Jaipur Foot 2014 India Business Conference

2014 C.K. PRAHALAD CASE COMPETITION

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2014 Rao and Kumar. This case was written by Menaka Rao and Professor U. Dinesh Kumar of the Indian Institute of ManagementBangalore. It won Honorable Mention in the 2014 NextBillion Case Writing Competition

The Jaipur Foot: Challenges in Leading a Free Service Organization

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The Jaipur Foot: Challenges in Leading a Free Service Organization

case 1-429-388April 1, 2014

Published by GlobaLens, a division of the William Davidson Institute at the University of Michigan.

2014 Rao, Menaka and U. Dinesh Kumar. This case was written by Menaka Rao and Professor U. Dinesh Kumar of the Indian Institute of ManagementBangalore. This case is intended to be used as a basis for class discussion and is not meant to illustrate either the effective or the ineffective handling of an administrative situation.

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It was around 9:00 a.m. and patients were being admitted at the Sawai Mansingh Hospital (SMS) in Jaipur, India, where the not-for-profit organization (NPO) Bhagwan Mahaveer Viklang Sahayata Samiti (BMVSS), better known for its productthe Jaipur Foot (JF)was located. Streams of people with different kinds of locomotive disabilities were admitted daily. A few had traveled more than a thousand kilometers to reach the center.

Anybody could walk in at any time and register even with the security guard. The registration process was simple: a staff member walked around with a registration book in which the patients name was noted, along with his/her disability. Patients were first admitted as they arrived and then registered without regard to time or filling in tedious details on a form, unlike in other health-care systems where registration preceded admission. The patients were asked a few questions, such as Where have you come from? What do you do? Who is accompanying you? and so on. This simple process was all that was needed to register for a free prosthetic limb, a caliper, or other aids and appliances.

Some patients, particularly those in need of tricycles and economic assistance for self-employment, were retained at the SMS Jaipur Foot center. Other amputees and polio patients in need of calipers were moved in ambulances to BMVSSs second facilitythe Jaipur Foot center at Malviya Nagar, Jaipur, located about six kilometers away from the SMS center. At the SMS Jaipur foot center, once the registration process was completed, measurements would be taken. The customized shank/socket would then be fabricated and fitted with the Jaipur Foot piece. The patients were usually discharged on the same day or at the most within three days. If there was a delay in the fitting, the patients and their caretakers were provided free boarding and lodging.

Many of the technicians and employees (around 150 in all) working at the BMVSS were victims of locomotive accidents, and they all wore a Jaipur Foot. In its 37 years, BMVSS had fitted approximately 425,000 artificial limbs and over 350,000 calipers at its Jaipur center and 20 other branches spread over the country.1 Other aids and appliances, such as hand-paddled tricycles, wheelchairs, crutches etc, provided by BMVSS had helped about 525,000 disabled people in India.2 In all, over 1.3 million disabled people in India

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2The Jaipur Foot: Challenges in Leading a Free Service Organization 1-429-388

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had been rehabilitated between 1975 and 2012 (Table 1).3 Approximately 20,000 disabled people were rehabilitated in various on-the-spot limb fitment camps that had been organized in 26 countries (Appendix 1).4 Approximately 60,000 beneficiaries received various aids and appliances from the organization annually.5 Over the years, BMVSS had grown to be recognized as the worlds largest organization for the disabled. The organization was popular, as it catered to people at the bottom of the pyramid (BOP) without a single rupee (USD 1 = INR 62 in October 2013) collected from patients. According to D. R. Mehta, the founder and chief patron of BMVSS: We have come a long way since we began in 1975, but now the call of the day is to widen our presence, as we are able to serve only a minor fraction of the disabled people in India.

Table 1

Fitments and Other Aids and Appliances Provided by BMVSS (19752012)

Category No. of FitmentsArtificial Limbs 416,272

Calipers 348,666

Tricycles/Wheel Chairs 84,662

Crutches & Other Aids 403,643

Hearing Aids 21,502

Polio Corrective Surgery 7,376

Total 1,282,121Source: http://jaipurfoot.org/media/statistics/index.html#.Uw7Mu85Zc3g.

