ask anybody to put a double mask, it was automatic. This is where it goes, how the training and long term really helps.

Then we took care of their daily needs. That is your groceries, fruit, vegetables, online shopping. And then the most important: talking all the time, connecting all the time, so that the fear can be taken care of. And this has to be done at multiple levels and the correction and the feedback has to be real time. And most important is that nobody was allowed to feel in this organization that you are alone. We were all together, no matter what happened.

So then this is, initially, we didn’t deduct any money. Then we had to deduct money for up to two months and then we refunded all the money. And the codeword was that there was, in the end, there was no deduction at all. Good benefits, especially about the education, money and all that were real important. People were kept quite challenged and excited by the change they were doing. That was really important. We ensured that everybody who was doing good work was appreciated. And made them understand they are the value of organization and leadership. Leadership is nothing minus them. This is what it was and they love to hero worship their organization.

Compensation and statutory compliance, I’m sure we all are doing it. But recognition on daily basis and weekly basis was very important. It really motivated people a lot more. We were not able to send really anybody for a holiday because it was not possible. But otherwise enjoying life, we have places where we could send people. And engagement of a spouse is a very important factor. If the spouse is not engaged, it’s very difficult for the people to work in any organization.

Then career development. We really worked on the development of career of medicals and paramedicals. This year itself, 20 research papers were published which was not actually a suitable culture, so this was really a very good achievement by the doctors and paramedics.

Then trainees are vital resources. Their needs are different. So we shifted on completely to online education for lectures, demonstrations, and examinations, so that nobody would lose a year. Surgical trainings suffered during lockdowns because the patients were not able to come, so we took them to wet lab. In between the patients came, there was live training. There was no loss of anything academic and they were promoted a lot, we conducted the webinars ourselves, attended the webinars and this activity was a continuous process.

The patients. They are the backbone of HR. And soon as we identify the better off we are. We connected with these people in any way that was possible. Whether it was door-to-door screening that we had six teams going all the time, just after lockdown onwards, just because we were not able to do camps.

Vision centers were open most of the times. Then community, there were volunteers and ASHAs. They were connecting with people and collecting them together and sending to hospital for surgery. That also really helped us. On the whole, 70,000 people were actually addressed in the field without actually doing a single camp during this one year period. I felt it was a big achievement and this thing is, we were not able to manage too many appointments because people are not used to it. But appointments and WhatsApp and phone calls, those were the routine back there. On the whole it worked in a way.

To conclude, lead from front, fearlessly. HR is a leader and not a manager. Foresee the degree of challenge and prepare mentally, mentally is more important. Those who sweat in peace don’t bleed in war. So train, train, and train and more your HR so that they are comfortable. Forewarned is forearmed. Truly speaking, prepare everybody mentailly, physically, and prepare materials and everything whatever is required. Work on customized protocols, because old ones won’t this thing. Discipline is the codeword in a determined manner. Stay connected, don’t let anybody be off connected at any time. And then, human beings are emotional beings so they need to be mentored, guided through a value system, whether it is COVID crisis or otherwise more in the crisis. Deal with the heart and not really with the head. And prepare for third wave December, that is what I feel it will come. Thank you.

[Aaron] Thank you so much, Dr. Madhu, I think that was a fantastic presentation and everybody would have got a lot to learn from whatever you have shared. And it is truly a time where we need to be empathetic not only for patient care but even for all the staff who are the backbone of our entire service delivery system.

Coming to the questions, ma’am, I will be asking you a couple of questions. The first question is did you have to curtail on salaries through the course of the lockdown for your staff? And if yes, how did you communicate the same to the staff?

[Madhu] We did a small amount for two months. And the method of communication was that I put them all together, that means doctors in one setting, SODs in one setting and I spoke to them, we are short of money right now. We cannot give full salary but it can be incremental depending upon the little deduction for the lesser salary. And I, myself, offered 50% reduction straight away. So that was the role modeling thing. And second thing was, I assured them that by the end of the year we will pay 100% to you because in my mind I was sure of my people, I trusted them, I knew they would be able to earn. Once they knew that this money is only deducting because if I took loan from bank to pay them, I would have needed to pay interest and that kind of increment. We were able to give increments also.

[Aaron] All right, ma’am, just following up on that question. How did you go about the entire appraisal system knowing that financially the system, the situation was actually still pretty uncertain?

[Madhu] The appraisal I had spoken earlier only as a prepare mentally people at least a few months in advance. I told everybody that we will not be able to give you a big appraisal, but we will give you an appraisal. And if we have more money left in the year end, the money would go to you all. It’s your money they would.

[Aaron] Great, ma’am. The other question is as an institution you’ve already highlighted some but could tell of any measures that you have taken for any COVID-19 affected staff or their family members? In terms of how did you go about handling the entire situation?

[Madhu] Yeah, we have a safety officer. First and foremost, anybody who has complained, the first person to be reported to is the safety officer who gets the tests done for them. If anybody comes positive, or comes negative. If a person is positive or otherwise second wave on symptoms alone, we would issue a medical kit and isolation at home as possible. Not possible, a board the hospital where the person will stay.

And those people then would not be able to go out, so their groceries, everything is delivered at home, if there’s nobody to cook, food is delivered. One person required oxygen from the vision center site. So we got this person to Sitapur, got their CT and everything done. This is also to go back, again, we are to get impact. We had people here. Then we had oxygen cylinders and oxygen concentrators. But that’s, other than him, nobody really required it. Two doctors were sick, but one was on leave so he was in his hometown. And other one chose to go to a medical college in Hyderabad because he had somebody over there who would be taking care of him. These two were doctors, so they choose to be in bigger centers because Sitapur doesn’t really have anything much latest.

