Pr oduct Number 000

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From the Department of
LEADI NG I N THOUGHT AND ACTI ON
C
CORPORATE STRATEGY AND INTERNATIONAL BUSINESS CORPORATE STRATEGY AND INTERNATIONAL BUSINESS


ASE STUDY SERI ES E STUDY SERI ES

[= [=



















This report was written by Scott Macke, This report was written by Scott Macke,
Ruchi Misra and Ajay Sharma under the
supervision of Professor C.K.Prahalad. The
reports are intended to be catalysts for
discussion and are not intended to illustrate
effective or ineffective Strategies.

Copyright, The University of Michigan
Business School, 2003

Jaipur Ioot:
Challenging Convention
At age J!, Sudha Chandran, an aspiring dancer, lost her right
limb in a car accident. Devastated and convinced she would never
walk, let alone dance again, she spent several months on crutches.
1hen one day in J8!, she read about Jaipur Ioot.
1here are ive and a hal million amputees in India ;ust like
Sudha Chandran. In addition, each year, according to one estimate
an additional !,000 people lose their limbs due to diseases,
accidents or other ha.ards. 1he ma;ority o these people are well
below the poverty line and cannot aord healthcare or medical
services.
1
In a world where prosthesis is a complicated and
epensive industry, there is hope or these patients. However,
nestled in the desert o Ra;asthan is an operation o impressive
scope that oers hope to the some o the most impoverished
citi.ens o India and maybe even the world. It oers these
handicapped citi.ens a chance to return to their livelihoods and
pursue their dreams. 1his operation is called Jaipur Ioot.
THE INNOVATION. . .
A prosthetic foot in the U.S. averages $8,000. The Jaipur Foot is
tailored to the active life styles of the poor and costs only about $30
- and it is given away free to the many handicapped poor who have
lost a limb.

Developed in J68, Jaipur Ioot is a hand-made artiicial oot
and lower limb prosthesis.
2
It has revolutioni.ed lie or tens o
thousands o amputees around the world. 1his oot was originally
designed to meet the needs o a developing country liestyle such
as squatting, bareoot walking and cross-legged sitting. Primarily
abricated and itted by Bhagwan Mahaveer Viklang Sahayata
Samiti (BMVSS), a non-governmental, non-religious and
nonproit organi.ation, Jaipur Ioot is itted on approimately


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J6,000 patients annually, while BMVSS services approimately 60,000 patients by providing Jaipur oot,
calipers and other aids and appliances. 1here are seven centers throughout India and a number o mobile
camps held every year in various parts o the country. Jaipur Ioot camps also have been ound in J
countries, including Aghanistan, Bangladesh, Dominican Republic, Honduras, Indonesia, Malawi,
Nigeria, Nepal, Nairobi, Panama, Philippines, Papua New Guinea, Rwanda, Somalia, 1rinidad,
Vietnam, Zimbabwe and Sudan.
With innovations in technology and management, as well as understanding the needs o its
patients, BMVSS developed a unique business model. 1his model spreads the Jaipur Ioot technology
that allows rickshaw-wallah (pedicab operators) amputees to be rickshaw-wallaws, armer amputees to
be armers and in the case o Sudha Chandran, classical Indian dancer amputees still to be classical
Indian dancers.
THE NATURE AND SCOPE OF THE PROBLEM:
Global Amputees
1here are anywhere rom J0 million to ! million amputees in the world, with an additional !0,000
added each year. 1he causes o amputation vary greatly. In countries with a recent history o warare and
civil unrest, amputation is due to trauma and landmine accidents.! In places like the United States, the
causes are more related to accidents, circulatory diseases and cancer. Regardless, prosthesis in both
developing and developed nations is epensive and complicated, leaving a si.able number o amputees
unable to aord adequate prosthetic care.!
Developed World
According to a J6 National Center or Health Statistics study, there are more than ! million amputees in
the United States and approimately !00,000 new amputees every year, o which approimately 0/ are
lower limb amputees (October J). According to the World Health Report in J8, amputation
resulting rom diabetes will more than double globally rom J!! million cases in J to !00 million by
!0!.6 1he most common causes o amputation o lower etremities are disease (0/), trauma (!!/),
congenital or birth deects (!/) and tumors (!/). Upper etremity amputation usually is due to trauma or
birth deect. 1he cost o prosthesis is very high in the United States, leaving many without appropriate
care. According to Mark 1aylor, rom the University o Michigan Prosthetics Department, due to
insurance company policies and high costs, only 0/ o patients in the U.S. receive the prosthetic medical
care they require.
Developing World
In the developing countries o Asia and Arica, land mines have let millions o people limbless. According
to the U.S. Centers or Disease Control, approimately !00,000 children are severely disabled because o
land mines, with an additional J,000 to !0,000 new victims each year. Moreover, most victims are not

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soldiers, but women and children who happen to live in areas that were once war .ones. By some
estimates, there are more than J00 million land mines buried all over the planet. In many poor nations,
most amputees have to settle or a lietime on crutches. In Vietnam alone, land mines in;ure more than
!,000 people each year.8 It costs approimately 3!00 to provide a high-quality artiicial leg in Vietnam.

