The Jaipur Foot


People Engagement Series

Case Study # 2

“A true friend knows your weaknesses, but shows you your strengths;  Feels your fears, but fortifies your faith; Sees your anxieties, but frees your spirit; Recognizes your disabilities, but emphasizes your possibilities 1

– William Arthur Ward

Background

The Jaipur Foot is a low cost, artificial lower limb that is manufactured in India. It has transformed the lives of innumerable amputees in India, Afghanistan, Bangladesh, Dominican Republic, Indonesia, Kenya, Lebanon, Nigeria, Pakistan, Panama, Philippines, Rwanda, Somalia, Sudan, Trinidad, Uganda, Zimbabwe, Zambia and other countries.2The origins of Jaipur Foot go back nearly half a century to the capital city of the Indian state of Rajasthan, from which it derives its name.

The story goes back to 1968 when Dr. Pramod Karan Sethi was working as an orthopedic surgeon at the Sawai Man Singh (SMS) Hospital in Jaipur. The hospital’s rehabilitation centre provided treatment to amputees. However, the available western limbs were too expensive and rigid to allow the easy mobility and resilience that was needed by the common people of India.

At around the same time, an ace craftsman by the name of Master Ram Chandra Sharma (fondly known as Masterji) was engaged by the SMS Hospital to teach the art of making handicrafts to leprosy patients. Masterjifelt frustrated by the expensive and impractical foreign-made prostheses that he saw being fitted on to the amputees. 

Masterjiresolved to create a better alternative that would be strong and flexible enough to withstand the rigours of manual labour, and also accommodate the full range of motions that were required for daily prayer at the temple or mosque. To that end, he worked together with the SMS doctors (including Dr. Sethi, Dr. S.C. Kasliwal, and Dr. Mahesh Udawat) to make a better prosthesis. 

Like every great innovation, their solution was simple and elegant. Instead of using costly alloys and polymers, they opted for a core of high-density foam rubber and wood that was wrapped in vulcanized rubber. When pressed in a metal mould and heated, these components were found to bond together. They took on a form that was uncannily close to the shape of a real human foot. 3

This was then attached to a sturdy wooden leg. 

The resulting prosthetic foot consisted of a shell filled with sponge rubber, a stuffed piece for the meta-tarsals, and microcellular rubber for the heel that was cut in places to allow for joint-like movement. 4This design was flexible. It allowed the wearer to climb trees, pedal bicycles, and use Indian-style toilets. 

In 1971, Dr. P.K. Sethi presented the Jaipur Foot to orthopedic surgeons from Oxford University. They were very impressed. During the early seventies, the Jaipur Foot transformed around 50 lives. But for Dr. Sethi’s involvement, the Jaipur Foot would not have been recognized by the medical world.

By a stroke of serendipity, an Indian Administrative Services (IAS) officer by the name of Devendra Raj Mehta was receiving recuperative physiotherapy at the SMS Hospital at that time. This was after a debilitating accident in 1968 that had crushed his right femur bone and nearly left him dead. 

Seeing patients queue up for the few fittings of the foot provided there, D.R. Mehta came to the conclusion that this simple prosthetic innovation had much greater potential for social good. He became consumed by the idea of reaching this service out to as many people as possible. 

In 1975, D.R. Mehta raised Rs. 4 lakhs in government aid and private donations – in order to start the Bhagwan Mahaveer Viklang Sahayata Samiti(BMVSS) as a human welfare project to provide the Jaipur Foot free of cost. In doing so, he turned a brilliant invention into the foundation of a formidable charitable concern. 5

The Bhagwan Mahaveer Viklang Sahayata Samiti(BMVSS)

The BMVSS is a voluntary non-governmental, non-religious, non-sectarian, and non-political Society. Popularly known as the Jaipur Foot Center, it is the world’s largest organization serving the disabled and handicapped people, particularly those who lack adequate resources. 

The mission of BMVSS is to facilitate the physical, social and economic rehabilitation of the disabled population around the world. The institution seeks to help restore the glory of the disabled person’s life, and help advance the person’s dignity, self-respect, mobility as well as usefulness as a normal member of the community. The focus is particularly upon the poor amputees, who remain deprived of these aids and appliances under the unaffordable modern health care system.

