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Take a minute

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and think of yourself
as the leader of a country.

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And let's say one
of your biggest priorities

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is to provide your citizens
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
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
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,
clinical innovation,

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they are all important.

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But nothing changes
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,

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or tried to change a personal habit,

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you know that motivation
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
that all of us humans care about,

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it's an inherent desire
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
was supposed to serve in the first place.

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And today,

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I'd like to tell you

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how Rajasthan has transformed
its public health system dramatically,

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by using the citizen
to trigger motivation.

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Now, Rajasthan is one
of India's largest states,

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with the 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
health system of Rajasthan,

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we found it in a state of crisis.

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For example,

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the neonatal mortality rate,

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that's the number of newborns who die
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
to a public health facility."

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

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you would go to a PHC
or primary health center.

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

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But in Rajasthan,

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only one out of four PHCs

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was seeing this minimum
number of patients.

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

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When we delved deeper,

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we realized that lack of accountability
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
uncontrollable dysentery.

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So she decides to take the day off.

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That's a loss of about
350 rupees of five dollars.

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And she picks up her daughter in her arms

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and walks for five kilometers
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
that she's entitled to have run out,

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because they forgot
to reorder them on time.

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So now, she rushes
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
worsening with every passing hour,

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she can't help but wonder

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if she should have gone
to the private medical center

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in the first place,

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and payed the 350 rupees

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for the consultation and drugs.

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No one is held accountable

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for this incredible failure of the system.

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Costing time, money,
and heartache to Sudha.

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And this is something
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
to improve accountability.

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So we created these fancy
performance dashboards

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to help make the review meetings
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
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
has been diluted.

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So why not bring the citizen
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
the coffee shop strategy.

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You've probably seen
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,
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
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
across the state.

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And we got them to paint very clear
citizen promises along the wall.

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We assure you that
you will have a doctor each time.

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We assure you that you will get
your free drugs each time.

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We assure you

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that you will get
your free diagnostics each time.

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And finally, we worked
with elected representatives

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to launch these revived PHCs,

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who shared the citizen promises
with the community

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with a lot of fanfare.

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Now the promise 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
in less than a year.

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The public health system
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
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
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
simply weren't motivated enough

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to help the doctors.

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This is where the head
of the public health department,

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

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A monthly ranking of all districts.

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And this ranking would assess
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 in social media,

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and before you knew it,
the media got involved,

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with newspaper articles
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 district the rankings

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to impact the best and the worst
performing districts.

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We wanted the rankings
to motivate every district.

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So we took inspiration
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
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
were to improve,

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you could get promoted
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
to be known as exemplars.

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It's actually very simple
if you think about it.

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If the performance data
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 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
and public competition,

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you now had a public-health system

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which was significantly more motivated

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to improve citizen health.

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And now that you had
a more motivated health system,

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

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Because now, there is a pull
for the support.

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Whether it's resources,
data or skill building.

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Let me share an example.

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

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This is one of the districts
that had been rising rapidly

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in the rankings.

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And there were a group
of passionate doctors

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

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One of the doctors held
upscaled health workers

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to tackle the problem of nurse shortages.

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Another doctor was using WhatsApp
in creative ways,

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to share information and ideas
with his frontline workers.

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For example,

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where are the children
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
for immunization?

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And because their teams were now
significantly motivated,

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they were simply lapping up the support,

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because they wanted to perform
better and better.

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Broken systems certainly need
more resources and tools.

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But they won't drive much impact

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if you don't first address
the motivation challenge.

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Once the motivation tide begins to shift,

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that's when you get the real returns

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off resources and tools.

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But I still haven't answered
the key question.

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

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In 2016, when our work began,

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the government of India and the World Bank

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came out with a public health index.

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Rajasthan was ranked 20th
out of 21 large states.

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But in 2018,

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when the next ranking came out,

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Rajasthan showed one
of the highest improvements

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among all large states in India,

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leapfrogging four positions.

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For example, it showed one
of the highest reductions

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in neonatal mortality.

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With 3,000 additional newborn lives
being saved every year.

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Typically, public health transformations
take a long time, even decades.

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But this approach had delivered results

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in two years.

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But here's the best part.

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

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In fact, this approach

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of using the citizen to trigger motivation

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is not even limited
to public-health systems.

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I sincerely believe

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that if there is any public system,

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in any country,

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that is in inertia,

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then we need to bring back the motivation.

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And a great way to trigger the motivation

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is to increase transparency
to the citizen.

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We can do this with education,

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and sanitation and even
political representation.

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Government schools can compete publicly
on the basis of student enrollment.

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Cities and towns
on the basis of cleanliness.

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And politicians on the basis
of a scorecard

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of how exactly they're
improving citizen lives.

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There are many broken systems
out there in the world.

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We need to bring back their motivation.

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The citizen is waiting.

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We must act today.

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Thank you very much.

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(Applause)