How motivation can fix public systems
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0:01 - 0:02Take a minute
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0:03 - 0:05and think of yourself
as the leader of a country. -
0:07 - 0:09And let's say one
of your biggest priorities -
0:09 - 0:13is to provide your citizens
with high-quality healthcare. -
0:14 - 0:16How would you go about it?
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0:16 - 0:18Build more hospitals?
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0:18 - 0:20Open more medical colleges?
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0:20 - 0:22Invest in clinical innovation?
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0:23 - 0:27But what if your country's health system
was fundamentally broken? -
0:27 - 0:30Whether it's doctor absenteeism,
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0:30 - 0:33drug stock-outs or poor quality of care.
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0:33 - 0:35Where would you start then?
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0:36 - 0:38I'm a management consultant,
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0:38 - 0:40and for the last three years,
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0:40 - 0:42I've been working on a project
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0:42 - 0:46to improve the public heath
system of Rajasthan, -
0:46 - 0:47a state in India.
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0:48 - 0:51And during the course of the project,
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0:51 - 0:53we actually discovered something profound.
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0:55 - 0:59More doctors, better facilities,
clinical innovation -- -
1:00 - 1:01they are all important.
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1:02 - 1:06But nothing changes
without one key ingredient. -
1:06 - 1:07Motivation.
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1:09 - 1:11But motivation is a tricky thing.
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1:11 - 1:18If you've led a team, raised a child
or tried to change a personal habit, -
1:18 - 1:21you know that motivation
doesn't just appear. -
1:22 - 1:25Something has to change to make you care.
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1:26 - 1:31And if there's one thing
that all of us humans care about, -
1:31 - 1:35it's an inherent desire
to shine in front of society. -
1:36 - 1:38So that's exactly what we did.
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1:39 - 1:42We decided to focus on the citizen:
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1:42 - 1:47the people who the system
was supposed to serve in the first place. -
1:48 - 1:51And today, I'd like to tell you
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1:51 - 1:56how Rajasthan has transformed
its public health system dramatically -
1:56 - 2:00by using the citizen
to trigger motivation. -
2:01 - 2:05Now, Rajasthan is one
of India's largest states, -
2:05 - 2:08with a population of nearly 80 million.
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2:09 - 2:11That's larger than the United Kingdom.
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2:13 - 2:16But the similarities probably end there.
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2:16 - 2:20In 2016, when my team was called in
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2:20 - 2:24to start working with the public
health system of Rajasthan, -
2:24 - 2:26we found it in a state of crisis.
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2:27 - 2:31For example, the neonatal
mortality rate -- -
2:31 - 2:36that's the number of newborns who die
before their first month birthday -- -
2:36 - 2:40was 10 times higher than that of the UK.
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2:41 - 2:43No wonder then that citizens were saying,
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2:43 - 2:46"Hey, I don't want to go
to a public health facility." -
2:47 - 2:52In India, if you wanted to see a doctor
in a public health facility, -
2:52 - 2:56you would go to a "PHC,"
or "primary health center." -
2:57 - 3:02And at least 40 patients
are expected to go to a PHC every day. -
3:03 - 3:07But in Rajasthan,
only one out of four PHCs -
3:07 - 3:09was seeing this minimum
number of patients. -
3:09 - 3:13In other words, people
had lost faith in the system. -
3:15 - 3:18When we delved deeper,
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3:18 - 3:22we realized that lack of accountability
is at the core of it. -
3:24 - 3:25Picture this.
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3:25 - 3:28Sudha, a daily-wage earner,
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3:28 - 3:31realizes that her one-year-old daughter
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3:31 - 3:34is suffering from
uncontrollable dysentery. -
3:34 - 3:37So she decides to take the day off.
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3:37 - 3:41That's a loss of about
350 rupees or five dollars. -
3:41 - 3:44And she picks up her daughter in her arms
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3:44 - 3:48and walks for five kilometers
to the government PHC. -
3:49 - 3:50But the doctor isn't there.