Over the last 43 years, BMVSS has grown into the world’s largest limb fitting society – without having an articulated revenue model. It has transformed the lives of nearly 1.6 million people across 26 countries in Asia, Africa, and Latin America. 

BMVSS fits around 20,000 limbs every year. It also provides 65,000 other people with calipers, hand-pedaled tricycles, wheelchairs, crutches, hearing aids, and other orthopedic aids and appliances. The organization presently employs nearly 173 people – including doctors, therapists & administrative staff.

Scores of patients visit the BMVSS campus in Jaipur daily. 95% of these people fall below the poverty line. Most of the time, the security guard himself admits them. 

The procedures for client admission, treatment, and prosthetic fitting have been kept simple. Patients are provided with free lodging & boarding facilities till the time they are given prosthetic limbs, calipers or other aids. The Jaipur foot is usually custom-fitted within twelve hours of the patient-checking in. 5

Outside of its own centers, BMVSS holds regular on-site field camps at various places in different parts of India. In addition, mobile clinics have been set up in 26 countries around the world. Doctors and technicians travel with equipment and materials to these camps. 6They provide on-the-spot fabrication, fitment, and delivery of limbs and other aids to patients for whom distant travel is otherwise difficult.

The mandate of BMVSS extends beyond medical care to include economic self-sufficiency. Previously unemployed patients are provided with equipment to establish small businesses. For instance, needy beneficiaries are provided with all the utensils that are necessary for setting up “tea and snack” stalls. 

The backbone of BMVSS’s steady growth is rooted in a suite of incredibly inexpensive prosthetics, aids, and appliances, coupled with beneficiary-centric management practices. The foundation of its philanthropic activity rests upon the twin pillars of compassion and scrupulous expenditure policies. 

For instance, in order to account for the grants received from the government, the Jaipur Foot organization maintains a detailed spreadsheet that spans 17 columns of information about its patients. Since the money is received from an external agency, the institution considers it as a duty to be accountable for these funds.

As a humanitarian organization, BMVSS knows no frontiers. The organization treats all its beneficiaries across the world equally. Assistance is provided to them without any geographical, gender or religious bias. BMVSS also undertakes research and development towards the improvement in the quality and reduction in the cost of the artificial limbs, calipers, and other aids. 

Further, the grounds of its Jaipur campus serve as a hub for the local community. It provides a quiet space where students often come to study their books. 

The beneficiaries of BMVSS include the young and old alike, as also the rich as well as the poor. One of the most celebrated cases is that of the Bharatanatyamdancer Ms. Sudha Chandran. In 1981, she met with a road accident. Her right leg had to be amputated at the tender age of 17 years. 

Sudha overcame her disability with the help of a prosthetic Jaipur Foot. Subsequently, she went on to become a highly acclaimed dancer as well as film and television actress. With the help of the prosthetic, she performed at many international events. Sudha thus became an inspiration for numerous people. 6

The Jaipur Foot Technology

Once an amputee enters the Jaipur Foot Center, a caretaker is assigned to each patient until the Foot is fitted. Orthopedic specialists inspect the level of amputation, and prescribe the Jaipur Foot. 8There is a trauma counseling session to help the person accept the idea of having to live with the artificial limb. 

Next, a foot technician takes correct measurements of the stump as well as the rest of the limb (for reference) and proceeds to make a hollow cast. Plaster of Paris (POP) is poured into the cast to get a model of the amputee’s limb. A pre-heated high-density polyethylene (HDPE) pipe is now pressed around the mould. This results in an artificial limb assuming the natural shape of the missing limb. 2

The POP mould is now broken and removed from inside, and a rubber or polyurethane foot is attached. Finally, the artificial foot is attached to the stump with leather belts to hold it in place.  It looks just like a natural limb, and fits quite easily. The Foot is lightweight, and has a life of around five years. 

The person then learns many gait training exercises. This helps him or her to get used to the artificial limb, and also build the required strength in the supporting muscles. Proper maintenance and care of the foot is also taught to the amputees. 

