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← How motivation can fix public systems

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Showing Revision 8 created 10/23/2019 by Erin Gregory.

  1. Take a minute
  2. and think of yourself
    as the leader of a country.
  3. And let's say one
    of your biggest priorities
  4. is to provide your citizens
    with high-quality healthcare.
  5. How would you go about it?
  6. Build more hospitals?
  7. Open more medical colleges?
  8. Invest in clinical innovation?
  9. But what if your country's health system
    was fundamentally broken?
  10. Whether it's doctor absenteeism,
  11. drug stock-outs or poor quality of care.
  12. Where would you start then?
  13. I'm a management consultant,

  14. and for the last three years,
  15. I've been working on a project
  16. to improve the public heath
    system of Rajasthan,
  17. a state in India.
  18. And during the course of the project,
  19. we actually discovered something profound.
  20. More doctors, better facilities,
    clinical innovation --
  21. they are all important.
  22. But nothing changes
    without one key ingredient.
  23. Motivation.
  24. But motivation is a tricky thing.
  25. If you've led a team, raised a child
    or tried to change a personal habit,
  26. you know that motivation
    doesn't just appear.
  27. Something has to change to make you care.
  28. And if there's one thing
    that all of us humans care about,
  29. it's an inherent desire
    to shine in front of society.
  30. So that's exactly what we did.
  31. We decided to focus on the citizen:

  32. the people who the system
    was supposed to serve in the first place.
  33. And today, I'd like to tell you
  34. how Rajasthan has transformed
    its public health system dramatically
  35. by using the citizen
    to trigger motivation.
  36. Now, Rajasthan is one
    of India's largest states,
  37. with a population of nearly 80 million.
  38. That's larger than the United Kingdom.
  39. But the similarities probably end there.
  40. In 2016, when my team was called in
  41. to start working with the public
    health system of Rajasthan,
  42. we found it in a state of crisis.
  43. For example, the neonatal
    mortality rate --

  44. that's the number of newborns who die
    before their first month birthday --
  45. was 10 times higher than that of the UK.
  46. No wonder then that citizens were saying,
  47. "Hey, I don't want to go
    to a public health facility."
  48. In India, if you wanted to see a doctor
    in a public health facility,
  49. you would go to a "PHC,"
    or "primary health center."
  50. And at least 40 patients
    are expected to go to a PHC every day.
  51. But in Rajasthan,
    only one out of four PHCs
  52. was seeing this minimum
    number of patients.
  53. In other words, people
    had lost faith in the system.
  54. When we delved deeper,
  55. we realized that lack of accountability
    is at the core of it.
  56. Picture this.

  57. Sudha, a daily-wage earner,
  58. realizes that her one-year-old daughter
  59. is suffering from
    uncontrollable dysentery.
  60. So she decides to take the day off.
  61. That's a loss of about
    350 rupees or five dollars.
  62. And she picks up her daughter in her arms
  63. and walks for five kilometers
    to the government PHC.
  64. But the doctor isn't there.
  65. So she takes the next day off, again,
  66. and comes back to the PHC.
  67. This time, the doctor is there,
  68. but the pharmacist tells her
  69. that the free drugs
    that she's entitled to have run out,
  70. because they forgot
    to reorder them on time.
  71. So now, she rushes
    to the private medical center,
  72. and as she's rushing there,
  73. looking at her daughter's condition
    worsening with every passing hour,
  74. she can't help but wonder
  75. if she should have gone
    to the private medical center
  76. in the first place
  77. and payed the 350 rupees
    for the consultation and drugs.
  78. No one is held accountable
    for this incredible failure of the system.
  79. Costing time, money
    and heartache to Sudha.
  80. And this is something
    that just had to be fixed.
  81. Now, as all good consultants,

  82. we decided that data-driven reviews
  83. had to be the answer
    to improve accountability.
  84. So we created these fancy
    performance dashboards
  85. to help make the review meetings
    of the health department
  86. much more effective.
  87. But nothing changed.
  88. Discussion after discussion,
  89. meeting after meeting,
  90. nothing changed.
  91. And that's when it struck me.

  92. You see, public systems
  93. have always been governed
    through internal mechanisms,
  94. like review meetings.
  95. And over time,
  96. their accountability to the citizen
    has been diluted.
  97. So why not bring the citizen
    back into the equation,
  98. perhaps by using the citizen promises?
  99. Couldn't that trigger motivation?
  100. We started with what I like to call
    the coffee shop strategy.
  101. You've probably seen
    one of these signs in a coffee shop,
  102. which says,
  103. "If you don't get your receipt,
    the coffee is free."
  104. Now, the cashier has no option
  105. but to give you a receipt each time.
  106. So we took this strategy
    and applied it to Rajasthan.

  107. We worked with the government
  108. on a program to revive 300 PHCs
    across the state,
  109. and we got them to paint very clear
    citizen promises along the wall.
  110. "We assure you that you will have
    a doctor each time."
  111. "We assure you that you will get
    your free drugs each time."
  112. "We assure you
  113. that you will get
    your free diagnostics each time."
  114. And finally, we worked
    with elected representatives
  115. to launch these revived PHCs,
  116. who shared the citizen promises
    with the community
  117. with a lot of fanfare.
  118. Now, the promise
    was out there in the open.
  119. Failure would be embarrassing.
  120. The system had to start delivering.
  121. And deliver it did.
  122. Doctor availability went up,
  123. medicines came on hand,
  124. and as a result,
  125. patient visits went up by 20 percent
    in less than a year.
  126. The public health system
    was getting back into business.
  127. But there was still a long distance to go.