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3:52 - 3:55So she takes the next day off, again,
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3:55 - 3:57and comes back to the PHC.
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3:57 - 3:59This time, the doctor is there,
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3:59 - 4:01but the pharmacist tells her
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4:01 - 4:04that the free drugs
that she's entitled to have run out, -
4:04 - 4:07because they forgot
to reorder them on time. -
4:08 - 4:11So now, she rushes
to the private medical center, -
4:11 - 4:12and as she's rushing there,
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4:12 - 4:16looking at her daughter's condition
worsening with every passing hour, -
4:16 - 4:18she can't help but wonder
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4:18 - 4:21if she should have gone
to the private medical center -
4:21 - 4:22in the first place
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4:22 - 4:27and payed the 350 rupees
for the consultation and drugs. -
4:29 - 4:35No one is held accountable
for this incredible failure of the system. -
4:36 - 4:42Costing time, money
and heartache to Sudha. -
4:44 - 4:47And this is something
that just had to be fixed. -
4:47 - 4:50Now, as all good consultants,
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4:50 - 4:54we decided that data-driven reviews
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4:54 - 4:57had to be the answer
to improve accountability. -
4:58 - 5:01So we created these fancy
performance dashboards -
5:01 - 5:04to help make the review meetings
of the health department -
5:04 - 5:06much more effective.
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5:07 - 5:09But nothing changed.
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5:10 - 5:12Discussion after discussion,
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5:12 - 5:14meeting after meeting,
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5:14 - 5:16nothing changed.
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5:17 - 5:19And that's when it struck me.
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5:19 - 5:21You see, public systems
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5:21 - 5:25have always been governed
through internal mechanisms, -
5:25 - 5:27like review meetings.
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5:28 - 5:29And over time,
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5:29 - 5:33their accountability to the citizen
has been diluted. -
5:34 - 5:37So why not bring the citizen
back into the equation, -
5:37 - 5:41perhaps by using the citizen promises?
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5:41 - 5:43Couldn't that trigger motivation?
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5:44 - 5:49We started with what I like to call
the coffee shop strategy. -
5:49 - 5:53You've probably seen
one of these signs in a coffee shop, -
5:53 - 5:54which says,
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5:54 - 5:58"If you don't get your receipt,
the coffee is free." -
5:59 - 6:02Now, the cashier has no option
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6:02 - 6:05but to give you a receipt each time.
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6:07 - 6:11So we took this strategy
and applied it to Rajasthan. -
6:12 - 6:14We worked with the government
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6:14 - 6:19on a program to revive 300 PHCs
across the state, -
6:19 - 6:25and we got them to paint very clear
citizen promises along the wall. -
6:26 - 6:30"We assure you that you will have
a doctor each time." -
6:30 - 6:34"We assure you that you will get
your free drugs each time." -
6:34 - 6:36"We assure you
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6:36 - 6:38that you will get
your free diagnostics each time." -
6:39 - 6:43And finally, we worked
with elected representatives -
6:43 - 6:46to launch these revived PHCs,
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6:46 - 6:49who shared the citizen promises
with the community -
6:49 - 6:51with a lot of fanfare.
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6:52 - 6:56Now, the promise
was out there in the open. -
6:57 - 6:59Failure would be embarrassing.
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7:00 - 7:02The system had to start delivering.
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7:04 - 7:06And deliver it did.
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7:07 - 7:09Doctor availability went up,
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7:09 - 7:11medicines came on hand,
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7:11 - 7:13and as a result,
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7:13 - 7:17patient visits went up by 20 percent
in less than a year. -
7:18 - 7:22The public health system
was getting back into business. -
7:24 - 7:26But there was still a long distance to go.
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7:27 - 7:28Change isn't that easy.