The Jaipur Foot and its allied aids are made with the developing country lifestyle in view. Their design provides for mobility in all the three planes: a) dorsiflexion and plantar flexion, b) inversion and eversion, and c) transverse rotation. This allows the amputees to sit cross-legged, squat, walk barefoot on uneven surfaces, climb trees, negotiate muddy terrain and even run without shoes. 6

The performance of the Jaipur Foot provides users with an affordable natural gait. This prosthetic may be worn with or without shoes. It has enabled many amputees to lead a nearly normal life. Cycle-rickshaw operator amputees have been able to resume operations, while the farmer amputees have got back to farming. Many other individuals who had lost their limbs are able to participate in their previous vocations once again. 9

All this is made possible at just a fraction of the cost of the foot prosthesis available in the western world. A Jaipur limb presently costs around Rs. 2,500 to prepare. It is made available to the beneficiaries across the world totally free of charge. BMVSS believes that the moment a service begins to be charged for, the most vulnerable parts of society are the first to be marginalized. And that is precisely the segment of the population that the institution is most keen to serve. 

The Jaipur Foot has been constantly improved upon. However, its essence remains intact – low cost, quick fabrication out of locally available materials, crafted by local artisans, lightweight, and suitable for working people across the developing world. 2

The Operational Strategy

In order to provide limbs, aids, and appliances to disabled beneficiaries at its centers, BMVSS follows an operational strategy whose salient features are as follows:

a) An open-door policy: Any disabled person may visit and register at the BMVSS centre at any time of the day or night, without any appointment. The admission system enables the patient as well as an accompanying attendant to get immediate board and lodge facilities (free of cost too).

b) One-stop-shop: Its centers are one-stop providers of artificial limbs, calipers etc.  The beneficiary stays put at BMVSS for one to three days, until he or she satisfactorily receives the medically advised prosthetics and other aids. 10

c) Assembly line method: The entire process, from measurement and fabrication to fitting and training, resembles an assembly line approach. The design of the product and its manufacturing processes are kept simple and practical. The product quality is never compromised.

d) Procurement at concessional rates: To keep costs under control, most input materials are sourced locally. On account of its demonstrated integrity and ethical dealings, many suppliers provide raw material to BMVSS at highly concessional rates. 

e) Reduction of Overheads: Special efforts are made to keep the overhead costs as low as possible. To that end, the 22 BMVSS centers across India operate mostly from the local Government Hospitals. The hospital premises are used for the production of the artificial limbs as well as for service to the patients.

The society’s office bearers do not serve tea at their meetings. They even carry drinking water from their homes. Travel is not reimbursed, unless it is inevitable towards the work at hand. At around 4% of the total budget, the administrative expenses of BMVSS are among the lowest in the world for any organization of its kind. 11

f) Recycling:The waste products generated during the manufacturing process are auctioned through open bidding. The buyers often recycle the waste. The entire operation is very environment-friendly.

g) Finances: BMVSS meets around one-third of its costs from the grants provided by the Ministry of Social Justice & Empowerment of the Government of India. A portion of the cost is also met out from the interest income earned from the BMVSS corpus that has been created over the last four decades.6

The rest of the expenses are met through the donations made by generous and caring individuals as well as institutions. A culture of scrupulous accountability has been inculcated, by means of regular internal as well as statutory audits. 

The Sustainability Challenge

In the light of its noble mission, the main issue for BMVSS through its four decades of existence has been that of sustenance. 12Going forward, some specific challenges that BMVSS might face are as follows:

(i) The Free of Charge model:  Since BMVSS does not charge any money whatsoever from its beneficiaries,no revenue accrues to it directly. Around half of its annual budget of Rs. 15 crores is met through erratic donations and grants. Many of the donors, patrons, and experts are concerned that the “free-of-cost” and “free-for-all” model may not sustain for long.They see nothing wrong in doing “well” by doing “good.” However, this debate has only reinforced D.R. Mehta’s faith in the present model. 

