0:00:01.341,0:00:02.492
Take a minute

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and think of yourself[br]as the leader of a country.

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And let's say one[br]of your biggest priorities

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is to provide your citizens[br]with high-quality healthcare.

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How would you go about it?

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Build more hospitals?

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Open more medical colleges?

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Invest in clinical innovation?

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But what if your country's health system[br]was fundamentally broken?

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Whether it's doctor absenteeism,

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drug stock-outs or poor quality of care.

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Where would you start then?

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I'm a management consultant,

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and for the last three years,

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I've been working on a project

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to improve the public heath[br]system of Rajasthan,

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a state in India.

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And during the course of the project,

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we actually discovered something profound.

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More doctors, better facilities,[br]clinical innovation --

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they are all important.

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But nothing changes[br]without one key ingredient.

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Motivation.

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But motivation is a tricky thing.

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If you've led a team, raised a child[br]or tried to change a personal habit,

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you know that motivation[br]doesn't just appear.

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Something has to change to make you care.

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And if there's one thing[br]that all of us humans care about,

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it's an inherent desire[br]to shine in front of society.

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So that's exactly what we did.

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We decided to focus on the citizen:

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the people who the system[br]was supposed to serve in the first place.

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And today, I'd like to tell you

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how Rajasthan has transformed[br]its public health system dramatically

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by using the citizen[br]to trigger motivation.

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Now, Rajasthan is one[br]of India's largest states,

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with a population of nearly 80 million.

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That's larger than the United Kingdom.

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But the similarities probably end there.

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In 2016, when my team was called in

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to start working with the public[br]health system of Rajasthan,

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we found it in a state of crisis.

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For example, the neonatal[br]mortality rate --

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that's the number of newborns who die[br]before their first month birthday --

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was 10 times higher than that of the UK.

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No wonder then that citizens were saying,

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"Hey, I don't want to go[br]to a public health facility."

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In India, if you wanted to see a doctor[br]in a public health facility,

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you would go to a "PHC,"[br]or "primary health center."

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And at least 40 patients[br]are expected to go to a PHC every day.

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But in Rajasthan,[br]only one out of four PHCs

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was seeing this minimum[br]number of patients.

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In other words, people[br]had lost faith in the system.

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When we delved deeper,

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we realized that lack of accountability[br]is at the core of it.

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Picture this.

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Sudha, a daily-wage earner,

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realizes that her one-year-old daughter

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is suffering from[br]uncontrollable dysentery.

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So she decides to take the day off.

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That's a loss of about[br]350 rupees or five dollars.

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And she picks up her daughter in her arms

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and walks for five kilometers[br]to the government PHC.

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But the doctor isn't there.

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So she takes the next day off, again,

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and comes back to the PHC.

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This time, the doctor is there,

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but the pharmacist tells her

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that the free drugs[br]that she's entitled to have run out,

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because they forgot[br]to reorder them on time.

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So now, she rushes[br]to the private medical center,

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and as she's rushing there,

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looking at her daughter's condition[br]worsening with every passing hour,

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she can't help but wonder

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if she should have gone[br]to the private medical center

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in the first place

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and payed the 350 rupees[br]for the consultation and drugs.

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No one is held accountable[br]for this incredible failure of the system.

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Costing time, money[br]and heartache to Sudha.

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And this is something[br]that just had to be fixed.

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Now, as all good consultants,

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we decided that data-driven reviews

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had to be the answer[br]to improve accountability.

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So we created these fancy[br]performance dashboards

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to help make the review meetings[br]of the health department

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much more effective.

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But nothing changed.

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Discussion after discussion,

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meeting after meeting,

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nothing changed.

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And that's when it struck me.

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You see, public systems

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have always been governed[br]through internal mechanisms,

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like review meetings.

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And over time,

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their accountability to the citizen[br]has been diluted.

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So why not bring the citizen[br]back into the equation,

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perhaps by using the citizen promises?

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Couldn't that trigger motivation?

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We started with what I like to call[br]the coffee shop strategy.

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You've probably seen[br]one of these signs in a coffee shop,

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which says,

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"If you don't get your receipt,[br]the coffee is free."

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Now, the cashier has no option

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but to give you a receipt each time.

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So we took this strategy[br]and applied it to Rajasthan.

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We worked with the government

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on a program to revive 300 PHCs[br]across the state,

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and we got them to paint very clear[br]citizen promises along the wall.

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"We assure you that you will have[br]a doctor each time."

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"We assure you that you will get[br]your free drugs each time."

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"We assure you

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that you will get[br]your free diagnostics each time."

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And finally, we worked[br]with elected representatives

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to launch these revived PHCs,

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who shared the citizen promises[br]with the community

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with a lot of fanfare.

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Now, the promise[br]was out there in the open.

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Failure would be embarrassing.

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The system had to start delivering.

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And deliver it did.

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Doctor availability went up,

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medicines came on hand,

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and as a result,

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patient visits went up by 20 percent[br]in less than a year.

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The public health system[br]was getting back into business.

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But there was still a long distance to go.

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Change isn't that easy.

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An exasperated doctor once told me,

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"I really want to transform[br]the maternal health in my community,

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but I just don't have enough nurses."

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Now, resources like nurses

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are actually controlled[br]by administrative officers

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who the doctors report to.

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And while the doctors were now motivated,

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the administrative officers[br]simply weren't motivated enough

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to help the doctors.