Countries with the Most Number of Landmines
COUNTRY # OF LANDMINES
Aghanistan ,00,000
Angola ,000,000
Iraq ,00,000
Kuwait ,000,000
Cambodia ,00,000
Western Sahara J,00,000
Mo.ambique J,00,000
Somalia J,000,000
Bosnia-Her.egovina J,000,000
Croatia J,000,000
Source: United Nations Data

In Aghanistan, there are approimately J0 million landmines and at least 0,000 amputees.J0 In
Cambodia, there are !,000 to !0,000 amputees, or one amputee per !00 inhabitants. 1here are nearly as
many land mines in Cambodia as people. Government hospitals are so severely under-resourced that
patients, including the very poor, are orced to pay or services or drugs, leaving many without care.JJ
In Kosovo, the World Health Organi.ation (WHO) estimated the J land mine in;ury rate at J0 in
J00,000, eceeding the rates o both Aghanistan and Mo.ambique. In India, there are . million
people suering rom locomotor disabilities in India. O these, about one million have lost their limbs
and our million suer rom polio. Due to the increase in road accidents, diseases and other ha.ards,
!,000 new cases add to the population o amputees every year.

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Treatment Costs
Developed World
PROSTHETIC COSTS IN THE UNITED STATES
BELOW THE KNEE LIMB
Legs
$4,000 $5,000
(Low End)
$7,000
$9,000 (Middle
End)
$10,000
$25,000 (High
End)
Prosthetic Sockets
$3450
(Replacement
Socket)
$650
(Replacement
Cover)
Prosthetic Feet $250 $12,000
Prosthetic Socks $19 (Sheath) $80 (Sheath w/Gel) $25 (Wool Socks)
$9 (Single
Ply); $50
(Shrinker)
Above the Knee Legs
Legs
$8,765 (Low
End)
$12,265 (High End
without Knees and
Feet)
Prosthetic Sockets
$4300
(Replacement
Socket)
$900 (Replacement
Cover)
Prosthetic Knee $700 $5400
Prosthetic Socks $25(Sheath) $80 (Sheath w/Gel) $25 (Wool Socks)
$10(Single
Ply), $80
(Shrinker)

Developing World
OpenRoads, a U.S.-based NGO, will be shipping J00 prosthetics every year to each site. Below is a table o
their estimated costs o providing limbs. It is based on the assumption that buying in bulk will reduce
overall costs. With prosthetic care as epensive as it is today, it leaves many patients, in both the developing
and developed world, without the care they need. A ast, dependable solution, at a cost people can aord
(in the developing world, this cost is 30.00), is not only necessary but also imminent. Innovative business
models, such as Jaipur Ioot, already have started to accomplish this successully.



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Year Location Number of
People Served
Cost per Site
Kosovo 50 $15,000
Rwanda 50 $15,000
Kosovo 100 $30,000
Rwanda 50 $15,000
Kosovo 100 $20,000
Rwanda 100 $20,000
Afghanistan 50 $10,000
Kosovo 100 $15,000
Rwanda 100 $15,000
Afghanistan 100 $15,000
Mozambique 50 $7,500
Kosovo 100 $15,000
Rwanda 100 $15,000
Mozambique 100 $15,000
Afghanistan 100 $15,000
Total: 1250 $237,500
4
5
OpenRoad
Cost Estimates For Providing Prosthetic Care Globally
Year and Number of People Served per Site
1
2
3

History of Prosthesis
1he history o prosthetics begins at the very dawning o human medical thought. Its historical twists and
turns parallel the development o medical science, culture and civili.ation itsel.
1he prostheses o ancient cultures began as simple crutches or wooden and leather cups depicted in
Moche pottery. An open socket peg leg had cloth rags to soten the distal tibia and ibula and allow a
wide range o motion. 1hese prostheses were very unctional and incorporated many basic prosthetic
principles.
An artiicial leg invented by Pare in J6J or individuals amputated above the knee was
constructed o iron and was the irst artiicial leg known to employ articulated ;oints. Ma;or advances
have been made in the ield o prosthetic rehabilitation, stimulated in part by wars that increased the
number o individuals who lost limbs. During the American Civil War (J86J-J86), interest in artiicial
limbs and amputation surgery increased in the U.S., with the government paying or artiicial limbs or
veterans. In J86!, the U.S. government enacted the irst law providing ree prostheses to people who lost
limbs in warare. In J80, Congress passed a law that entitled war amputees to receive prostheses every
ive years.
World War II spurred urther developments. Dissatisaction with heavy, uncomortable artiicial
limbs gave impetus to prosthetic research. 1he American Orthotic and Prosthetic Association was
established in J! and developed educational criteria and eaminations to certiy prosthetists and
orthotists. In J!, the National Academy o Sciences set up a Committee on Artiicial Limbs (CAL) to