[Aaron] Thank you so much, ma’am. And the last question is, while it’s very difficult and gently rostering is part and parcel of the HR department, and you’ve shared some of the key measures. It would be great if you could just highlight on how you went about scheduling rosters for the staff of the hospital as well as vision centers in the pandemic time.

[Madhu] The vision centers, we have 12 functioning vision centers because two have been taken over by the government. In vision centers, if anybody fell COVID positive, we had to see the gravity at that time. If there are so many cases or not so many cases. If there weren’t so many cases in any center, there were centers like that, which were in falling in containment zone and all that, we did not replace a person there. Otherwise we would replace the person, so that was for vision centers.

For the hospital, as I said, the wave itself, the wave is about three to four months. So you divide this into three months. One month is a hell. In that hell, we get only about ¼ to 1/3 patients. For that ⅓, I have maintained even people who don’t fall sick. Send them on leave, let them take leave and feel more comfortable. And then the rest of the team is in two parts. Because at this point somebody become positive, or many people become positive in one team. The other person immediately comes over and takes over. And then normally, as a standard, until a person is symptomatically comfortable. Even if the person is COVID negative, would not come back no matter what because we have that sufficient, what should I say, we have sufficient cushion and people were willing to work more. Suppose somebody fall sick, there were people who were willing to work so there was no challenge here.

[Aaron] Thank you so much, ma’am. I think it’s been a great learning for everybody here. I’ll be following up with questions-

[Madhu] Thank you, Aaron.

[Aaron] Post session, thank you so much, ma’am.

[Madhu] Thanks, Aaron.

[Aaron] With that we come to the end of the retaining HR segment. And now we go into the next component which I felt is one of the most neglected components from many of the institutions that are working in eye care. And for that we had to look, we went ahead and found a resource person outside the eye care scenario who’s an expert in what we call corpus building. With so many things being affected through the course of the pandemic with low patient flows, low surgeries, it is absolutely important for an organization to be financially sustainable. And to create that solid foundation, we thought it would be right to get an expert’s opinion on how an organization or an institution can go about building a corpus of their own. So that in times of crisis like this, we don’t have to take hard steps of laying off staff or basically curtail on our service delivery mechanisms. So for that we’re really fortunate to have Mrs. Vanessa D’Souza who’s the CEO of SNEHA. And ma’am, I request you to kindly share your presentation and take it forward from here.

[Vanessa] Sure, thanks. Thank you, Aaron, and hello to everyone over here. I’ve actually really enjoyed the sessions because I’m from a completely different background. I work with an organization called SNEHA. And SNEHA works to improve the health and nutrition of women and children in urban slums of Mumbai and also reduce gender-based violence.

When you look at funding, and I think this last pandemic, I think one thing that all NGOs have struggled with is how do we resource ourselves to be able to just continue our work? And none of us can leave our beneficiaries. We’re in the middle of work and like I heard you all saying, there are so many patients, there are different eye issues, you can’t just stop your work. How do we build this corpus of funding which will actually help us to tide over difficult times?

I want to actually share with you an example of one of the best known universities which is Harvard University. Harvard University has built a corpus of $40 billion. And their annual operating expense is $5.4 billion. So they actually use the corpus to fund their annual operating expense. Harvard has taken four centuries and 14,000 people to build this corpus. All of us don’t have that luxury of time, we don’t have the name that Harvard has. But we can take some steps to start, if we’ve not already been doing it, to begin building this corpus.

Before I go into the how of building the corpus, I wanted to just bring out a very critical distinction between what we call the corpus versus general donations or reserves, or general reserves. For most of us when we think of an organization, we think of corpus as being this fund that is available to us to use at any time for our operational expenses, especially at a time like a pandemic. But a corpus in the legal sense of a term is actually a permanent fund. It is a fund that requires permission of either the board and in some places the charity commissioner to be able to use those funds. The corpus itself is capital. So like a company has capital an NGO can also have capital. But the interest on that corpus can be freely used by the NGO. It is important for every NGO to build some capital or corpus to be able to tide them over through emergence and difficult times.

But some NGOs which are governed by the charity commissioner in some cities like SNEHA Mumbai, Delhi, et cetera, they actually have to take prior permission to use funds of the corpus. Now this can be very painful because we all know how difficult it is to get funding from the government. So what we do at SNEHA, while we build a corpus we simultaneously build what we call general reserves and program reserves. These general reserves typically can be used, you can either allocate it for a particular program. I don’t understand your business very well, but let’s assume that you have some amount of money that is put for surgery, some amount that is put for training, something for research, you can actually start allocating funds to each of these. You don’t necessarily need to use them in that year, but you can start building a reserve for each of these different functions in your organization. The general reserves don’t need any prior permission, you can use the funding at any time. Most organizations will always try and build a judicious mix of corpus as well as general reserves.

Let’s come to fundraising. Fundraising always seems like this enigma. How do you raise funds when you’re a hospital, you’re a medical professional, you’re a nurse? And you’re trying actually to provide services to people who need the services. I think the first thing that fundraise, you have to recognize that fundraising is a very core function. And most of us at the NGOs focus on our programs and on the beneficiaries and the work and the impact we want to deliver without giving as much focus to fundraising. But fundraising of course, as we all know, is the blood of an organization.

The first is to have a dedicated team of fundraisers, it doesn’t have to be a big team, it can be a smaller team. And we can discuss that later. The second is to have a very clear fundraising plan. You need to know how much money you want to raise, from where you want to raise it, and how you want to raise the funds. And it is a continuous process that goes on through the year, every year.

Like all our other work, it’s very important to measure the impact of fundraising at every single stage. Because when we start measuring we learn what is effective and what is not effective in fundraising. As most NGOs, we try a million things, but everything doesn’t give results. I wanted to share with you, we actually used to try and do a lot of crowdfunding. So we would use Instagram, we would use Facebook, and try and run campaigns. But we were never successful in running online fundraising campaigns until a certain event, and I will come later to how things changed overnight for us.