Mehta knew that the organization had grown serendipitously and that the reach of the Jaipur Foot centers was still limited. Though the Jaipur Foot had made significant inroads geographically, there were still several thousands of people who needed the foot. He wanted to expand BMVSSs operation to reach as many disabled people as possible and wondered how he could scale operations. In addition, he was handing over the running of the organization to a successor, and many onlookers and well-wishers had expressed that the organization might face existential issues without him. He felt among several questions that surrounded the longevity of BMVSS, three important ones had to be answered before he handed over BMVSS completely to his successor:

1. How would BMVSS identify representation gaps geographically and locate suitable partners or associates to run more branch offices?

2. The organization was largely dependent on government grants and donors for funds. How could the organization overcome its donor dependency? How would it address the issue of donor fatigue?

3. Though the organization was able to meet its annual budget, sometimes it dipped into its corpus to cover expenditures. Grants had been erratic and unpredictable in the past. How could the organization find more money to reach interior India and enter international markets?

In addition to these problems, there was a strong feeling among many that the free for all model had to change . Mehta refused to listen to this line of thinking. But at the back of his mind there was nagging doubts: Would the organization finally have to resort to charging patients? And at a more philosophical level, what would become of the organization if the business model changed from the core principles it had been built upon?

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Loco-motor Disabilities in India

According to the government of India, there were about 10 million people suffering from loco-motor disabilities, of which about 1 million had lost their limbs and 4 million were polio-affected.6

The loss of limbs was rampant as the result of accidents, land mine explosions, and gunshot wounds in war zones and strife-torn areas, as well as the effects of diseases such as diabetes and Burgers disease.i Disabled people constituted about 56% of Indias population in 2012, of which about 70% had locomotive disabilities.7 The urban and rural population had similar numbers of people with loco-motor disabilities (Exhibit 1).8 A combination of poverty and the absence of facilities for rehabilitation exacerbated the problem. The World Health Organization estimated that in developing countries, only 12% of the patients who needed rehabilitation actually had access to it.9

Exhibit 1

Percentage Distribution of the Disabled in Urban and Rural India

Source: Disabled Persons in India NSS 58th round (JulyDecember 2002), Report No 485 (58/26/1). National Sample Survey Organisation, Ministry of Statistics and Programme Implementation, Government of India.

Prior to 1975, there were very few institutions in India that manufactured artificial limbs. The most popular was the Swami Vivekananda National Institute of Rehabilitation Training and Research (S.V. NIRTAR), an autonomous institute established in 1974 that functioned under the Ministry of Social Justice and Empowerment of India. Another was the Nevedac Prosthetic Centre, founded in 1973. The Artificial Limb Centre (Pune), a part of the Indian Armys medical services wing, was dedicated solely to amputees from the armed forces, and only its surplus capacities of a few hundred limbs were made available to civilians. In the 1960s, only traditional limbs were being made in India. The foot pieces used the solid ankle, cushioned heel (SACH) foot design and were made of laminated wood and rubber. The sockets were made of wood. As a result, the limbs were heavy and cumbersome to use, and hence, the percentage of rejection by patients was high. Moreover, the time taken to manufacture a custom-made limb was several weeks, if not months. They were also too expensive to be within the reach of most people at the BOP.

i Burgers disease is a recurrent acute and chronic inflammation and thrombosis of the arteries and the veins of the hands and feet. Ulcerations and gangrene in the extremities are common complications, often resulting in the need for amputation of the involved extremity.

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Bhagwan Mahaveer Viklang Sahayata Samiti (BMVSS)

The Idea for BMVSSOn January 7, 1969, while he was traveling to Pokhran, a truck hit Mehtas car. His right femur shattered

into several pieces and he began bleeding profusely. Since the accident occurred in a sparsely populated area, he waited for three hours for medical attention. Finally, a passing vehicle gave him a lift and Mehta obtained medical aid at a local dispensary. Five hours later, he was moved to Jodhpur. When he reached the hospital, his bleeding was so intense that the doctors contemplated amputating his leg. One of the doctors attending on him had second thoughts, as he felt that Mehta was young and maybe they could take a chance by not operating on him. Luck and age were on his side, and the leg healed over time, although it took five months in a hospital bed and nearly two years of physiotherapy to fully recover.

After he fully recovered, he made it a point to frequently visit the two doctors at Jodhpur who had operated on him to thank them for saving his life. Invariably, over each visit they would tell him:

You are living on borrowed time. You could have been dead. When you came to us, your-right alignment condition was so bad that we thought of cutting off your leg. Of course, in your case, as you are an IAS (Indian Administrative Services officer), it would have been different, as with funds from the government, you would have been sent to the U.S. or the U.K. for treatment. But think of a poor man in your positionwhat would he do and where would he go?