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develop design criteria that would improve their unctions. CAL inluenced development o modern
prosthetics rom J! to J6. During this period, plastic replaced wood as the material o choice, socket
designs ollowed physiological principles o unction, lighter-weight components were developed and
more cosmetic alternatives were abricated.
In J6, the biomechanics laboratory at University o Caliornia (Berkeley) introduced the solid
ankle cushion heel (SACH) oot, which became the most popular prosthetic oot. In the J60s, hydraulic
knee mechanisms became more prevalent; and J0 marked the inaugural year or the international
Society or Prosthetics and Orthotics. In JJ, Otto Bock introduced endoskeletal prostheses.
Modern times are characteri.ed by the emergence o prosthetics as a science as well as an art.
Research into human movement, new materials and new technology has led to creation o very light
and unctional components. Gel liners provide shock-absorbing interace between residual limb and
hard socket. Research is attempting to ind a method to bring sensation into the prosthetic limb.J!
Lower Limb Anatomy
1o understand ully the innovation behind Jaipur Ioot, it is important to know something about the
lower limb anatomy. 1he limbs must bear weight, provide a means or locomotion and maintain
equilibrium. Bipedalism is the process by which we are able to stand upright and to move about on two
limbs. It imparts three unique unctions on the lower limbs.
1he ankle ;oint is a hinge-type ;oint that participates in movement and is involved in lower limb
stability. Dorsileion and plantar leion (Please reer to basic oot movements below) movements take
place at the ankle. Dorsileion is necessary in order to have the oot contact the ground heel irst and to
allow the oot to clear the ground during the swing phase o gait (please reer to gate cycle below).
Plantar leion provides the propulsive orce necessary to lit the limb o the ground and start it
swinging orward during the toe-o portion o gait. 1he oot plays an important role in supporting the
weight o the entire body and in locomotion. 1he bones o the oot are arched longitudinally to help
acilitate the support unction. 1he transverse arch helps with movements o the oot. 1hese movements
help keep the sole in contact with the ground despite the unevenness o the ground surace. 1hey also
work in concert with the ankle ;oint to help propel the oot o the ground during the toe-o portion o
gait.


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Basic Foot Movements
DORSIILFXION: Ileion o oreoot away rom ground

PLAN1ARILFXION: Ileion o oreoot toward ground


ABDUC1ION: Movement away rom aial line (second toe position)

ADDUC1ION: Movement toward the aial line

FVFRSION: 1urning sole o oot outward away rom midline
INVFRSION: 1urning sole o oot inward toward the midline

PRONA1ION: 1riplane motion consisting o simultaneous movements o
eversion, abduction, dorsileion
SUPINA1ION: 1riplane motion, which combines the movements o
inversion, adduction and plantar leion




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Gait Cycle
1he rhythmic alternating movements o the two lower etremities are the gait cycle, which results in
orward movement o the body. Simply stated, it is the manner in which we walk. Gait cycle is the activity
that occurs between heel strike o one limb and the subsequent heel strike o that same limb and consists o
the ollowing phases:
Stance: It begins when heel o the orward limb makes contact with the ground and ends when the
toe o the same limb leaves the ground. It consists o:

Heel Strike: Heel o oot touches the ground.
Mid Stance: Ioot is lat on the ground and the weight o the body is directly over the limb.
1oe O: Only the big toe o the limb is in contact with the ground.
Swing: It begins when the oot is no longer in contact with the ground. 1he limb is ree to
move.
Acceleration Swinging limb catches up to and passes the torso.
Deceleration: Iorward movement o the limb is slowed down to position the oot or heel strike.
Double Support: Both limbs are in contact with the ground simultaneously.



1ypical gait cycles illustrating the phases and events during the cycle.
(Irom Human Walking, !nd Fdition, Rose and Gamble editors, Williams and Wilkins, Baltimore, J!, p. !6.)
i=i=mW=^=^==p~=k~~=i=c=

People with limb loss (acquired amputation) or limb absence (congenital deiciency) use prosthetic
limbs to restore or imbue some o the unction and/or cosmetics o an anatomical limb. Solutions dier
in the way they mimic` the natural oot`s unctionality (or a part thereo).


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DEVELOPMENT OF JAIPUR FOOT
Ram Chandra, born into a amily o master artisans, is commonly recogni.ed as one o Jaipur city`s inest
sculptors. Growing up, Chandra saw that local people who were amputated were itted with artiicial
limbs, either imported rom abroad or locally made, that were not leible enough and did not allow or a
normal range o motion. 1he prosthesis did not acilitate postures common in India such as squatting or
sitting cross-legged. Iurther, the shoes attached to the limb were made o heavy sponge, which made the
prosthesis useless or armers working in the rain or irrigated ields. 1his led to a high re;ection rate o the
prosthesis by the local amputee population.
While watching these patients, Chandra came up with an idea o creating an artiicial limb that
more closely resembled a natural oot, was lighter and was tailored or local conditions. He took his
ideas to doctors at the city hospital and learned about human oot anatomy. Fquipped with this
knowledge, Chandra eperimented with locally available materials such as willow, sponges and
aluminum molds to create an artiicial limb.
J!
One o many deining moments came one day when Chandra suered a lat tire while riding his
bicycle. According to Chandra, he went to a roadside stall whose owner was retreading a tire with
vulcani.ed rubber. Once his bicycle was ied, Chandra rushed to doctors to determine i this material
could be used or a limb. Later he returned to the tire shop accompanied by an amputee and a oot cast,
and asked the owner to make a rubber oot. 1he oot had the mobility and durability that Chandra
sought, although it had to undergo numerous reinements. Working urther with Dr. P.K. Sethi, an
orthopedic surgeon.and Dr. S.C.Kasliwal and Dr. Mahesh Udawat, Chandra reined and improved the
design to eventually create what is now known as the Jaipur Ioot. 1o acilitate the spread o the oot, its
creators decided not to patent the Jaipur Ioot.
Step 1: Design Considerations
1he Jaipur Ioot was designed to simulate normal oot movements and provide a quality solution or the
masses. Ior those poor in India who had lost their limbs, continuing to earn their livelihood was the
biggest concern. In absence o an eicient social security system, being able to work was essential or their
survival. It necessitated a prosthesis, which supported their work and liestyles. Jaipur Ioot`s design
process emphasi.ed the ollowing activities, which are commonly en;oyed by India`s working poor:

ACTIVITY MECHANICAL REQUIREMENT
14
Squatting Need or dorsileion
Sitting Cross Legged Need or transverse rotation o the oot
Walking on Uneven Ground Need or inversion and eversion in the oot so that varying terrain is not
transmitted to stump
Bareoot walking Cosmetically similar to natural oot


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Step 2: Overcoming Constraints
However, the technical demands were not the only demands orced by the creators o Jaipur Ioot. In
addition, they aced the ollowing constraints.