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7:30 - 7:33An exasperated doctor once told me,
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7:33 - 7:37"I really want to transform
the maternal health in my community, -
7:37 - 7:39but I just don't have enough nurses."
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7:39 - 7:42Now, resources like nurses
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7:42 - 7:45are actually controlled
by administrative officers -
7:45 - 7:47who the doctors report to.
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7:48 - 7:50And while the doctors were now motivated,
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7:50 - 7:54the administrative officers
simply weren't motivated enough -
7:54 - 7:56to help the doctors.
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7:57 - 8:00This is where the head
of the public health department, -
8:00 - 8:03Ms. Veenu Gupta, came up
with a brilliant idea. -
8:04 - 8:08A monthly ranking of all districts.
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8:08 - 8:12And this ranking would assess
the performance of every district -
8:12 - 8:14on each major disease
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8:14 - 8:16and each major procedure.
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8:17 - 8:19But here's the best part.
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8:19 - 8:21We made the ranking go public.
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8:22 - 8:24We put the ranking on the website,
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8:24 - 8:26we put the ranking on social media,
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8:26 - 8:29and before you knew it,
the media got involved, -
8:29 - 8:33with newspaper articles
on which districts were doing well -
8:33 - 8:34and which ones weren't.
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8:35 - 8:38And we didn't just want the rankings
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8:38 - 8:41to impact the best-
and the worst-performing districts. -
8:41 - 8:45We wanted the rankings
to motivate every district. -
8:46 - 8:49So we took inspiration
from soccer leagues, -
8:49 - 8:52and created a three-tiered ranking system,
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8:52 - 8:55whereby every quarter,
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8:55 - 8:58if a district's performance
were to decline, -
8:58 - 9:01you could get relegated to the lower tier.
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9:01 - 9:04But if the district's performance
were to improve, -
9:04 - 9:07you could get promoted
to the premiere league. -
9:08 - 9:10The rankings were a big success.
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9:10 - 9:12It generated tremendous excitement,
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9:12 - 9:17and districts began vying with each other
to be known as exemplars. -
9:18 - 9:21It's actually very simple,
if you think about it. -
9:21 - 9:26If the performance data
is only being reviewed by your manager -
9:26 - 9:28in internal settings,
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9:28 - 9:31it simply isn't motivating enough.
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9:31 - 9:34But if that data is out there,
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9:34 - 9:38in the open, for the community to see,
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9:38 - 9:40that's a very different picture.
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9:41 - 9:44That just unlocks a competitive spirit
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9:44 - 9:47which is inherent
in each and every one of us. -
9:48 - 9:51So now, when you put these two together,
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9:51 - 9:55the coffee shop strategy
and public competition, -
9:55 - 9:57you now had a public health system
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9:57 - 10:02which was significantly more motivated
to improve citizen health. -
10:04 - 10:07And now that you had
a more motivated health system, -
10:07 - 10:11it was actually a system
that was now much more ready for support. -
10:11 - 10:14Because now, there is a pull
for the support, -
10:14 - 10:18whether it's resources,
data or skill building. -
10:19 - 10:20Let me share an example.
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10:21 - 10:25I was once at a district meeting
in the district of Ajmer. -
10:25 - 10:28This is one of the districts
that had been rising rapidly -
10:29 - 10:30in the rankings.
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10:30 - 10:32And there were a group
of passionate doctors -
10:32 - 10:37who were discussing ideas
on how to better support their teams. -
10:37 - 10:41One of the doctors
had up-skilled health workers -
10:41 - 10:44to tackle the problem of nurse shortages.
