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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)