It was a nagging and powerful question to which Mehta had no answer at the time. Further, during his visits to the hospital for physiotherapy, he was struck by the large number of people with amputated feet and legs, which started him thinking: What can I do for them? It was here that his life changed.

The Origins of BMVSSThe idea of starting a nonprofit service organization had been lying dormant in Mehtas mind for a

long time. However, as fortune would have it, as a member of the IAS, he became a member secretary of the Rajasthan state-level committee to commemorate the 2,500th anniversary of the death of Bhagwan Mahaveer (a renowned Indian sage) in 1975. With the use of funds available to the committee and private donations amounting to INR 400,000 (approximately USD 6,450), Mehta set up BMVSS to provide free prosthetic limbs to the poor. The authorities at the SMS, a government hospital in Jaipur, allowed the organization to operate in their garages and use the space as storage depots and to make the Jaipur Foot and other artificial limbs on a small scale. As the efforts grew, Mehta realized he needed to set up a formal organization, so Mehta registered BMVSS on March 29, 1975.

The organization was an amalgam of several ideas the technology (the Jaipur Foot), a social value system, a patient-centric management system, and a donation funding option. The objectives of the initiative were to answer a humanitarian need and to attract government and donor funds.

In the first year of its formation, BMVSS fitted 59 limbs using the interest generated by the corpus of INR 400,000. Since then, people not only from the BOP but from all walks of life have been drawn to the free Jaipur Foot as a viable alternative to other costly prosthetic limbs. What began as a dream gradually turned into reality as the small initiative grew into one of the largest organizations catering to the disabled with centers across the country. However, since it was a free for all model, many wondered if the organization would be sustainable over the long-term.

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Growth of BMVSSThe organization slowly grew over time with the help of Mehtas network of influential people in the government

and the support of several donors. As word spread of the free Jaipur Foot, more and more people began to stream into BMVSS. Mehta was a professional fund-raiser with profound knowledge in running the operations of the organization. In raising funds, Mehta deployed a unique style. He revealed the following incident:

I received a telephone call from an individual who was abroad who wished to donate USD $10,000. Refusing the donation, I explained that I did not accept such large gifts from individuals who had not yet witnessed the operation in action, and thus invited the donor to view our facility in India. After touring the operational headquarters and witnessing firsthand individuals limping in and walking out with a free limb that cost the organization a meager USD 45, the visitor wrote a check for USD $20,000, which was double his original intention.

Mehta was also a visionary with unique skill of simply looking at a disabled person and discerning what could be done for his/her livelihood and rehabilitation. The organization went beyond just fitting high-quality limbs at zero cost to those living in poverty. It prided itself on its ability to restore and advance human dignity and self-respect. The organization ensured that no patient would be turned away.. The organization had emerged as a large entity that had won several accolades (see Exhibit 2); Mehta personally was the recipient of a number of awards for his work.

Exhibit 2

Awards Won by BMVSS

1988 National Award for the Best Institute Working in the Field of Rehabilitation of the Disabledfrom the Ministry of Social Justice and Empowerment, Government of India

1999 Mahavir Award for philanthropic services and welfare of the handicapped

1999 Diwali-Ben Award to Master Ram Chandra Sharma (the inventor of the Jaipur Foot)

2007 Tech Award for Innovation awarded to D. R. Mehta by the world-renowned Tech Museum Innovation Organization, San Jose, California, for spreading the innovation of the Jaipur Foot on an unprecedented scale. (Mehta was chosen from a pool of outstanding innovators from 68 countries.)

2008 The Padma Bhushan (Social Work), the Government of Indias third-highest civilian award, was conferred on D. R. Mehta

Source: http://www.jaipurfoot.org/01_progress_awards.asp

The Jaipur Foot

The Jaipur Foot (JF) had a life span of three to four years. It had two parts: the factory-made foot and the custom-made plastic shank/socket. The foot piece was invented in the SMS Medical College, Jaipur, by a group of doctors (P. K. Sethi, S. C. Kasliwal, and Mahesh Udhawat) and a craftsman, Ram Chandra Sharma.10 The foot was fashioned out of two pieces of microcellular rubber and a wooden ankle piece to which toes were attached. Rubber provided the foot with flexibility and the ability to absorb shocks. The assembled foot was covered with skin-colored rubber, and was then placed in a die and steamed at high pressure to vulcanize the foot. This foot was attached to a custom-made socket/shank made of high-density polyethylene (HDPE) pipe. Making the foot was simple and replicable. Mehta explained:

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The technology for making this prosthetic device requires only a little start-up capital and some machinery, locally available materials such as rubber, wood, etc. It is a combination of science and art. We did not patent it, so that its benefit could spread without any let or hindrance.