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10:44 - 10:48Another doctor was using WhatsApp
in creative ways -
10:48 - 10:52to share information and ideas
with his frontline workers. -
10:52 - 10:53For example,
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10:53 - 10:57where are the children
who are missing from immunization? -
10:57 - 10:59And how do you convince the mothers
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10:59 - 11:02to actually bring their children
for immunization? -
11:03 - 11:06And because their teams
were now significantly motivated, -
11:06 - 11:09they were simply lapping up the support,
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11:09 - 11:12because they wanted to perform
better and better. -
11:14 - 11:20Broken systems certainly need
more resources and tools. -
11:21 - 11:23But they won't drive much impact
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11:23 - 11:27if you don't first address
the motivation challenge. -
11:28 - 11:31Once the motivation tide begins to shift,
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11:31 - 11:36that's when you get the real returns
off resources and tools. -
11:38 - 11:41But I still haven't answered
a key question. -
11:41 - 11:45What happened to the performance
of Rajasthan's public health system? -
11:47 - 11:50In 2016, when our work began,
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11:50 - 11:53the government of India and the World Bank
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11:53 - 11:56came out with a public health index.
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11:56 - 12:01Rajasthan was ranked 20th
out of 21 large states. -
12:02 - 12:04But in 2018,
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12:04 - 12:06when the next ranking came out,
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12:06 - 12:09Rajasthan showed
one of the highest improvements -
12:09 - 12:11among all large states in India,
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12:11 - 12:14leapfrogging four positions.
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12:14 - 12:18For example, it showed
one of the highest reductions -
12:18 - 12:20in neonatal mortality,
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12:20 - 12:25with 3,000 additional newborn lives
being saved every year. -
12:26 - 12:32Typically, public health transformations
take a long time, even decades. -
12:32 - 12:35But this approach had delivered results
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12:35 - 12:37in two years.
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12:38 - 12:40But here's the best part.
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12:40 - 12:44There is actually nothing
Rajasthan-specific about what we learned. -
12:45 - 12:50In fact, this approach
of using the citizen to trigger motivation -
12:51 - 12:54is not even limited
to public health systems. -
12:55 - 13:00I sincerely believe
that if there is any public system, -
13:00 - 13:01in any country,
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13:01 - 13:03that is in inertia,
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13:03 - 13:06then we need to bring back the motivation.
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13:07 - 13:10And a great way to trigger the motivation
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13:10 - 13:13is to increase transparency
to the citizen. -
13:14 - 13:16We can do this with education
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13:16 - 13:20and sanitation and even
political representation. -
13:21 - 13:25Government schools can compete publicly
on the basis of student enrollment. -
13:26 - 13:29Cities and towns,
on the basis of cleanliness. -
13:29 - 13:32And politicians on the basis
of a scorecard -
13:32 - 13:35of how exactly they're
improving citizen lives. -
13:37 - 13:41There are many broken systems
out there in the world. -
13:41 - 13:44We need to bring back their motivation.
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13:45 - 13:47The citizen is waiting.
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13:47 - 13:50We must act today.
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13:50 - 13:51Thank you very much.
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13:51 - 13:54(Applause)
- Title:
- How motivation can fix public systems
- Speaker:
- Abhishek Gopalka
- Description:
-
How do you fix broken public systems? You spark people's competitive spirit. In a talk about getting people motivated to make change, public sector strategist Abhishek Gopalka discusses how he helped improve the health system of Rajasthan, a state in India home to more than 80 million people, using the powers of transparency and public accountability. "Motivation doesn't just appear," Gopalka says. "Something needs to change to make you care."
- Video Language:
- English
- Team:
- closed TED
- Project:
- TEDTalks
- Duration:
- 14:07
Erin Gregory edited English subtitles for How motivation can fix public systems | ||
Erin Gregory edited English subtitles for How motivation can fix public systems | ||
Erin Gregory edited English subtitles for How motivation can fix public systems | ||
Erin Gregory edited English subtitles for How motivation can fix public systems | ||
Erin Gregory approved English subtitles for How motivation can fix public systems | ||
Erin Gregory edited English subtitles for How motivation can fix public systems | ||
Krystian Aparta accepted English subtitles for How motivation can fix public systems | ||
Krystian Aparta edited English subtitles for How motivation can fix public systems |