And last, and very importantly, is using technology to fundraise. I know in the medical profession, I’m sure you have a lot of priorities to invest in equipment. But somewhere I think it’s important to see how you can invest in technology. The way I see it, it isn’t an expense, it’s more an investment that more than pays for its expense.

I want to share with you how SNEHA started using technology. Earlier we were using spreadsheets, Excel sheets, we had multiple sheets of prospects, we would lose the sheets, somebody would resign, we would lose names of prospects until we decided to get a customer relationship management system called Zoho. One of the things that Zoho does very effectively is Zoho helps us to track our prospects. We have this prospect database in Zoho, and you can see this funnel over here. If you look at the top of the funnel, you typically see at the top of the funnel, you identify a certain prospect. And then you’ll have a site visit. Once you have the site visit, you begin to understand what exactly that donor is looking for. Donors have different needs and different expectations and it’s very important to understand that to match their expectations.

And then you move down the pipeline, you send your proposal, you negotiate with the donor, you have an MOU, et cetera. But what we do in all this is that every stage you have an amount that you expect the prospect to get and sometimes you have to estimate that amount, you don’t always know the amount. And the second is, there is a probability attached to every stage of the funnel. At any given point in time, you know quantitatively how much money is in your pipeline and what is the probability of that money coming in. And this is very valuable because the more you have with higher probability, the more chance you are to be able to fund your work on the ground.

Another dashboard I want to share with you is these are all different programs. CHN is Child Health and Nutrition, the next is the empowerment of adolescents, there is a Healthy Cities program. For every one of these programs we have an annual target and then we are constantly measuring ourselves against the target. If you have gone over the target, then you know you’ll have funding not just for this year, but you have a small reserve for the next year. And especially for a senior manager, it is very easy for you to very quickly know where your funding gaps are and where you need to pay attention.

This is an example of a campaign. We run a lot of fundraising campaigns and this one example of an annual fundraiser that we had. And these are individuals and corporates that subscribe and donate for the annual fundraiser. So we’re able to track every single campaign of ours online and we know exactly which prospects the campaign material has gone to, how much they’re willing to give us, and what it will take to reach the target amount. Using this data, we found, has made a huge difference to our efficiency. We’re able to be much more focused on the larger names. We’re able to allocate larger names to board members, to senior members of the team, and keep the smaller donors to the rest of the fundraising team.

But before we go to fundraising, one of the most important things is brand building and communication. When I joined SNEHA, I joined SNEHA in 2013. But two years before that, I volunteered as a fundraiser. The founder of SNEHA was a medical doctor. She came to me and she said, “We’re a bunch of doctors and we don’t know how to fundraise. So can you come and help us?” And what surprised me is when I went out to meet prospective donors, nobody knew the name of SNEHA. So then I asked the founder one day, I said, “You know, people know Akanksha, they know Pratham, they know Magic Bus. Why doesn’t anyone know SNEHA?” And the founder sweetly said, “We try and keep a low profile.” Now that’s a very noble task, but when you need to raise money, you really need to be out there. You need to talk about what you’re doing. You need to create a brand identity. When people see your name, there must be a promise of certain quality that the prospective donor gets to mind. And this really helps to simplify the whole decision making process.

I want to share with you how we have actually done, this is one of the brand building exercises we did. We had, during the pandemic, in the early days of the pandemic, we had a professional marketing organization that just sent our communications person an email saying, “I’d like to run a campaign for SNEHA. I know you work on gender-based violence and we’ll provide our services free of charge.” And this was actually the first time when we were extremely successful in crowdfunding.

We ran this campaign called Lockdown mein Lockup. And as most of you had heard, during the lockdown domestic violence had increased quite significantly in the slum communities that we work on. People were locked in, there was high anxiety, there was little or no income. And we ran this campaign and this marketing company was able to bring celebrity endorsements for us, all done pro bono. We had a target of five lakhs when we started this campaign, we ended up raising 15 lakhs in two weeks. But more importantly if you see our social media followers, in two weeks we increased from 700 plus to 9,000 plus. Now that’s important because one year later we still have some of those followers who come back to us wanting to support us in various ways.

Focusing on building your brand. If you can get professional organizations to work pro bono and there are many organizations that are happy to support NGOs. Please try and do that because this is one way that you can really increase your fundraising.

The other point I wanted to share with you is leverage the network of your corporate donors and volunteers. One of the things that we have done is we have done so many campaigns. No amount is too little, no campaign is too much effort. One on the extreme left that you see, this is a school student who wanted to just run a campaign for SNEHA.

We’ve had one of the most successful ones has been what we call the Campaign Gratitude, a very interesting model. Where we had an investment, a private equity company that reached out to all their employees and asked their employees to run small campaigns within their own networks to raise funds for SNEHA. They contacted their vendors, they contacted their clients and they asked as many people as possible to run little mini campaigns for us to show gratitude during the time of the pandemic. We were able to raise 83 lakhs in one month’s time. And this all started with just one conversation with this one private equity firm.

Similarly we’re looking at artists. You see Saving the Artist, we’ll do tie up with artists, with photographers. It doesn’t always raise a lot of money, but I think the awareness of your name and the work you do pays in the long run to bring in the funding.

Where do we start? I think that’s a very good question for anyone who’s not really focused on fundraising. And I would say start with the core. The core is your founder, your board members, your senior management team, or any significant donor who really understands your work. They feel aligned to the mission of your organization. They can be the best spokesperson for you. Start with them, and then you move out to the next layer which are your employees, in your case your medical doctors, nurses, technicians. Everything counts. Even a sharing on social media followers will help you. Running a little campaign which they can possibly do in their own network, that will also help. We’ve had many of our staff running very small campaigns but everything counts.