All the raw materials for the Jaipur Foot/limb were available locally in each of the geographical areas in which the organization operated. The other requirements for the foot, such as the socks and the pipes were sourced at Jaipur from agents or suppliers that often charged concession rates. For instance, the pipe was sourced from Reliance Industries at a reasonable price. According to Mehta, a company making socks exclusively for global brands such as Reebok and Nike charged BMVSS only INR 60 per pair as compared with its market rate of INR 200300 (approximately USD $3.55).11

Exhibit 3

The Jaipur Foot

Source: BMVSS

Building the Organization

According to Mehta:

We provide over 20,000 amputees round the year with limbs. I dont think any other organization in the world fits even a thousand limbs a year. In addition, we hold on-the-spot limb fitment camps outside India; in all, we have held more than 50 camps in 26 countries of Asia, Africa, and Latin America. And whatever we provide, we do so totally free of charge with support from sponsors. One major feature about us, apart from the efficiency of the limb, is the time taken for making it. People come in the morning and leave in the evening or within three days at an outer limit.

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BMVSS operated with an annual budget of INR 150 million (approximately USD 2.5 million): government grants accounted for about INR 50 million (approximately USD 0.8 million) of the budget.12 A section of the Malviya Nagar Jaipur Foot Center was sublet to a software company, which agreed to provide training to some of the patients of BMVSS. The interest generated by the INR 23 million corpusii that had been built over the past 37 years accounted for 15% of the organizations income.13 The remaining 50% of the expenditure came from large and small donations from India and abroad (Table 2).14 Complete operational integrity was maintained right from inception with the result people trusted the organization and donated wholeheartedly.

Exhibit 4

Parts of the Jaipur Foot

The Jaipur Foot is made of rubber generally used in the manufacture of automobile tires and looks like a natural human foot. Barefoot walking is possible and the foot enables the user to sit cross-legged and walk on uneven surfaces.

The total contact socket is made of 10mm high-density polyethylene (HDPE) sheet thermo formed on a plaster positive mold.

The outer socket or shank connects the socket and is made of HDPE pipes and gives the shape of the leg to the prosthesis.

The suspension belts are made of leather.

Source: BMVSS

The administrative and overhead costs of BMVSS hovered at 4%, compared with the nonprofit industrys norm of 10%.15 In the case of many other international NGOs such costs could go up to 70% or 80%.16 BMVSS was mindful of every rupee that was spent. Austerity and a parsimonious attitude were reasons why the organization was able to provide limbs free for millions of people. Mehta said:

From the beginning, we instituted a culture that did not allow the use of funds for any purpose other than our core objective. We did not even serve tea costing just 5 rupees a cup during our meetings; and to cut costs each of us even gets water from home to drink. We believe that if we divert even one rupee to an activity other than serving the poorest of the poor, we are committing a moral sin and are legally wrong.

ii Total amount of money invested by all investors in a scheme.

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BMVSS was largely dependent on the government for funds. However, the funds were received only if representation from the organization was made annually. Mehta recounted:

For government grants to us, we detail an Excel spreadsheet that spans 21 columns of information about our patients, including their signature and thumbprint. This is not our money, and therefore it is our duty to be absolutely accountable for these funds, or we might not receive them again.