One way to improve finances is to increase the corpus. The stipulation in the Indian Companies Act (2013) that requires organizations to spend at least 2 percent of their net profits on Corporate Social Responsibility is likely to help bring in more funds.

(ii)No Patent: The prosthetic has not been patented due to the purely altruistic motivation behind its creation. The technical know-how has been freely shared with centres in other geographies, so as to serve the maximum possible number of people. As a result, cheap or inferior imitations have come up in the past using the “Jaipur Foot” name. This spoils its brand value.

(iii)Quality and Technology:The lack of ISO and other Quality certifications has prevented the spread of the Jaipur Foot among the developed countries. Being handcrafted, it also suffers on consistency parameters. However, collaborations with Dow Chemicals and the Indian Space Research Organization for polyurethane technology has helped to reduce the cost, weight and fabrication time of the Jaipur Foot while increasing its durability.

(iv)Demand Growth: There has been an exponential increase in the need for artificial limbs across the world. However, the Jaipur Foot centers are still very limited in number. Representation gaps need to be identified. Suitable partners also need to be located in order to run more branch offices. This may call for a drastic re-ordering of the institutional values and priorities. 

(v) Cost Escalations:  As the organization scales up, the administrative expenses are likely to increase. The rising costs of raw material and manpower also keep pushing the budget. 

(f) Patient/Technician Ratio:In order to cater to the enormous volume of patients being served daily, and adhere to the policy of admission and discharge within 12 hours as far as possible, BMVSS is required to maintain a Patient to Technician ratio of 1:1. Most of its technicians are ex-patients, who now earn a remuneration that is twice the Indian average per capita income. The challenge is to find and retainalarge number of employeeswho will faithfully abide by the mission of the organization.

(g) Succession Planning:The Jaipur Foot initiative cannot be replicated very easily, because it is driven by the extraordinary vision and passion of Devendra Raj Mehta. In order to sustain and grow the organization in the future, BMVSS needs another person with the same charisma and stature. 

After ‘experimenting’ with young professionals, social activists, and retired bureaucrats, DR Mehta has chosen a ‘distant’ relative Bhupendra Raj Mehta to succeed him. 13

Accomplishments

Jaipur Foot is one of the most technologically advanced social enterprises in the world. It represents the triumph of Gandhian engineering, or the frugal approach to innovation. 14

The Stanford-Jaipur Knee was developed as a result of the joint research between BMVSS and Stanford University. It was hailed by the Timemagazine (November 23, 2009 issue) as one of the world’s 50 best inventions for 2009. 19

BMVSS has been conferred with the National Award for being the best institution for the handicapped in 1982, and for the best institution working in the field of rehabilitation of the disabled in 1998. 15

D.R. Mehta has ceaselessly championed the cause of BMVSS for 43 years. During much of this time, he was simultaneously engaged in an illustrious administrative career that included such high-profile positions as the Deputy Governor of the Reserve Bank of India (RBI), the Director General of Foreign Trade (DGFT) and the Chairman of the Securities and Exchange Board of India (SEBI).

Thankfully, his efforts over the decades have not gone unrecognized. The Government of India conferred the Padma Bhushanon D. R. Mehta in 2008. The prestigious Rajiv Gandhi National Sadbhavana Awardwas presented to him in 2012. He was also conferred with the Clairmont Lincoln Ahimsa Awardfor 2014 in California, among many others. 15

Further, the Parliament of Philippines felicitated his brother VR Mehta in 2010 for the efforts towards providing Jaipur Foot and other prosthetics to the disabled in their country.