And then finally you go to your peripheral supporters, these are typically retail donors who’ll come on your website, maybe they’ll give you 500 or 1,000 rupees. Some of your social media followers who may not give you anything, they might like your page, they might share your page, but you would definitely want to get ahold of these people and move them from that outer circle into the core of this circle. So they really understand what you’re doing and feel very, very aligned to your work.

How do you do this? It’s not so simple to do. And here I want to share a specific case story to share with you that moving somebody from an outer circle to an inner circle takes time, it takes effort. But the return… You obviously need to be very selective about which of these people you move in and that’s where data really counts. You can profile people as soon as they give you, you can just allocate a probability to somebody whom if you run a large campaign and have just 1,000 rupees being given by say 100 people. But if somebody’s able to profile these people through a LinkedIn profile, you can quickly know who is potentially not a 1,000 rupee donation.

This is an example of a US donor who we first met in 2014. It was actually a dinner hosted by a board member of ours and that’s where he got to hear about SNEHA. And then gradually we did site visits, we could send regular updates on our work. But the big shift really happened in 2017 and 2018. In 2017, this US-based donor wanted to set up a technology platform for NGOs. and he came and he wanted to understand what SNEHA does in technology and we use a lot of technology for our program-related work. And at that time, we opened the doors to him, we shared with him how we do data collection analysis, we use a business intelligence system for our programs. And that’s when he actually began to understand the work and value it.

And in 2018, he came with his entire family to do a three week volunteering assignment. And at that time he ran a campaign before he came down. And you see a donor from 2014 to 18, from being a prospect, he moved to raise $148,000. And then subsequently just to support a strategy initiative, this is not core work, he gave us another $10,000. I think the important thing is to keep investing. Choosing the right prospects and keep investing time in these prospects.

Everyone is a fundraiser. I think one of the important things here is it doesn’t matter who you are in the organization, it doesn’t matter what level you are. If every one of the employees can consider themselves important in the wheel of fundraising, I think that’s critical.

I want to share with you how we bring in our field staff. Our field staff are typically people who live in the slum community. They certainly cannot contribute in terms of funding to us. But when we do a donor review meeting, it may be a donor’s office or it may be a visit into our office, we always make sure that a team always addresses the donor. We make sure that everyone at every level, even if they have to contribute for two or three or four minutes in that review meeting, they contribute. For two reasons. One is the donor really gets a sense of what these different level of people are doing in your organization. Or two, the passion with which a field worker can speak, I don’t think many senior management people can speak like that. And third is, I think that the field staff begins to value the donor. They don’t consider themselves just operational people…for which you are trying to raise funds.

Leveraging the power of the board is another very important thing. Like I shared with you earlier, we very proactively reach out to our board members. They host dinners, we reach out to their networks, everytime we have a prospect list, we bounce it off the board members. Find out if any of them can speak to a senior person in that organization. So that we’re constantly leveraging off the network of the board members.

The third is bring in pro bono services. Everything doesn’t need to be paid for. Like I shared with you, how we brought in the marketing organization. In 2014, the year after I joined, the board was extremely concerned because SNEHA was running 28 day care centers, addressing malnutrition in children under the age of three years. And they were extremely concerned about the risks to these children. And we wanted to bring in one of the big four accounting firms to do a risk audit for us. And obviously we couldn’t afford it. So we actually worked with them to see how they could do this for us pro bono. And I think we often don’t ask enough but I think the most important thing in fundraising is to ask. And most people, all of you are doing amazing work. And I think it would be very difficult for most people to say no to you if you ask for a pro bono service.

And the last is volunteers. I think we sometimes underestimate the power of the volunteers. A lot of our fundraising is done by volunteers, they don’t charge us anything, they reach out to their networks, they bring in very unique skills. For example, at annual fundraiser, and I’ve actually put a graph there to show you how we run a fundraiser every year. This fundraiser, the funds are by and large raised by a team of volunteers. Our own field staff do more of the operational stuff, but the network is mostly the volunteers.

The reason I wanted to share this campaign with you is actually the biggest message that I have is fundraising is a process. It is a process that means to be done consistently every day by everybody, year in and year out. Unless you build in that discipline of constantly looking at fundraising as a very core function in your organization, it’s really hard to build a continuous source of funding which will help you, especially at a time like this. Thank you.

[Aaron] Thank you, so, so, so much, Vanessa, ma’am, for all of those unique insights that is coming from a different sector altogether. But definitely very, very relevant for all of the institutions that are majorly induced within the eye care sphere. And even for those which aren’t, I do think that there were a lot of valuable lessons that are there.

Taking to quickly to some of the questions that we’d like to ask you which were already selected. The first question, ma’am, is on an average, what percentage of surplus should an institution apportion to the corpus development each financial year?

[Vanessa] We try and do between 5-10% each year. It’s not that we always manage it, but we try. Our aim is to go 5-10%. But there’s just one important point I want to raise here. When we present budgets to donors, we always ask for a 10% administrative cost, and that 10% is quite important to manage your central functions like finance, HR, fundraising, communication. Anything you raise over and above through campaigns, and different activities and events, through crowdfunding, you can actually put that away towards your corpus. And that’s what helps you to constantly keep filling your reserves in corpus.

[Aaron] Ma’am, following that up, I think the one question that comes to mind now is how should an NGO go about building and developing their entire fundraising team?

[Vanessa] You know, Aaron, when we started, when I joined SNEHA, we did not have anybody in the fundraising team. Our founder used to use her network to reach out. And I have to thank the board. The board was actually quite keen that we build a team. So we started off with only one person and this was in 2013. Today, in 2021, we’re three people. So we have a very small team. We have very different skills in the team. So we have one person who heads the team who actually used to work, she’s a management consultant, she’s an IIM Bangalore person, extremely qualified and competent. And I think your senior person needs to be very competent because that’s the person that will be meeting the donors, is going to be checking budgets, proposals, et cetera.