CONSTRAINTS IMPLICATION
Poverty 1he vast ma;ority o local amputees were poor. Lower cost o prosthesis with the possibility o
alignment and ad;ustments would acilitate speciali.ed yet equally unctional solution.
Closed Fconomy Limited import o oreign materials in India meant the oot had to be abricated rom readily
available local materials
Work Liestyle Most amputees worked hard and long hours. 1he ability to walk on uneven ground was essential
or their work. India was largely an agricultural economy, and days spent without limbs
threatened their livelihood and in many cases sustenance. 1his led to a need or accessible
prosthesis that could be itted quickly.
Limited 1rained
Manpower
Lack o skilled labor relative to the huge demand or prostheses necessitated a simpliied
manuacturing process, which could be perormed with limited training.
Step 3: Deviation from Traditional Design
1he design o Jaipur Ioot was initially based on the SACH oot design.
15
However, the design divorced
away rom the SACH oot due to problems such as weight and non-suitability to local conditions. 1he
endoskeletal design was pursued, and a new, knee ;oint design evolved. Distortions were introduced in the
sockets so that adequate pressure was put only on those tissues, which could resist them. 1otal contact
sockets also were introduced.
Jaipur Ioot is made o three blocks simulating the anatomy o a normal oot. 1he oreoot and heel
blocks are made o sponge rubber and the ankle block consists o light wood. 1he three components are
bound together, enclosed in a rubber shell and vulcani.ed in a mould to give it the shape and cosmetic
appearance o a natural oot.
Below-knee as well as above-knee prosthesis products are indigenously designed and abricated
rom locally available and durable high-density polyethylene pipes and a Jaipur Ioot. 1hese are rapid-
it limbs with low abrication times. Iitting and abrication times vary rom one hour or below-knee
prostheses to about ive to si hours or above-knee prosthesis. Iunctionality o the prosthesis mirrors
that o a natural human limb, and it permits amputees to run, squat, sit cross-legged, climb trees and
;ump rom heights. 1he Jaipur Ioot is waterproo and does not require maintenance ater it is itted.
Bareoot walking is possible, an amputee can work in wet and muddy ields and the oot is suitable or
any type o terrain. 1he patient also can wear shoes. Bio-mechanically, it is based on the standard
Patella-1endon-Bearing prosthesis and scientiically abricated to meet its weight distribution
requirements or maimum comort. Average weight o the prosthesis is !.JJ kg; the weight o a kg
person`s lower limb is !.!6 kg.

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Step 4: Materials Sourcing
1he Society produces the prosthesis with readily available and inepensive components in order to limit
the cost o procurement as well as the cost o the prosthesis itsel. A typical Jaipur Ioot, shank and
simulated knee ;oint is constructed with the ollowing materials:

COST ANALYSIS OF ABOVE KNEE LIMBS

WITH PLASTIC KNEE JOINT
S.
NO.

NAME OF MATERIAL

QUANTITY

RATE

AMOUNT
J. Jaipur Ioot J No. J!0.!/No. J!0.!
!. HDPF Pipe 0 MM 0.60 RM1 J!6.J6/Mtr. 8.0
!. HDPF Pipe JJ0 MM 0.60 RM1 !J.!/Mtr. J!J.
!. Plastic Knee Joint J Set J00/Set J00.00
. Plaster o Paris ! Kg. !/Kg. J6.00
6. Stockinatte !' J0 Gms JJ/Kg. J.!
. Stockinatte !' !00 Gms. JJ/Kg. !!.00
8. A.K. Belt J No. !/No. !.00
. Flastic belt J No. J0/No. J0.00
J0. Cotton Bandages ! Nos. !/No. J!.00
JJ. Dunlop Solution !0 Gms. 0.8/Kg. J.8J
J!. Steel Screw ! Nos. 0.J!/No. 0.!
J!. Press Buttons ! Nos. 0.06/No. 0.!!
J!. Soap Stone Powder 0 Gms. !/Kg. 0.J0
J. Loctite J/! 1ube 0 .00

1otal Material Cost

6!.!!
IUS3 Rs.!

1he estimated US3.68 cost o materials outlined above includes the cost o the components o the
Jaipur Ioot itsel as well as the simulated ;oints or a below-knee limb. Fach material is locally sourced
and does not require special procurement agreements. Most are virtual commodities. Iurthermore,
most o the materials can be sourced locally i necessary when the Jaipur Ioot is manuactured in other
developing nations.
Step 5: Production Equipment
1he Jaipur oot, as well as the calipers and other portions o the prosthesis ultimately itted on the patient,
is constructed with very basic tools. Most o the abrication process is completed with the tools o an
ordinary artisan. 1he most speciali.ed piece o equipment consists o the oot-shaped die used to mold the
shape o the oot. However, its cost is not signiicant enough to even warrant listing on a ied asset
schedule. 1he most epensive piece o equipment is the vacuum-orming machine used to get eact replica
o the mould and is used when heated HDPF sheet or pipe is draped over the mould o the patient's
remaining limb (stump). 1he machine costs approimately !00,000 Rupees, or roughly US3!,000. Ior
heating pipe and sheets a machine is used which resembles an ordinary oven. 1he machine is commonly
ound throughout India and the rest o the developing world. 1he Jaipur location o the Society requires