Table 2

Concise Expenditure and Income of BMVSS

Fiscal Year 200809 200910 201011 201112Expenditure(in USD)Cost of limbs and calipers distributed 675,737 651,826 656,933 1,004,311

Assisting devices 331,279 266,348 364,424 577,911

Expenses on amputees 113,072 150,236 245,049 205,302

Administrative and other expenses 186,280 156,110 198,909 221,531

Material transferred to branches 545,510 185,649 198,156 506,700

Total Expenditure 1,851,878 1,410,169 1,663,471 2,515,755Income(in USD)Grant in aid 898,985 424,650 874,358 1,166,000

Rent receipts 64,174 50,956 61,567 60,855

General collections 976,345 1,121,730 931,801 1,308,451

Interest 142,993 184,039 189,272 125,281

Dividend 47,644 53,194 45,563 69,407

Total Income 2,130,141 1,834,569 2,102,561 2,729,994Source: BMVSS

The marketing of the Jaipur Foot was intimately tied to BMVSSs culture of accountability and the quality of its products, rooting the organizations growth in rigid expenditure policies and scrupulous accounting. A preaudit, an internal audit, and a statutory audit were performed on a regular basis. Mehta repeatedly reaffirmed that the organization was squeaky clean and the office bearers did not debit even a rupee to BMVSS for personal expenditures. The office bearers would not be reimbursed for travel, with the result that any travel undertaken was only if required and at the individuals expense or with support from sponsors.

Inventory was taken on a quarterly basis. Requirements were calculated based on the number of forthcoming camps and the average number of patients expected in all the branches, and a rough estimate was drawn up, thus simplifying production and stock management.

The waste generated during manufacturing was auctioned through a bidding process and sold to the highest bidder. Almost 810 kilograms of waste that was sold per day was recycled by the buyer. Environment-friendly waste management was handled by the organization on a regular basis.

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All the technicians at each center were trained at Jaipur. Additionally, BMVSS partnered with a government-run training center to set up a vocational training center at Jaipur for the rehabilitation of patients. Patients were trained in carpentry and stitching. Mehta also provided financial aid to some of the patients. Patients would be given seed money or kits to, for example, start a tea stall or buy a sewing machine to help kick-start their self-employment efforts.

Mehtas Formula

In 2007, a professor from Cornell University said he would like to study BMVSS. Mehta, open to new ideas, welcomed him. After studying the organization, the professor said: Sorry, you are not sustainable as an organization. To the professors surprise, Mehta acknowledged that he was aware of this. The professor asked:

What if your funds dry up? What would happen if the government or donors stopped supporting the organization? What would you do? Today, you boast of not sending back a single patient without treating him, but is it going to be the same always?

Mehta said:

We will beg and borrow, not steal. I feel compassion exists in the world and people will support us, provided we work well and do not merely showcase ourselves. I also realize that people must believe in us, believe that genuine work is going on, that there is no fudging of accounts, and that the office bearers are not misusing their positions. Money will come.

In a lighter vein, he asked the professorwho had been teaching for several years and had come to be known as a management guruhow many companies had sought advice from him. He estimated that the number must run into several hundred. Mehta then asked how many of those companies still existed. The point he was trying to make as he recounted the conversation was that despite not making plans, BMVSS had survived for 37 years; certainly with doubts about its survival every year, but nonetheless, it had survived.

To Mehta the principle of solvency was simple:

Professor, let me have the audacity of telling you a paradigm of mine: E = mc2. To most people, this would mean energy = matter x (the speed of light)2. I have changed it to E = effort, m is for money, and c is for compassion. Hence, my formula is E = mc2. We are all human beings and we all have empathy and sympathy. This empathy and sympathy has carried us through, and it has become a part of the enjoyment of growing; every time you come out of it successfully, you realize that its all a part of social work.

Growing Domestically

BMVSS over the years had grown to become a pan-India organization with 22 centers spread across India, most of which were located in government hospitals in the area of operations. Though each center was independent, the Jaipur Foot technology and the principles on which BMVSS operated were common. To set up a branch was simple. It needed little resources but plenty of dedication and passion to serve the limbless. The cost of the equipment required for starting a center was approximately INR 1 million (approximately USD 20,000). The operational cost of running a center depended on the number of fitments. The flow of donations for centers to operate smoothly was crucial. The Bangalore center of BMVSS, for instance, secured donations amounting to about INR 200,000 (approximately USD 4,000) annually (although not consistently), which was adequate to operate from the local government hospital.17

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The Jaipur Foot: Challenges in Leading a Free Service Organization 1-429-388


All materials required for making the prosthetic foot were sourced from Jaipur. While some branches paid for the foot, others were given the materials required to manufacture the foot free of charge from headquarters. The technicians were trained in Jaipur, and the branches acted as fitment centers.