  128. Change isn't that easy.
  129. An exasperated doctor once told me,
  130. "I really want to transform
    the maternal health in my community,
  131. but I just don't have enough nurses."
  132. Now, resources like nurses
  133. are actually controlled
    by administrative officers
  134. who the doctors report to.
  135. And while the doctors were now motivated,
  136. the administrative officers
    simply weren't motivated enough
  137. to help the doctors.
  138. This is where the head
    of the public health department,

  139. Ms. Veenu Gupta, came up
    with a brilliant idea.
  140. A monthly ranking of all districts.
  141. And this ranking would assess
    the performance of every district
  142. on each major disease
  143. and each major procedure.
  144. But here's the best part.
  145. We made the ranking go public.
  146. We put the ranking on the website,
  147. we put the ranking on social media,
  148. and before you knew it,
    the media got involved,
  149. with newspaper articles
    on which districts were doing well
  150. and which ones weren't.
  151. And we didn't just want the rankings
  152. to impact the best-
    and the worst-performing districts.
  153. We wanted the rankings
    to motivate every district.
  154. So we took inspiration
    from soccer leagues,
  155. and created a three-tiered ranking system,
  156. whereby every quarter,
  157. if a district's performance
    were to decline,
  158. you could get relegated to the lower tier.
  159. But if the district's performance
    were to improve,
  160. you could get promoted
    to the premiere league.
  161. The rankings were a big success.

  162. It generated tremendous excitement,
  163. and districts began vying with each other
    to be known as exemplars.
  164. It's actually very simple,
    if you think about it.
  165. If the performance data
    is only being reviewed by your manager
  166. in internal settings,
  167. it simply isn't motivating enough.
  168. But if that data is out there,
  169. in the open, for the community to see,
  170. that's a very different picture.
  171. That just unlocks a competitive spirit
  172. which is inherent
    in each and every one of us.
  173. So now, when you put these two together,
  174. the coffee shop strategy
    and public competition,
  175. you now had a public health system
  176. which was significantly more motivated
    to improve citizen health.
  177. And now that you had
    a more motivated health system,
  178. it was actually a system
    that was now much more ready for support.
  179. Because now, there is a pull
    for the support,
  180. whether it's resources,
    data or skill building.
  181. Let me share an example.

  182. I was once at a district meeting
    in the district of Ajmer.
  183. This is one of the districts
    that had been rising rapidly
  184. in the rankings.
  185. And there were a group
    of passionate doctors
  186. who were discussing ideas
    on how to better support their teams.
  187. One of the doctors
    had up-skilled health workers
  188. to tackle the problem of nurse shortages.
  189. Another doctor was using WhatsApp
    in creative ways
  190. to share information and ideas
    with his frontline workers.
  191. For example,
  192. where are the children
    who are missing from immunization?
  193. And how do you convince the mothers
  194. to actually bring their children
    for immunization?
  195. And because their teams
    were now significantly motivated,
  196. they were simply lapping up the support,
  197. because they wanted to perform
    better and better.
  198. Broken systems certainly need
    more resources and tools.
  199. But they won't drive much impact
  200. if you don't first address
    the motivation challenge.
  201. Once the motivation tide begins to shift,
  202. that's when you get the real returns
    off resources and tools.
  203. But I still haven't answered
    a key question.

  204. What happened to the performance
    of Rajasthan's public health system?
  205. In 2016, when our work began,
  206. the government of India and the World Bank
  207. came out with a public health index.
  208. Rajasthan was ranked 20th
    out of 21 large states.
  209. But in 2018,
  210. when the next ranking came out,
  211. Rajasthan showed
    one of the highest improvements
  212. among all large states in India,
  213. leapfrogging four positions.
  214. For example, it showed
    one of the highest reductions
  215. in neonatal mortality,
  216. with 3,000 additional newborn lives
    being saved every year.
  217. Typically, public health transformations
    take a long time, even decades.
  218. But this approach had delivered results
  219. in two years.
  220. But here's the best part.

  221. There is actually nothing
    Rajasthan-specific about what we learned.
  222. In fact, this approach
    of using the citizen to trigger motivation
  223. is not even limited
    to public health systems.
  224. I sincerely believe
    that if there is any public system,
  225. in any country,
  226. that is in inertia,
  227. then we need to bring back the motivation.
  228. And a great way to trigger the motivation
  229. is to increase transparency
    to the citizen.
  230. We can do this with education
  231. and sanitation and even
    political representation.
  232. Government schools can compete publicly
    on the basis of student enrollment.
  233. Cities and towns,
    on the basis of cleanliness.
  234. And politicians on the basis
    of a scorecard
  235. of how exactly they're
    improving citizen lives.
  236. There are many broken systems
    out there in the world.

  237. We need to bring back their motivation.
  238. The citizen is waiting.
  239. We must act today.
  240. Thank you very much.

  241. (Applause)