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two vacuum orming machines to serve an estimated 60 patients per day. Fach machine lasts rom ive to
seven years
Step 6: Labor
Iabrication o the Jaipur Ioot, as well as the process by which a patient is itted, is a very labor-intensive
process. 1his process capitali.es on the large supply o skilled artisans in India and their manageable labor rates.
A Jaipur Ioot artisan is a cratsman with several years o eperience and is urther trained or several more
years to mold, sculpt and orm the Jaipur Ioot. 1he Society typically schedules 0 trained technicians and
artisans each day to achieve a one-to-one patient-to-employee ratio. Artisans and technicians, who are more
eperienced artisans, operate in a supervisory capacity and are paid by the hour plus overtime. A typical artisan
earns ,000 Rupees per month, or roughly US3J00 including beneits. 1he estimated US3J,!00 annual income
o an artisan is approimately twice that o the per capita income in India.
An on-site doctor supervises the entire abrication and itting process. 1he Society has one doctor
on the payroll ull-time. In addition, other local doctors either volunteer their time or work on a part-
time basis to ensure that a certiied physician approves a patient`s inal prosthesis and itting.
Step 7: Fab ication r
Iabrication o Jaipur Ioot is a ast and simple process. 1he oot incorporates locally available
materials/equipment. 1hese include a die, tread rubber compound, sponge rubber, cosmetic rubber, nylon
cords, a vulcani.er, wood and scissors. Ioot and ankle assembly is made o a vulcani.ed rubber
compound. An aluminum die is used to cast a normal oot shape. 1he die consists o our sections, which
can be bolted together. 1his allows or ease o setting up dierent material components. 1he process thus
involves several stages with serial sequences o plaster mould-die in our sections. 1he position o under-
surace o the oot and toes is slightly rocketed with the toes slightly o the ground to achieve the rolling
action. 1he heel is kept slightly o the ground to accommodate the heel when worn in the shoe. 1his
complements the rocker` action o the oot. Please reer to ^=a=or details o abrication processK==
Sole
Fabrication
Lower Leg
Fabrication
Hind Foot
Fabrication
ForeFoot
Fabrication
Assembly
Vulcanization
Jaipur Foot Fabrication Process


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Step 8: Fitting of the Jaipur Foot
Nearly 60 patients each day obtain prostheses rom Jaipur Ioot`s main acility in Jaipur, India.
Remarkably, unless other medical conditions intervene, each patient is custom itted with a prosthesis in
one day - usually within three hours. 1he goal is to return the patient to their proession and an
independent lie ater the patient`s irst visit to the clinic.
However, the Society`s desire to accommodate the social requirements o India`s poor does not
consist solely o the speed o service. 1he Society`s operating process also attends to the psychological
needs o its patients. 1he Society provides on-site meals and overnight accommodations to patients at no
cost. 1hese services are shared with other patients in order to provide an immediate support group or
the patients and to develop a sense o community within the acility. Additionally, ree meals and
accommodations are provided to the patient`s amily members, again at no cost. 1his permits amily
members to aordably travel with patients and provide on-site support and comort. A typical patient
eperience to receive a Jaipur Ioot might proceed as ollows:

Monday 1:00 PM The patient catches a train from New Delhi to Jaipur, India. The patient's husband and child accompany her on the journey.
6:00 PM The family arrives at the front gate of the Society in the heart of Jaipur. A guard at the gate of the one-story facility admits the family inside.
6:30 PM The family joins other patients and family members at a communal dinner prepared by the Society's food service employee.
9:00 PM The family sleeps on mattresses in a large room within the facility's modest housing wing.
Tuesday 8:00 AM The family shares breakfast with other patients and families at the facility.
8:30 AM The patient joins the line forming in the Society's inner courtyard and awaits registration.
9:00 AM A doctor checks the patient and outlines the prosthesis that is required. The patient will keep the card until it is given to a technician.
9:10 AM prepared for a cast.
9:30 AM A trained artisan wraps a cast around the limb, forms it tightly around the limb and removes it.
9:45 AM
The patient is ushered back to the inner courtyard and waits. The artisan pours a mold into the cast, lets it dry, and then carves it to the limb's
specifications under the supervision of a technician.
10:15 AM A common polyurethane pipe is heated in a vacuum forming machine, is removed, and is stretched over the mold of the patient's remaining limb.
10:30 AM polyurethane prosthesis.
11:00 AM A prefabricated Jaipur Foot is attached to the prosthesis.
11:30 AM The patient is ushered back into the medical wing of the facility and a technician fits the prosthesis to the patient.
NOON
The on-site doctor supervises as the patient tests the new prosthesis in the inner courtyard. The patient describes some modest discomfort as
she walks around a separate inner courtyard.
12:15 PM prosthesis.
12:30 PM The patient and her family share lunch at the facility.
2:00 PM The family catches a train back to New Delhi.
7:30 PM The family returns home to resume a life similar to their lives before the loss of the patient's limb.