The second person we have focuses on running all these campaigns that I shared with you. Whether it’s art campaigns, crowdfunding, finding partnerships, constantly looking for new and innovative ways to raise corpus. And the third person just manages our backend. Managing the customer relationship management system, making sure donor receipts go out on time. All the backend work, MOUs, et cetera. It’s a very lean team. Generally, so we’re right now 2021-22, we’re at an annual budget of 32 crores. For our size of NGO, typically we’ve seen in most organizations, they have between three to five people that fundraise. I think anything more than that, you’ll have a problem because donors will ask you what the cost of your fundraising is. Our cost is 1-2% of our annual budget so it’s very affordable. Most donors don’t mind paying for that kind of funding. And this is where you bring in volunteers, you bring in pro bono services and you can keep your costs pretty low.

[Aaron] Ma’am, one follow up question to what you just mentioned. How does one develop that into a system that helps creating a pipeline of funding resources over a period of time?

[Vanessa] That’s a very important thing, Aaron. The pipeline really is what I call the leading indicator of your fundraising. If you have a strong pipeline, then you know that money will keep coming. So what we do is very proactively we build out our pipeline. You have directories that can give you CSR donors for the kind of focus area you’re working on. Somebody is reviewing this every year, the new directories that come out from FICCI, Assocham all the industry associations and updates it.

The second we focus on Indian foundations so again, we use organizations like Samhita, Funds for NGOs. And there’s another one which I would urge all of you, it’s called India.candid.org. I would urge all of you to use this because this is a really interesting database created by somebody in the US, where you can narrow down exactly what kind of focus area. Whether you want an Indian donor, international donor, the size of the donor, et cetera. And you can actually get names from there. We have somebody who’s constantly updating this prospect database. And not just updating, then it has to move down the funnel. You’ve seen how the funnel is and we’re constantly monitoring that names move from that prospect right down the funnel. So there has to be a movement that is happening. And this is, again, where the CRM system happens.

When it comes to individuals, like I said, most people give to a person, they don’t give so much to the organization. Especially if you want a large amount. A small amount, they may give through a crowdfunding. But the minute you’re talking of somebody giving a lakh, five lakhs, 10 lakhs, 50 lakhs, they are actually giving to the person. They’re actually giving to somebody whom they trust. Therefore you need to cultivate these relationships. Like I said, it takes a long time, it’s not easy. But we actually, I personally had a list of HNIs with whom I am regularly in touch with.

And in the pandemic, Aaron, we had actually a funder who overnight withdrew funding from an entire program. All I had to do was make calls to some of these big HNIs and we covered three months of funding until we were able to get an alternate funder in, just with relationship. And therefore having this group of HNIs, whom you know you can pick up a call, they’ll cut a check for 20 lakhs, 25 lakhs, 30 lakhs, is so important during a time like this. You need to build this, it doesn’t happen overnight, it means regular meetings, it needs updates to them, it needs very personal, board members might need to meet them. But I think it’s worth investing in a group of people like this who are your go-to people for a crisis.

[Aaron] And ma’am, the last question. What is the typical turnaround cycle time from identification of a prospective donor to going ahead and closing a funding day through your years of experience?

[Vanessa] Typically in terms of time, I would say it would take anything between three to six months. Right from the time you first meet the donor, then the site visit, proposals, et cetera, the MOU, et cetera. If you look at the numbers, if you reach 100 prospective donors, you will probably be lucky if you close maybe three or four. I’m talking about large, I’m talking about one crore, two crore, three crore type donors. If you’re looking at, you need to define your pipeline is so important. From those hundred, many will fall off along the way. And by the time you reach to the high probability, you’re probably down to just four or five, maybe six people, and of which maybe you’ll close three because you’ve brought them so far down the pipeline.

And therefore large donors, not only do you need to have many prospects that you need to keep working. Because many will drop along the way. But you also need to keep that timeframe. If your financial year’s starting in April, by October your proposals, your budgets, your prospect lists, everything has to be ready and you have to be out there actively fundraising. Because this is large numbers that you’re talking about. Therefore that discipline is really important. Typically when we start a financial at the start of the year, we’ve probably locked in about 60-70% of our annual budget in April of each year. And that’s an important indicator that you need to track. Because you know if you’re behind that then it’s going to be very difficult to catch up that balance 30-40%.

[Aaron] Thank you so much, ma’am. We’ll be taking the follow up questions post this. And that brings me to the next topic. One key that is following from Dr. Madhu’s presentation of discipline, even in times of crisis for HR and similarly discipline even in terms of fundraising endeavors. Thank you so much, ma’am. Now I request Mr. U.V. Kannan who’s there from Appasamy Associates to come for the last session. I’ll just give a quick introduction.

A lot of the hospitals are going to face challenges with regard to the support service of equipment within the hospital during the pandemic time. Whether it be slit lamps, whether it be phaco machines, whether it be your microscopes, or your investigation diagnostic machines. And I think this is a critical aspect which all hospitals will face challenges because service engineers might not be able to travel, like during lockdown restrictions, state guidelines which can cause a lot of problems. Our goal was to reach out to an all encompassing company and none other than Mr. Kannan who’s presenting Appasamy Associates, which is known for their service delivery across these years, at least in our country. And we’ll be very happy to learn from you in terms of what are the preventive and preemptive measures that we can take to ensure that patient care doesn’t suffer? Over to you, sir.

[U.V.] Hi, thanks for the introduction, Aaron. I’ll be talking about why prepare for preventative maintenance and we’ll go by practice sizes and we’ll also go by types of equipment and also acknowledge the people who helped me prepare this.