Most branches were managed by a combination of social workers and industrialists/businessmen. While the former provided the social input, the latter brought in funds and their business acumen. Each branch aimed at transforming itself into a replica of the Jaipur center, right up to the point of manufacturing the foot, working on partnerships, and their ability to be independent and self-sufficient. In addition to fitting limbs at the hospital outlets, the branches held on-the-spot camps in areas close to the branch offices to avoid the need for patients with financial and physical difficulties to travel far. These camps were sponsored by institutions, individuals, or the government. The doctors and technicians from BMVSS or from the closest branch traveled with equipment and material to the camps. They provided on-the-spot fabrication, fitment, and delivery of the limbs in addition to other aids and appliances. This system particularly helped the rural areas get access to the limbs.

Some branches also had mobile workshops set up in vans. The vans, fitted with the required equipment to manufacture the limbs, cost approximately INR 1.5 million ($30,000 USD). These vans would travel to nearby villages to benefit the local villagers. In addition, to address BMVSSs lack of presence in rural areas, the branches networked with local or national NGOs and partnered with them to service rural areas. For instance, the Bangalore branch had a tie-in with the Red Cross. Funds from the state government were allocated to the Red Cross, and a part of this was given to the Bangalore branch of BMVSS to be used for foot fitments in rural areas. The Bangalore branch would bear the cost of obtaining the foot from Jaipur and the Red Cross provided travel, fitment, and other expenses free of cost.

Additionally, the branches networked with local NGOs dealing with prosthetics. The foot was given to these NGOs with a no profit, no loss payment, while the fitment was done by BMVSSs staff.

Going International: Putting a Foot across the Ocean

Wanting to spread its wings, the organization in 1995 began its first overseas venture. Four camps were held in Afghanistan, with the government of India sponsoring three of them.18 The fourth camp was sponsored by J. P. Morgan Bank, U.S.A., on the recommendation of Frank Wisner, a former U.S. ambassador.19 Following the success of this camp, other international camps were organized. Camps were held at Karachi and Islamabad in Pakistan with the help of a leading industrialist.

BMVSS was also involved in a joint venture (JV) called the Mahaveer K-Mina Foundation in Madeline, Colombia, with the support of a local industrialist whose trust met the expenses while BMVSS provided some of the foot pieces free of cost from Jaipur.20 As of 2012, about 2,373 limbs had been fitted in Sri Lanka.21 Further, an associate of the BMVSS, Mahaveer Philippines Foundation Inc., Manila, operated three centerstwo in Manila and one in Zamboanga.

In all, more than 50 on-the-spot camps had been held in 26 countries, all of which were sponsored by the country where the camp was held, by the local government, or by individuals.22

All the other overseas ventures were managed as camps and were handled locally. Further, BMVSS helped set up a large number of independent artificial limb fitment centers in Asia, Africa, and Latin America. The organization had also been given a special consultative status with the Economic and Social Council of the United Nations Organization (UNO). However, BMVSSs presence in the developed world was absent mainly because of regulatory issues.

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The Expansion Phase

On August 10, 2008, Mehta visited Stanford University to request assistance to develop a knee joint for above-knee amputees.He was accompanied by Armand Neukermans, founder of Xros (part of Nortel), an entrepreneur for over 35 years and a patron and major contributor to BMVSS for over a decade.

Mehta said:

I signed an MOUiii with Stanford University in late 2008. The first research project was to develop a new knee joint for above-knee amputees. Their team came to Jaipur four times and interacted with our doctors and also our technical committee, which had professors from IITs,iv MNIT,v and other experts from the field of prosthetic and orthotics and material sciences. Finally, a four-bar-linkage polycentric knee joint was developed. It was hailed by Time magazine as one of the 50 Best Inventions of the World for the year 2009.

Time wrote:

Poor patients who lose a knee joint have few options: a titanium replacement can cost $10,000, and crude models dont work very well. Now a team of Stanford engineering students have designed a knee that is not only dirt cheapjust $20but also mimics the natural joints movements. Developed with the Jaipur Foot group, the Jaipur Knee is made of self-lubricating, oil-filled nylon and is both flexible and stable, even on irregular terrain.23

The Jaipur and Delhi centers of BMVSS were involved in the manufacture of the new knee, and from late 2008 to 2012 BMVSS had fitted more than 5,000 such joints.24