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Competitive Benchmarking
Jaipur Ioot supports developing country liestyles (such as squatting, sitting cross-legged, walking on
uneven suraces and bareoot walking) while a conventional SACH oot does not. Please reer to ^=
_=or a comparison o Jaipur Ioot with the conventional prosthesis (SACH oot).
1he table below details comparison o Jaipur Ioot with VariIle (Ossur) and 1rueStep (College
Park Industries), two leading prostheses in the developed world. 1he table compares the prostheses or
range o motion, general attributes such as cost, activities supported, and quality standards to which they
adhere.
Jaipur Ioot provides or an ecellent range o dorsileion movement. As the table demonstrates,
though not eplicitly superior to the Western prosthesis shown, the Jaipur Ioot possesses technical
characteristics that make it a comparable product. 1he clear dierentiating eatures are the respective
prices and the years o introduction o the products. 1he Jaipur Ioot presents an interesting comparison
to the Western prosthesis at a price perormance basis despite being introduced nearly two decades
beore its Western counterparts. Iurthermore, the Jaipur Ioot compares avorably on the activities or
which it was designed, especially walking bareoot, working in wet ields, walking on uneven ground
and climbing trees.

FEATURE/
FUNCTION
VARIFLEX
16
(SINCE 1990)
COLLEGE PARK FOOT
17

(SINCE 1991)
JAIPUR FOOT
18
(SINCE 1968)
o~==j=
Dorsileion Limited Dynamics !
0
!0
0
Plantar Ileion Limited Dynamics !
0
0
0
Inversion J!
0
(split toe version) J!
0
J0
0
Fversion J!
0
(split toe version) J!
0
J0
0
Supination Not Applicable !0
0

0
Pronation Not Applicable !0
0

0
^=
Cost (Ioot Piece) 3J,!00 3J,0 3 (!!0 Indian Rs.)
Average Cost (including
Prosthesis Iitting)
3!,00 3!,00 3!0 (J00 Indian Rs.)
Iitting/Iabrication time J-! hours. J-! hours ! hours

Ioot piece Weight !!0g J0 g 80 g

Si.e/weight rating Up to J66 kg Up to J60 kg Not rated
Ad;ust or heel height change Low/high heel options No No
Warranty !0 months !6 months None
Maintenance Requirements None Limited None
Average Lie !-! years ! years !. - !.0 years
^=p=
Work in wet ields Yes Not recommended Yes
Walk bareoot Special sole required Yes Yes
Sit on loor Yes Yes Yes
Squat Yes Yes Yes

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FEATURE/
FUNCTION
VARIFLEX
16
(SINCE 1990)
COLLEGE PARK FOOT
17

(SINCE 1991)
JAIPUR FOOT
18
(SINCE 1968)
Drive a car Yes Yes Yes
Ride a bike Yes. Yes Yes
Walk on uneven ground Yes (split toe version) Yes Yes
Climb trees Yes (with Limitations) Yes (with Limitations) Yes
Hike Yes Yes Yes
Swim Yes Not Recommended Yes
Run Yes Yes Yes
Quality Standards
CF Marked Yes Yes No
Additional ISO J0!!8 standard Internal Quality standards
1his is average cost or complete solution, which may involve multiple clinic visits. Actual costs will vary depending on options chosen.

Community Outreach: Providing Access
Bhagwan Mahaveer Viklang Sahayata Samiti (BMVSS)
1he designers o Jaipur Ioot quickly discovered that designing a prosthesis that could withstand the
rigorous use o India`s poor was only the beginning. 1he net challenge was to construct an organi.ation
and operating system, which could make the Jaipur Ioot available to as many amputees as possible. 1he
epectation was that nearly all prospective amputees would all below the poverty line. Subsequently,
Jaipur Ioot`s custodians ocused their attention on the inancial and social needs o India`s working poor.
1heir eorts eventually took the orm o the nonproit society named Bhagwan Mahaveer Viklang
Sahayata Samiti (BMVSS), generally reerred to as the Society.`
1he desiging o the prosthesis that could withstand use by India's poor was only the beginning.
1he net challange was to construct an organisation and operating system; which could make Jaipur
Ioot available to as many amputees as possible. 1he epectation was that nearly all o the prospective
amputees would all below the poverty line. 1o meet the inancial and social needs o the amputees and
also to promote urther technical development, a non-proit society named Bhagwan Mahaveer Viklang
Sahayata Samiti (BMVSS) was established in March J by Mr. D.R. Mehta. In the irst year ater the
development o Jaipur Ioot in J68, hardly 0 limbs were itted. In the irst year ster the ormation o
the society limbs were itted. Now, the number o limbs itted every year is around J6,000. Between
the March J, when BMVSS was established to March !00!, BMVSS has itted !!6,J limbs in India
and J!,00 around the world (Please reer to table below). But or the value system and patient centric
management practices ollowed by BMVSS, Jaipur Ioot might have remained on the shel and in limbo.
1he BMVSS emphasi.es a holistic approach to addressing the problems o amputees. 1he society
ocuses on not only the medical problems o the underprivileged, but also the inancial and social
problems as well.
1he society has laid down etremely simple procedures or reception, admission, measurement
taking, manuacturing, itment and discharge o patients. Unlike in all other medical centers all over the
word, patients are admitted as they arrive without regard to the time o day. Iurther patients are
provided boarding and lodging acilities at the centers o BMVSS till they are provided with limbs,

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calipers or other aids. In most orthopaedic centers in the world, patients must come back several times
or a custom it. 1his process could take several weeks. Such a system would be unsuitable to the poor
patients who ind it etremely diicult, both in physical and inancial terms, to come back a second time
rom long distances. Jaipur Ioot is custom itted on the same day; in act in less than ! hours. Most
signiicantly the prosthetics orthotics and other aids and appliances are provided totally ree o charge to
the handicapped. But or this policy, virtually more than 0/ o the patients would have remained
deprived o artiicial limbs, calipers and other aids and appliances. 1he setting up o patients oriented
value and management system was an equally important innovation.
BMVSS has ten branches in India. In addition, there are approimately 60 workshops that abricate
or it the Jaipur Ioot in India. 1he Society also has aided the establishment o several centers abroad.
Iunded by the Indian government and philanthropic groups, BMVSS and similar organi.ations oer
medical care, room, board, and a prosthetic at no cost to the patient. It also has helped launch ree clinics
in more than a do.en countries.