Why do we really need equipment maintenance in ophthalmology? We’re one of the advanced fields of medicine where there’s lots of diagnostic and therapy equipments that allows us to provide standardized care for all of our patients. And having these equipments very fit ensures that we are able to minimize the turnaround time with the patient and the staff have decreased exposure to any of these pandemic risks. And we get really good equipments, some imported, some high good quality standardized, but they still do fail. But why do they fail? The reason being there is always a lot of mechanical movement with these equipments and there’s wear and tear. Electrical connectors have wear and tear because of these movements. And sensors and actuators have a lifetime and they fail after some time. Optics accumulate dust and there are lots of other environmental factors like humidity, dust that affects the instruments.

In the pandemic, there are many OPDs that have been structurally changed to have an increased airflow. This also exposes all the instruments to a lot of dust and organisms that were essentially not there. There need to be extra precautions in maintaining these equipments to prevent failures that we don’t really know of.

Not every hospital would follow the same size. Depending upon the size of your practice, you’ll have different protocols. What we see, we’ll start with the smallest size practices, which are typically only OPD, there’s probably an optometrist, registered nurse, and the doctor, and a couple of other assistants. They have no dedicated maintenance team, it’s mostly OPD only practice. What you do as a doctor, you advise your employees of how to operate the equipment. Most of the times the breakdown happens because of improper use of equipment. This point about know your friendly neighborhood electrician, this happens to be very important for these small practices. Their electricians or anybody who is good with wires or cleaning things, they come very instrumental in these times. All you need to have is probably a list of service numbers from your distributors of different equipments whom you can call quickly, get spares, or know what needs to be done to the equipment to keep it running.

Moving on to a medium size practice, let’s say 25 employees or less, multiple OPD bays and one or two OTs. Again, training is very critical. As you see, I got these two pictures of two medium-sized practices where they have a list of equipments, the list of distributors, and the contact numbers. One team goes further by adding the person’s name who takes care of installation and the service and there’s all the information for it. As in the previous talks there’s always a rotation of personnel. So the personnel who’s in charge of maintenance might not turn up in any part of the work week or the work month. This number list ensures that there is somebody whom you can call and know about these instruments. And try to maintain some critical spares. We go over which instruments need what kind of spares, it also might require a simple solder stationm and some cleaning consumables for optics.

And then we go to the larger ones. The larger ones are typically with more than 25 employees. They probably have a dedicated technical team taking care of many things like even their AHUs and their water supply and everything. There’s multiple diagnostic bays, multiple OTs. As we saw earlier there might be very low volume of patient flow. Even in case of failure, you have lots of redundancy there. With 20% or 30% of patients coming in, you really have a lot of redundancy. And even if one equipment fails, you probably have another one working on another bay or another OT.

Larger organizations, they probably have an induction training for all the staff where we should add a do’s and don’t of equipment usage and training them every person as possible. And also add refresher training for people early in their career, so that they always know what to do. Maintain critical spares. We spoke with a few hospitals, bigger ones like Sankara Nethralaya and we got what kind of critical spares they maintained for equipments.

Now we’ll talk about different equipments. What I have here is some data. One internally from Appasamy for what kind of spares we frequently ship and another from Aravind Eye Hospital Madurai about what kind of services their MYO medical team does.

For a slit lamp, a slit lamp on IDO, we would consider as the most basic equipments that need to be there in place so that you don’t miss a diagnosis. Advanced equipments could be open and used if needed. For the slit lamps, the most major figure is probably the bulb. It could be a halogen bulb or an LED and its electrical drivers. The other frequent service that you see is the filters don’t work properly, the mirrors accumulated dust, the bino has become loose, there’s doubling of images. These are some basic fixes that any biomedical team or an optometrist could be trained to fix. There’s also, because of increased outflow, there’s dusty optics. And equipments have been moved around to facilitate better ventilation for doctors when around patients. Things get loose, there are some mechanical failures that happen. Slit lamps come off the rails and things like that.

I also listed the spares that need to be maintained. It’s probably a bulb and a bulb holder, a fuse, power cord, switch, potmeter for varying intensity, the output cable, the power supply cord. You might need an even longer cord than you normally use inside your OPD base. And what we have been shipping to last few quarters of the pandemic, were essentially these mechanical misaligned bases, base wheels, and connectors that have gone wrong. Resuppressing our face frame assembly. This happens to be an outlier from what we saw from our own data because most of our customers use a refraction sharing. And people happen to pull the slit lamp instrument tray using the face frame handles. And just like the electrical data that you see for slit lamps is mostly changing bulbs and that reflects here in our data where the LED and the LED driver board needs to change, that’s 30% of the spares that we ship.

And we go on to the next equipment, IDO. IDO is very similar. We see that Aravind uses a lot of wired IDOs, so more than 40% of what service the biomedical engineers have been seeing essentially, loose connectors and soldering things back,. And the spares that we ship are essentially the ones that affect the optics, the dust on optics, the eyepiece covers to protect them, the power adapters, the change. And the fuses maintained in the bigger hospitals Sankara Nethralaya and Aravind are probably bulb and fuse holder and the connectors where they need to be.

All other practices, this is general best practice whatever your size might be. Always use the lens covers to protect because there’s increased ventilation, there is increased chance of dust. You could always use a sitoon and ear buds to clean it or call your equipment maintenance person to do that. And do use stabilizers for all electronic equipment. Now this being summer, there’s always a drop in the grid hold that goes on. So stabilize and if your equipment is using computers, definitely use a UPS and have a backup schedule so that all your data is being backed up and you have data for longitudinal study of all your patients or your research work.

Because of decreased workload, you might not be opening up all the bays. So try rotating the bays that you use so that every equipment is being used. Turn off all electrical equipment on and off so that you always know what the working condition is and you’re not surprised because you might not be able to use a bay because air conditioning didn’t work. And clean all the equipment as per the training given by the installing technician or in the manuals and use the dust covers after the use. And cover them with dust covers before you do sanitization of the work area with any other chemicals. And never let any of these to be always in dark or damp places. Even if it might be an OT, I’ll at least have a bulb running, or if you have a dehumidifier that’s even better in highly humid places.