After the initial signing of the MOU with Stanford, BMVSS established a technical committee to guide its research and development. The organization then signed an MOU with the Indian Space Research Organization (ISRO) for a new design of the polyurethane foot (PU foot) called the Mahaveer-ISRO foot, which was through a computer-controlled injection molding process.25 The Department of Science and Technology of the government of India sanctioned a research project for additional gradations of the Jaipur Foot. There were other projects as well, such as the development of a terminal device (hand) for upper-limb amputees in collaboration with Stanford University, the development of upper-limb prosthetics with the Rehabilitation Institute of Chicago, the designing of a wheelchair-cum-tricycle with the Massachusetts Institute of Technology (MIT), and so on.26

The Paul Hamlyn Foundation, a British charity, donated $1.5 million in 2012 to BMVSS.27 The amount was invested to establish a corpus to aid long-term financial sustainability and set up an International Research Center for Prosthetics & Orthotics. The center was intended to attract ideas and experts from all over the world and help in-house and collaborative research with universities such as Stanford, MIT, and the Indian Institutes of Technologies of Delhi, Mumbai, Chennai, and Jodhpur.

As part of Dow Indias corporate social responsibility (CSR) program, the company collaborated with BMVSS on an initiative called the Jaipur Foot on Wheels. From 2005 over the next several years, Dow Chemical donated INR 40 million (approximately USD 800,000) to fund the manufacture and distribution of limbs andcalipers through a fully equipped mobile workshop, where company employees would volunteer as camp facilitators.28 Dr. Ramesh Ramachandran, the president and CEO of Dow India, then said:

iii Memorandum of understanding.iv Indian Institute of Technology.v Malviya National Institute of Technology, Jaipur.

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The Jaipur Foot initiative shows how successful a close collaboration between a technology company and an NGO can truly transform science and innovation into tangible benefits for the societys less fortunate. Our partnership with BMVSS has reached out to more than 40,000 people since 2005.

Challenges

Mehta said, At the current setup in Jaipur, we have the capacity to fit 10,000 more limbs each year, but we lack the funding to fulfill that capacity. And because of this challenge, Im the biggest beggar in India.

A lack of funds had haunted BMVSS from the time of its inception, and though the organization had managed to ward it off to some extent, mainly with money from the corpus and several large donations, it was perennially cash-strapped. Being largely donor dependent, BMVSS would look for funds in every nook and corner possible. In 2012, the Indian government had introduced a new Companies Bill, which prescribed that every company with a net worth of over INR 5,000 million ($100 mil USD), or turnover of over INR 10,000 million ($200 mil USD), or a net profit of over INR 50 million ($1 million USD) would have to spend 2% of its three years average profit on CSR activities.29 This gave hope to BMVSS. In addition to managing the organization with meager sporadic funds, there was an immense need to invest in research and development in order to seek lighter and cheaper material for the manufacturing of limbs. For example, the foot was hand-designed and at times suffered from a lack of adherence to consistency parameters, with the total weight of a below-knee limb varying between 1.3 and 1.5 kg. While the possibility of reducing the weight existed, it would require research, technical expertise, and adequate funds. In addition, with the lack of any quality certifications, the Jaipur Foot was not accepted in many countries. When the Jaipur Foot was used by people at the BOP, certification did not matter due to the sheer necessity of using the product, but it did pose a limitation when the class or quality of the user changed. Though BMVSS had undertaken several initiatives to improve the quality of the Jaipur Foot through research collaborations with national and international organizations, it still had a long way to go, especially in light of past failed attempts to foster partnerships in the joint manufacture of advanced prosthetics with international bodies, such as USAID and the Red Cross, on issues of product quality.30

Unique Method of Management

The BMVSS management consisted of an Executive Committee composed of honorary office bearers and members (Exhibit 2a). Mehta was the founder and chief patron. The secretary general managed the executive office, supported by the chief executive officer and the chief technical consultant. Following a resolution by the executive committee, Mehta was given the same powers as the secretary general. However, Mehta was mostly involved in strategic matters, patient care, and welfare. In addition, there were several sections at the head office in Jaipur, with independent functions reporting to the Executive Committee (Exhibit 2b).

The value system and the management practices followed at BMVSS were driven by a humane social philosophy that was patient-centric followed by an open-door policy.

The management of the organization was founded on four pillars. The first was free assistancelimbs, calipers, and other aids and appliances were given free of cost. Though several people criticized the organization for providing assistance free of cost, BMVSS believed that money was not the measure for everything. The second pillar was the philosophy that the limbless were provided help and not charity. The third pillar was equality in assistance, which was to provide help without any distinction based on caste, creed, religion, or

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region. The last pillar of the organization was proper treatment. In the language of BMVSS, this meant that patients were treated individually with respect and as human beings. BMVSS attempted to be different from other nonprofit organizations in its belief that as an institution, it was simply an instrument to provide need-generated assistance.