INDIA: NUMBER OF ARTIFICIAL LIMBS AND OTHER AIDS DISTRIBUTED BY BMVSS
Artiicial Limbs !J,!0
Calipers J!,J6
1ricycles !6,!J
Crutches Other Aids !!,!!
Hearing Aids 6,666
Polio Surgery !,860
Source: Jaipur Ioot (BMVSS)

World: Number of Artificial Limbs and other aids distributed
By BMVSS
Aghanistan J,! Panama !00
Bangladesh J,000 Philippines !,000
Dominican Republic 00 Papua New Guinea J0
Honduras !00 Rwanda 00
Indonesia 600 Somalia J,000
Malawi !0 1rinidad !00
Nigeria 00 Vietnam 600
Nepal !00 Zimbabwe !0
Nairobi 00 Sudan J,800
1O1AL J!,!!
Source: Jaipur Ioot (BMVSS)
Jaipur Foot: Filling a Social Need
1he determination was made at the outset that the Jaipur Ioot prosthesis would be provided ree by
means o a nonproit ramework. 1he prospect o no additional unds reali.ed or additional prostheses
itted orced administrators to ocus on containing costs. In particular, emphasis was placed on the cost o
the materials used to construct the Jaipur Ioot, the capital equipment required to abricate the oot and
the method by which the oot was itted to a patient in order to make the prosthesis widely available.

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Jaipur Foot Operations
1he result is an organi.ation that spends nearly !/ o its cost on the materials, labor and services
necessary to it amputees with a prosthetic limb. 1he ollowing diagram estimates the cost components o
providing each Jaipur Ioot:

Cost of Typical Jaipur Foot
Below Knee Limb
Materials
43%
Labor
31%
Camps
12%
Overhead
14%

Source: BMVSS Ad;usted Cost Report

Only J!/ o the cost o a typical Jaipur Ioot goes toward meeting overhead and administrative
costs. 1he remaining cost goes toward the materials used in the oot, the labor employed to manuacture
and it the limb and the cost o running camps, which reach the poor throughout India and beyond.
1his cost eiciency is also relected in the Jaipur Ioot`s annual epenses:

Jaipur Foot 2002 Expense by Classification
(overhead costs of camps are included in Cost of Limbs and Services)
Cost of Limbs and
Services
89%
Other Assistance
7%
Operating Costs
4%

Source: BMVSS Ad;usted Cost Report


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Jaipur Ioot`s epense breakout or the !00! iscal year underscores the eiciency o epense and
underpins the Society`s eort to serve as many patients as possible given its inancial resources. Nearly
0/ o the company`s epenses in the !00! iscal year were directly related to the cost o producing and
itting prostheses or the poor. Another / o the company`s epenses went toward other orms o
charitable assistance. Only !/ o its ependitures went toward administrative and overhead epenses.
Comparison with Ossur
1he Society`s cost structure diers signiicantly with that o Ossur, an Iceland-based publicly traded
company that manuactures, markets and sells prostheses throughout Furope and North America. Ossur
is the second-largest producer o prostheses in the world.
As the diagram demonstrates, ;ust over hal o Ossur`s annual epense goes toward administrative
and operating costs while hal its epense goes toward the actual cost o producing prostheses. A more
detailed eamination o the annual inancial statements o Jaipur Ioot and Ossur reveals that a
signiicant portion o Ossur`s ependitures are related to sales and marketing (!J/) and research and
development (/). Although this disparity in part underscores the dierent competitive environments,
regulatory environments and organi.ational goals that separate the two organi.ations, it also provides a
ramework that underscores the Society`s ability to unnel its resources directly to patients.

Ossur 2002 Expense by Classification
Cost of Limbs and
Services
48% Operating Costs
52%

Source: Ossur !00! Annual Report
Scalability
Camps
1he Society`s current method o epanding the reach o the Jaipur Ioot to more remote areas o India and
beyond is the camp system. Administrators, doctors, technicians and artisans rom the Society`s Jaipur
location travel to a predetermined site and set up a temporary acility reerred to as a camp. A camp is