And more to the OT equipments, we’ll start with the microscope. And in microscopes as well, the most failure is only in the bulbs. Most of the manufacturers keep a spare bulb and fuses and power cords. There’s also probable issues with foot switch, that’s the one that’s being moved mostly. And if there’s batteries in your wireless foot switch, see to that they’re always charged. And the cooling fans are operating so that the chances of your bulbing going bust are low.

For phaco and vitrectomy machines, most of my observations are mainly based on the spares that we ship. The most spares that we ship are the handpieces. Since these are mobile and they’re being passed between multiple hands and trays, this happens to be the spare that we ship out the most. Then the mother boards, essentially, because if people are not using stabilizers that’s the first thing that burns out. Always ensure that you have a 220V stable source of light. And if you’re not opening your OT for several days, ensure that you start the phaco unit, prime it, test the functions of irrigation, aspiration, and for variable phaco powers. And for vitrectomy, test the cutting and aspiration by dipping it in water. For doing diathermy, have the forceps on a wet gauze and see to that it gets cauterized. And try moving the IV poles up and down and lubricate them if necessary. Always clean up the handpiece after all these things, clean the tip, clean the tubing, and prepare as you would prepare for any other setting.

For all this data, I would like to thank Dr. Ramesh Dorairajna from Sundar Eye Clinic, Mr Vinoth from Sankara Nethralaya, Chennai, Dr. Naveen from RK Eye Center. And Mr. Thulasiraj and Professor Manickam from Aravind Eye Hospital. Mr. Ram and Dr. Mohan Rajan from Rajan Eye Care, and all the other knowledge that I got from the manufacturing head of the departments and the sales and service team.

I’m open to having questions. And this shows the distribution of our sales and service personnel during the lockdown in the week of May 9. Companies like us, we still help the doctors in hospitals keep their maintenance and their needs complete by having a pandemic presence there. Several other distributors with the same capabilities as well. If you have any set of questions please let me know. There’s one question-

[Aaron] Thank you so much, sir, for such a beautiful presentation and I think this will be of huge value even in the Cybersite e-resource library. Just to let all the panelists know this will be accessible still even post this even as a Vision 2020 archive.

Sir, coming quickie to the questions since we’re already beyond time. I would like to have some of the questions asked. The first question to you is, how should we approach negotiating our AMC and CNCs in times of pandemic if companies use the force majeure clause?

[U.V.] The first thing to remember in any contract is that negotiate before you sign the dotted lines and transfer your cash. That’s when you have most of your leverage. See to that you are able to include clauses where government is now having a forced lockdown, either at the national level or at the local level. If you’re able to exclude the CMC and AMC periods during that and bring that clause insight, there are very difficult times. If it is a no loss for either side, then it’s going to be a very good relationship. If one side feels pulled down a lot, then probably the relationship might not work. Because it needs to work in the toughest of the times. That’s when you know your relationship is really good. Any negotiation should be done prior to you sign the dotted lines and transfer your cash.

People do understand when things go wrong during these difficult times and I think most of the equipment manufacturers have given waivers on AMCs and CMCs. From what I heard, the big multinationals have given at least four or five, to six months of AMC, CMC waivers. I think many manufacturers in India, we don’t really have a CMC or an AMC program. But always people have a right to help and even if it means attending to other things that might not be in our product portfolio.

[Aaron] Sir, the next question is how should a hospital strategize building its equipment maintaining capacity?

[U.V.] We would first start with the person. If you have a trained optometrist or a technician, ask him to be around when the installation goes on. See what are the preventive measures that needs to be taken. It might be when putting on a simple dust cover. And a lot of institutions like Aravind Madurai and LVP Hyderabad that run training programs for maintenance of these equipments. If you’re a large hospital, probably send one of your optometrists or electricians to go. And maintenance solder station, have some cleaning supplies for your optics. That should be sufficient to start with. If you feel you’re in a remote place and the spares don’t reach you in time, then start setting up your library depending upon on your frequency of maintenance periods. I think that would be a good way to strategy plan your maintenance.

[Aaron] Thank you so much, sir. Now going to the light Q&A, so I’ll start in reverse order. So starting with sir, Kannan, there was one question that was asked with regard to the expensive spares. Our consumables, especially high end spares for ophthalmic equipment. How do we go ahead and by what ratio is there any formula for us to go ahead and store some of these equipment at our own premises?

[U.V.] For smaller practices, I really wouldn’t recommend. You might or might not use that spare. If your manufacturer maintains a library that has a very short lead time, then I would recommend using that. Since we talked about negotiating earlier, probably negotiate for your spares and expansions at the beginning of your contract so that you have a fixed rate during the tenure of your capital equipments.

[Aaron] All right, now quickly going to Vanessa. There were a couple of questions that were asked which she has answered in terms of type of questions used for platforms used for crowdfunding. And also what was the tentative proportion of funding that happens at various channels: corporate, individuals, and digital? Ma’am, if you could just give a small highlight regarding those two questions.

[Vanessa] Sure, so actually I responded. Typically, this proportion changes. We typically have about three years ago we had about 60% of our funding from CSR. Now we’re down to about 35% from CSR. And we are very deliberately increase the number of international and local Indian foundations and reduce CSR. Because the foundations, we found, tend to give you longer term funding. And not only do they do funding but some foundations like Ford Foundation, UNDP, Wellcome Trust, they also add a lot of value in terms of research capacity, collaborations for publications, et cetera. The HNI component continues to remain very small at about 5% of the funding. What was your second question, Aaron?

[Aaron] Ma’am, the second question was what are some of the platform that you’ve used for crowdfunding?

[Vanessa] Sure, so we used Facebook, Instagram, and LinkedIn. These have been the three platforms that we’ve used.