The Future

Neukermans (a patron and major contributor to BMVSS) would constantly tell Mehta: The way to develop the company is not by keeping the services free but by setting up a sustainable business. This was also the thinking of many well-wishers of the organization.

Growing the organization to its present state had not been a bed of roses. The growth was ad hoc and haphazard, with no clearly defined strategy. Critics questioned the sustainability of the organization with the suggestion that there should be a change in the free for all model. Though fortuitous expansions had taken place, many felt that there was nothing wrong in making a business out of doing good. However, Mehta continued to be against charging because it went against the basic objective of the company and his principles.

Mehta, realizing that he would soon be handing over his position became reflective. Thinking about how to make the organization better had almost become a habit for him. His thoughts wandered on many aspects, and he hoped his successor would do well in developing them:

How should BMVSS become self-sufficient and scale up simultaneously?Would the organization benefit from partnering with other NGOs for rehabilitation as it had with

technical partners?How could short-term assistance be coordinated with long-term livelihood and sustenance on a

more standardized basis? Was it the right time to expand? Would expansion mean an increase in the administrative costs

from the current 4%? How should BMVSS address the reality of cost escalations in raw material and manpower?Many people had told Mehta that he needed to charge some of his wealthier patients a nominal

fee. Was the option worth considering, especially now that a new leader would replace him soon in the organization?

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Appendices

Appendix 1

Jaipur Limb Fitments in Camps Held at Foreign Countries

Country No. of FitmentsAfghanistan 3,051

Bangladesh 1,000

Dominican Republic 500

Honduras 400

Indonesia 869

Malawi 250

Nigeria 500

Nepal 200

Nairobi 500

Panama 400

Philippines 3,000

Papua New Guinea 170

Rwanda 500

Somalia 1,000

Trinidad & Tobago 200

Vietnam 600

Zimbabwe 250

Sudan 1,800

Lebanon 381

Zambia 121

Pakistan 987

Iraq 882

Sri Lanka 1,210

Senegal 607

Fiji 300

Total 19,678Source: http://www.jaipurfoot.org/02_progress_performance.asp.

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Appendix 2

BMVSS Organizational Charts

Appendix 2(a): Organizational Chart of the Central Office of BMVSS

Appendix 2(b): Sections of the Executive Office of BMVSS

Source: http://www.jaipurfoot.org/02_management_whatisourorg.asp

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Appendix 3

The Jaipur Foot and Prosthetics to Be Fitted on an Amputee

Source: BMVSS

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Endnotes

1 Company website, http://jaipurfoot.org/media/statistics/index.html#.Uw7Mu85Zc3g.2 IBID3 IBID4 IBID5 IBID6 jaipurfoot.org/images/BROCHURE.pdf7 Disabled Persons in India Report No. 485 (58/26/1). National Sample Survey Organisation, Ministry of Statistics and Programme

Implementation, Government of India, December, 2003.http://mospi.nic.in/rept%20_%20pubn/485_final.pdf (last accessed on 2 December 2012).

8 Disabled Persons in India NSS 58th round (JulyDecember 2002) Report No. 485 (58/26/1). National Sample Survey Organisation, Ministry of Statistics and Programme Implementation, Government of India.

9 Disability Statistics and Facilities in India: Statistics on Locomotor Disabilities in India. http://pmr-sjmch.tripod.com/disabilityindia.htm (last accessed on 2 December, 2012).

10 http://www.nytimes.com/2008/01/08/world/asia/08seti.html?_r=0, also provided by the company.11 Company provided12 IBID13 IBID14 IBID15 http://www.fundsforngos.org/budget-for-ngos/defining-terms-budget/16 Company information17 IBID18 IBID19 IBID20 IBID21 IBID22 IBID23 The 50 Best Inventions of 2009: The $20 knee. Time (Print issue: 23 November, 2009) http://www.time.com/time/specials/

packages/article/0,28804,1934027_1934003_1933963,00.html (last accessed on 2 December, 2012).24 Company Information25 IBID26 IBID27 IBID28 IBID29 The Financial Express, 201230 Company Information

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Notes

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Notes

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