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typically unded by another private organi.ation or government that has invited the Society to the
location. A camp can last rom ;ust a ew days to several weeks depending on the number o amputees
epected to be itted with prostheses.
A BMVSS physician supervises camps. It takes about one day to set up and a hal day to close. 1he
sponsoring organi.ation pays the Society`s employees a travel allowance and a per diem while on site. In
general, the camp requires one artisan or every two patients epected to be treated per day. 1hough
most o the components o a typical Jaipur Ioot and caliper can be locally sourced, the Society usually
travels with the epected required materials. Likewise, employees travel with the equipment necessary
to abricate the prosthesis, including a vacuum-orming machine, the largest and most epensive piece
o equipment required or abrication. Any material shortages are usually covered with locally
purchased goods with little incident. 1he sponsoring organi.ation takes responsibility or promoting the
camp and or any transportation o amputees.
New Locations
1he Society also acilitates the establishment o new permanent locations to abricate and it the Jaipur
Ioot. Although the Society itsel supports several locations in India, including New Delhi and Mumbai
(Bombay), the Society encourages the establishment o other charitable organi.ations to run clinics. 1he
Society is active in assisting the new organi.ation in determining the easibility o clinic location, training
o employees and in making the Jaipur Ioot available to the clinic.
1he Society, in con;unction with a new organi.ation, studies the number o amputees near the new
location and estimates the ongoing need or the Jaipur Ioot prosthesis. A new location requires a
modest level o capital ependiture. 1he most signiicant piece o equipment is the vacuum-orming
machine at an estimated cost o US3!,000. Additional equipment and tools generally cost another
US3!,000. Artisans are trained at the Jaipur acility or up to si months. Virtually all this training takes
place with patients and under the supervision o technicians and doctors. 1he Society maintains and
updates a manual, which outlines the abrication and itting o the Jaipur Ioot to assist in this process.
Ater the new location is staed, its employees are trained and the new clinic is ready to it patients,
the Society sends a technician to supervise and support the clinic`s initial operations. 1he number o
artisans and technicians at the new acility depends on the epected patient load. Additionally, each
clinic retains a doctor to supervise the treatment and itting o patients. 1he Society makes the process to
abricate the Jaipur Ioot available to the new clinic, or the Society simply produces the required number
o prosthesis and supplies it to the new clinic ree o charge.
Future of Jaipur Foot
Jaipur Foot Technical Improvements
BMVSS collaborates with hospitals, but is also involved in its own research development to urther
improve the limb design. RD at BMVSS is led by Ram Chandra while Dr. M.K. Mathur, a trained
orthopedic surgeon and ormer head o physical medicine rehabilitation at a leading hospital, heads the
medical and technical eort. Its sta includes doctors, technicians and social workers.

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BMVSS/Jaipur Ioot has made several changes in the design and manuacture o lower-limb
prostheses to keep pace with increases in human understanding o biomechanics and advances in
material technology. High-strength plastics are now being used instead o aluminum. 1otal contact
sockets also have been incorporated in the design. However, the custodians o BMVSS have targeted
other areas or improvement. 1he Jaipur Ioot currently is being hand designed, which raises the issues
o inconsistency, its impacts on quality and reliability.
Iurthermore, at 80 grams, the current oot piece is heavy compared to other solutions. Jaipur Ioot
has not been tested/certiied or any well-known international standard. It also has not yet received
regulatory approvals or usage in certain developed countries such as United States (such an approval
has not yet been sought).
Collaboration with Space Research Organization
BMVSS has signed an agreement with the Indian Space Research Organi.ation (ISRO) to receive ISRO`s
polyurethane technology.
19
ISRO, established in J6, is one o the premier space research organi.ations
in the world. Its activities include space research, design, development and launch o satellites and other
space vehicles.
1he polyurethane technology developed by ISRO is borne out o ISRO`s pioneering research and
development o various polymeric materials. 1he materials are to ensure the reliability and quality o
launch vehicles and satellites. Polyurethane is a versatile polymer that can be produced in various orms
like adhesives, coating materials and in leible or rigid orms. ISRO has developed PU polymer and its
advanced derivatives, which are being etensively used in propellants, cryogenic insulation, thermal
insulation pads, structural damping, acoustic insulation and other lightweight structural materials or
vibration control, shock absorption liners and adhesives.
1his collaboration is epected to reduce the cost o manuacturing a Jaipur Ioot. Cost o each oot
will be reduced by about !0/ to Rs. J!0. 1he oot piece also will become lighter by approimately 60/
to !0 grams.
1he technology transerred to BMVSS will help produce a more durable and comortable artiicial
oot in large numbers. Average oot abrication time will be reduced rom three hours to around !0
minutes. PU oot prostheses would be bio-mechanically advantageous rom a comort level perspective.
1he slip resistance o the PU oot is much higher than rubber and allied materials used in conventional
artiicial oot prostheses. Amputees using the PU oot prostheses could walk more saely on any surace
since its abrasion resistance is higher. In addition, the PU oot lasts longer.
1he polyurethane oam oot molded with cosmetically attractive skin covers has been ound to be
more acceptable to amputees. 1he new polyurethane oot has been sub;ected to accelerated le atigue
tests, and several amputees have been successully itted with such prostheses produced under the
technology transerred by ISRO. Iield trials have been reported to be encouraging.

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Endnotes

J
www.;aipuroot.org
!
Please reer to=Appendi A or a description o lower limb unctionality and prosthesis
!
http://www.mossresourcenet.org/amputa.htm
!
http://www.limbsorlie.org/about.htm

http://www.ottobockus.com/products/op_lower_clegJ.asp
6
http://www.newbeginnings!000.org/acts.html

http://www.openroads.org/
8
http://www.posea.org/Outreach/Outreach.html

http://www.posea.org/Help.html
J0
http://www.dpa.org.sg/DPA/publication/dpipub/spring/dpiJ8.htm
JJ
http://telebody.com/sihanouk/About1heHospital/about-the-Hospital.html
J!
www.nupoc.northwestern.edu/prosHistory.html
J!
Interview with Mr. Ramchandra Sharma (BMVSS)
J!
Please see Appendi or description o lower limb unctionality
J
Interview with Dr. MK Mathur (BMVSS)
J6
Based on inputs rom Ossur
J
Based on inputs rom College Park
J8
Based on inputs rom BMVSS
J
1he Hindu Business Line (!0 July !00! edition)