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This is where the head[br]of the public health department,

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Ms. Veenu Gupta, came up[br]with a brilliant idea.

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A monthly ranking of all districts.

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And this ranking would assess[br]the performance of every district

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on each major disease

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and each major procedure.

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But here's the best part.

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We made the ranking go public.

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We put the ranking on the website,

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we put the ranking on social media,

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and before you knew it,[br]the media got involved,

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with newspaper articles[br]on which districts were doing well

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and which ones weren't.

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And we didn't just want the rankings

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to impact the best-[br]and the worst-performing districts.

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We wanted the rankings[br]to motivate every district.

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So we took inspiration[br]from soccer leagues,

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and created a three-tiered ranking system,

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whereby every quarter,

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if a district's performance[br]were to decline,

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you could get relegated to the lower tier.

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But if the district's performance[br]were to improve,

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you could get promoted[br]to the premiere league.

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The rankings were a big success.

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It generated tremendous excitement,

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and districts began vying with each other[br]to be known as exemplars.

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It's actually very simple,[br]if you think about it.

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If the performance data[br]is only being reviewed by your manager

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in internal settings,

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it simply isn't motivating enough.

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But if that data is out there,

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in the open, for the community to see,

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that's a very different picture.

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That just unlocks a competitive spirit

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which is inherent[br]in each and every one of us.

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So now, when you put these two together,

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the coffee shop strategy[br]and public competition,

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you now had a public health system

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which was significantly more motivated[br]to improve citizen health.

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And now that you had[br]a more motivated health system,

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it was actually a system[br]that was now much more ready for support.

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Because now, there is a pull[br]for the support,

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whether it's resources,[br]data or skill building.

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Let me share an example.

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I was once at a district meeting[br]in the district of Ajmer.

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This is one of the districts[br]that had been rising rapidly

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in the rankings.

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And there were a group[br]of passionate doctors

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who were discussing ideas[br]on how to better support their teams.

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One of the doctors[br]had up-skilled health workers

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to tackle the problem of nurse shortages.

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Another doctor was using WhatsApp[br]in creative ways

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to share information and ideas[br]with his frontline workers.

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For example,

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where are the children[br]who are missing from immunization?

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And how do you convince the mothers

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to actually bring their children[br]for immunization?

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And because their teams[br]were now significantly motivated,

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they were simply lapping up the support,

0:11:08.911,0:11:12.244
because they wanted to perform[br]better and better.

0:11:14.204,0:11:20.156
Broken systems certainly need[br]more resources and tools.

0:11:20.879,0:11:23.418
But they won't drive much impact

0:11:23.442,0:11:26.976
if you don't first address[br]the motivation challenge.

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Once the motivation tide begins to shift,

0:11:31.228,0:11:36.240
that's when you get the real returns[br]off resources and tools.

0:11:38.274,0:11:40.635
But I still haven't answered[br]a key question.

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What happened to the performance[br]of Rajasthan's public health system?

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In 2016, when our work began,

0:11:49.998,0:11:53.085
the government of India and the World Bank

0:11:53.109,0:11:55.509
came out with a public health index.

0:11:56.371,0:12:01.408
Rajasthan was ranked 20th[br]out of 21 large states.

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But in 2018,

0:12:04.075,0:12:06.217
when the next ranking came out,

0:12:06.241,0:12:09.045
Rajasthan showed[br]one of the highest improvements

0:12:09.069,0:12:11.466
among all large states in India,

0:12:11.490,0:12:14.180
leapfrogging four positions.

0:12:14.204,0:12:17.658
For example, it showed[br]one of the highest reductions

0:12:17.682,0:12:19.942
in neonatal mortality,

0:12:19.966,0:12:24.576
with 3,000 additional newborn lives[br]being saved every year.

0:12:25.751,0:12:31.552
Typically, public health transformations[br]take a long time, even decades.

0:12:32.052,0:12:34.847
But this approach had delivered results

0:12:34.871,0:12:36.609
in two years.

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But here's the best part.

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There is actually nothing[br]Rajasthan-specific about what we learned.

0:12:45.198,0:12:50.484
In fact, this approach[br]of using the citizen to trigger motivation

0:12:50.508,0:12:53.574
is not even limited[br]to public health systems.

0:12:54.969,0:12:59.778
I sincerely believe[br]that if there is any public system,

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in any country,

0:13:01.421,0:13:03.308
that is in inertia,

0:13:03.332,0:13:06.132
then we need to bring back the motivation.

0:13:06.601,0:13:09.744
And a great way to trigger the motivation

0:13:09.768,0:13:13.061
is to increase transparency[br]to the citizen.

0:13:14.379,0:13:16.291
We can do this with education

0:13:16.315,0:13:19.649
and sanitation and even[br]political representation.

0:13:20.863,0:13:25.402
Government schools can compete publicly[br]on the basis of student enrollment.

0:13:26.144,0:13:29.216
Cities and towns,[br]on the basis of cleanliness.

0:13:29.240,0:13:31.906
And politicians on the basis[br]of a scorecard

0:13:31.930,0:13:35.130
of how exactly they're[br]improving citizen lives.

0:13:37.117,0:13:40.717
There are many broken systems[br]out there in the world.

0:13:41.236,0:13:43.836
We need to bring back their motivation.

0:13:44.841,0:13:46.888
The citizen is waiting.

0:13:47.397,0:13:49.556
We must act today.

0:13:50.095,0:13:51.444
Thank you very much.

0:13:51.468,0:13:53.880
(Applause)