References

  1. Ward W. William Arthur Ward: A true friend knows your weaknesses but shows you your strengths; feels your fears but fortifies your faith; sees your anxieties but frees your spirit; recognizes your disabilities but emphasizes your possibilities. [Internet]. Quotes.net. [cited 26 May 2016]. Available from: https://www.quotes.net/quote/38924
  2. Artificial Limbs – Print [Internet]. Medindia.net. [cited 3 May 2018]. Available from: https://www.medindia.net/patients/patientinfo/artificial-limbs-jaipur-foot_print.htm
  3. Stelfox D. Versatile and inexpensive, Jaipur Foot prosthesis is transforming lives. The National [Internet]. 2012 [cited 3 May 2018];. Available from: https://www.thenational.ae/lifestyle/wellbeing/versatile-and-inexpensive-jaipur-foot-prosthesis-is-transforming-lives-1.388030
  4. Arya A, Klenerman L. The Jaipur Foot. The Journal of Bone and Joint Surgery (Br). 2008;90(B):1414-1416.
  5. The Case of Jaipur Foot [Internet]. Bottom of the Pyramid: Solutions for Social and Economic Development. 2004 [cited 4 May 2018]. Available from: http://bottomofpyramid.blogspot.in/2004/06/case-of-jaipur-foot.html
  6. Brochure 2017-18 [Internet]. Jaipurfoot.org; 2017 [cited 4 May 2018]. Available from: http://jaipurfoot.org/images/Brochure%202017-18.pdf
  7. Prahalad C. The fortune at the bottom of the pyramid: eradicating poverty through profits. New Delhi: Pearson; 2014
  8. Coutinho J. Jaipur foot [Internet]. Jaipurfoot.org. 2011 [cited 4 May 2018]. Available from: http://jaipurfoot.org/media/feature_stories/tarabai_ingle.html
  9. Valentinuzzi M, Johnson A, King P, Mysore H. The “Jaipur Foot” [Internet]. Pulse.embs.org. 2016 [cited 4 May 2018]. Available from: https://pulse.embs.org/may-2016/the-jaipur-foot/
  10. Azael G. Sudha Chandran: Awarded Dancer Overcomes a Life Changing Experience – Rewordit [Internet]. Rewordit. 2013 [cited 4 May 2018]. Available from: https://www.rewordit.org/sudha-chandran-awarded-dancer-overcomes-a-life-changing-experience/
  11. Jaipur foot [Internet]. Jaipurfoot.org. 2016 [cited 4 May 2018]. Available from: http://jaipurfoot.org/media/feature_stories/partnering_technology.html
  12. D.R.Mehta – India Conference at Harvard [Internet]. India Conference at Harvard. 2014 [cited 4 May 2018]. Available from: http://indiaconference.com/2014/speaker/d-r-mehta/
  13. Jaipur Foot | Patient-Centric Management | Patient Care [Internet]. Jaipurfoot.org. 2016 [cited 4 May 2018]. Available from: http://jaipurfoot.org/how_we_do/patient_centric_management.html
  14. The Economic Times. Jaipur Foot patron D R Mehta to get Clairmont Lincoln Ahimsa award in US Read more at: //economictimes.indiatimes.com/articleshow/43816081.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst. [Internet]. 2014 [cited 4 May 2018];. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/jaipur-foot-patron-d-r-mehta-to-get-clairmont-lincoln-ahimsa-award-in-us/articleshow/43816081.cms
  15. Impacting Lives with a No-Cost Business Model [Internet]. Jaipurfoot.org. 2016 [cited 4 May 2018]. Available from: http://jaipurfoot.org/blog/impacting-lives-with-a-no-cost-business-model
  16. Thomas P. Can the Jaipur Foot survive after DR Mehta? [Internet]. News18. 2013 [cited 4 May 2018]. Available from: https://www.news18.com/news/india/can-the-jaipur-foot-survive-after-dr-mehta-594624.html
  17. Khan R. How Frugal Innovation Promotes Social Sustainability. Sustainability. 2016;8(10):1034.
  18. India P. Jaipur Foot to be manufactured in Afghanistan too [Internet]. Business-standard.com. 2015 [cited 4 May 2018]. Available from: http://www.business-standard.com/article/pti-stories/jaipur-foot-to-be-manufactured-in-afghanistan-too-115110700807_1.html
  19. Jaipur Foot | Awards & Recognitions [Internet]. Jaipurfoot.org. 2016 [cited 4 May 2018]. Available from: http://jaipurfoot.org/who_we_are/awards.html

Additional Video Reference

Samatvam, (2016, January 24) The Jaipur Foot retrieved from  https://www.youtube.com/watch?v=VRYKoM_7ZCw&t=2s

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