[Aaron] Thank you so much, ma’am. Now moving to Dr. Corpsman Madhu Bhadauria. Ma’am, I’m going to ask you a couple of questions, actually. One was, what was some of the measures that you had taken to motivate the staff to continue their work during the pandemic times, specific to your institute?

And I would also request you to answer one technical question that has been asked about our hospital requiring RAT for all OPD patients, as it has come as a directive from a COVID noted officer from one of the regions in the northeast. Request you, ma’am, to quickly just give your inputs on those two points.

Ma’am, you’re on mute, could you kindly unmute?

[Vanessa] First and foremost is regard to identify what can cause demotivation? In COVID times, specifically it was fear of COVID, it was fear of dying from COVID, insecurity. Basically these two were the factors. How I dealt with them in the organization was first and foremost that the fear comes out of not knowing what the future is going to be. Arm them with knowledge about COVID through different kind of mediums, some fliers, verbal talk amongst different people, as to what are the things that we can do at our level to prevent COVID? In that came all the PPE and masking, et cetera, et cetera. Then what they can do themselves to save from COVID? And in case COVID comes, suppose. Then, max their full sick, we will take care of them. So that security, the moment that security came that we can prevent it, it is within our control to prevent it, and even if you have.

And then finally came the vaccination, again, there was a huge challenge. I had to be the first role model to get the vaccination done to myself. Only then the team will follow. So therefore when the vaccination came, they had to be told very clearly that it’s not to prevent the COVID, it is to prevent severe COVID disease. Despite vaccination, almost 70 odd people got positive. But they did not become severe, they did not become serious. Basic thing is alleviate the fear.

And then there is a category called fear mongers and the deniers. So fear mongers are the people who generate fear amongst their entire crowd. So the first important thing is to address the fear mongers, address their fears. The moment they get confident, they’ll stop fear mongering and the people who are in denial, like, “I am made of steel and nothing is going to happen to me,” those are another set of people who need to be really addressed. That, “Look, man, you are also a human being like any one of us and you need to have adequate protection as anybody needs.” (laughs) COVID doesn’t know that. This is what exactly was done. And then you know what, somebody’s behind you which really helps. The last word is that there is someone your organization will look after you, even if the ultimate happens to your family will not be on the road. That’s what helps people.

And what was the second question, Aaron?

[Aaron] Ma’am the second question was there’s a hospital that has been requested for a mandatory conducting RAT for all of its OPD patients as well. Could you just share your opinion with regard to that. They’re already doing-

[Madhu] OPD RAT is not possible. Because eye OPD is large OPD. But for OT, even we have been doing RAT, actually. And this thing is not a difficult thing. Now, of course, the self test kit is available. We were getting it done because we had a COVID center right inside the hospital. But suppose even if that’s not possible, RAT kits are available, reasonably, around 200 rupees a kit. And self test is 240 rupees a kit. Now it’s been legally permitted. The hospital can keep a RAT kit and do it right there, it’s as simple as that. And if it’s possible to have it done, because whatever you say, operation will be 10 minutes. But the patient is walking into the facility, staying with other people whom to be operated. And OR areas are slightly close knit areas for the people to be there because they have more fears and talk a lot more.

[Aaron] Thank you so much, ma’am. And last question for Mr. Anjaneyulu. There was a question asking how do we control overstocking and understocking in such volatile fluctuations in demand? We’re just told from zero demand to all of the sudden 140%. From a supply chain perspective, Mr. Anjaneyulu, what should we be doing? How do we ensure that we’re not understocked or overstocked in such volatile environments?

[Anjaneyulu] Basic thing is the consumption. How are we consuming the goods which you have already in stock? And based on the consumption levels you have to plan things. Either you are low stocking or under stocking. But under stocking will not happen but over stocking happens where because you do not know some particularly these times like lockdown times, you do not know how many patients will come into your facility. And then sometimes you tend to over stock because thinking that more and more patients will come.

Once you have signals like when you plan day to day, if you’re actually look into numbers, number of people coming into your facility. Academically you will know that there is an increasing trend of patients coming into the facility so that you can increase the stock levels.

[Aaron] Thank you so much, sir.

[Anjaneyulu] Particularly for drugs and medicines you should be very careful that you should not over stock. And if you stock under the expiry dates should be a little longer so that you can use at any point in time.

[Aaron] Sir, and the last question for you. Is there any key performance indicator or KPI that is being used within the LV Prasad network as far as stock management is concerned?

[Anjaneyulu] Yeah, there are a few key indicators, particularly inventory turnover and then average consumptions. How much inventory you’re consuming and an average. And then holding cost. Holding cost, how much it costs if you put inventory for certain period of time. And then the stockouts. How frequently your stock is getting out? How frequently are you able to get the stocks in place? And then service level is also very important, KPA. Whether you’re able to serve other people on time or not. And it’s getting delivered because there is no supply? And then another important thing is the lead time. How much time is it taking to replenish the things? Once you order, once you consumed the materials, how much time it will take to replenish? These are the key process indicators for the inventory management.

[Aaron] I would like to thank all the panelists for their amazing talks. First of all for their valuable time and for the contribution that they’ve given. We’ve crossed by almost half an hour but I’m sure that this has been an extremely valuable session for everybody, myself, and Phanindra included. And we would like to say to all the panelists and to all the members that might have come, we’ve tried our very best to answer as many queries as we could within this little bit period of time. If there’s any questions that are not answered, please write to the Vision 2020 secretary, we will get back to you. Due to posterity of time we’ve tried to collate and combine a lot of the questions and we hope that everybody had an engaging learning experience. Thank you so much, over to you, Dr. Phanindra.

[Phanindra] Thank you. Thank you, everybody. All the participants, all the resource persons, and Aaron for the excellence facilitation. We formally conclude the session here and we’ll meet you sometime next very soon.