Doctors Without Orders
To improve global health, what we need isn’t just Bill Gates’ billions, but Microsoft’s managers.
When I attended public health school in the early 1990s, my coursework included biostatistics, epidemiology, AIDS, and demography. These are all “issues” in public health, but less so in public-health delivery. Little of it helps me in the public health work I conduct today. Even at the time, I had spent enough time in the field to know that the study of these discrete areas was no match for the problems faced by implementers every day. Ironically, it wasn’t until I spent a few years working as a private-sector management consultant that I obtained skills that would be helpful in the public health arena. I wanted to understand how the world’s best companies strategized and implemented their strategies. How did they measure success and constantly improve? How did they bring their ideas and products to scale?
When I returned to public health in 2002, I worked to build out teams to aid in the preparation of Global Fund proposals for African countries. But instead of just picking people with strong public health resumes, I looked for MBAs and others with business acumen. I was often viewed skeptically by the public health establishment. My mentor and the dean emeritus of Columbia University’s Mailman School of Public Health, Allan Rosenfield, initially balked at my first hire for Rwanda, a senior manager from McKinsey, the global management consulting firm.
But attitudes changed quickly: By the time that manager had helped expand AIDS testing services from two clinics to 65–in the course of a year–the tide had already begun to shift (and so had Rosenfield’s opinion). His experience building professional management, deepening the pools of local capacity, and rapidly achieving results helped set Rwanda’s experience apart from other nations which were ostensibly better financed and positioned for success.
Today there is, from my own perspective at least, a new willingness to consider merging private-sector thinking with public health priorities. But the shift is incomplete. For too long, doctors have run the public health establishment. Their exclusiveness and insularity has crowded out those with other, equally needed, skills. Epidemiologists–perhaps the next-largest class of the public health cognoscenti–are taught a much different and more liberal way to think, but only by a matter of degrees. While doctors and epidemiologists are vital to global public health efforts, what’s missing is the sort of perspective economists, sociologists, management consultants, and even politicians can bring, a new and enlightened way of answering the question public health specialists and doctors ask: What do people die from? What is needed today is a spectrum of others with varied backgrounds in business, management, and public policy who can offer new, creative diagnoses that require far more complex approaches.
Public health professionals are latter-day martyrs–and, for better or worse, they know it. The dirty little secret of global public health is that the focus has always been on how to gallantly do as much as possible with as little as possible. That central fact of professional life for public health workers–dating back to Cicely Williams’s work on childhood nutrition in the Gold Coast in the 1920s and 1930s–has been the model into which all public health experts have been indoctrinated. This perspective has pushed public health to remarkable achievements given the funds invested. But it has also stifled the ambitions long advocated by the community, dreams like the 1978 Alma Ata declaration of “Health for All by the Year 2000” and today’s more tempered but still ambitious Millennium Development Goals to “have halved by 2015 and begun to reverse the spread of HIV/AIDS” and to “reduce by two-thirds” the “under five mortality rate.” More contentious, system-reinforcing efforts like providing family planning and maternal health services are notably absent from the Millennium Development Goals, thanks to lobbying by an unlikely group that includes Iran, the Vatican, and the Bush White House. Such idealism and ambiguity can only lead to unrealized dreams (with some exceptional successes in countries that manage to put together the right business plan and team for achieving this success).
Perhaps one of the leading drivers of poor performance–or at least acceptance of poor performance–is that unlike a corporation, which is clearly motivated by profits, NGOs’ and donors’ motives are less defined. Larry Diamond has noted in these pages that after spending $500 billion on aid in Africa, the continent is largely worse off for the expenditures [“End Foreign Aid as We Know It,” Issue #8]. That critique is often rejected for failing to consider some small accomplishment or another, as well as the relatively small amount of “good” aid that has gone to programs that deliver results. Correctly, however, Diamond joins a chorus of others who conclude that the way in which aid is given must be radically restructured, along with the way that aid is used.
The failure of aid in the past for global public health has influenced today’s approaches enormously. In part, we focus on AIDS today because counting people on AIDS medicines is an inarguably objective criteria hard to match in more complex endeavors such as comprehensive health systems’ improvements. Alas, this singular focus on AIDS and related pandemics means that doctors and nurses who previously focused on primary health care and childhood and maternal health have been lured away by higher wages for AIDS work, offered by donor-funded initiatives. Some countries, such as Rwanda, have attempted to steer disease-specific funds toward overall health advances by using investments to improve infrastructure where possible and to focus on diseases other than AIDS, many of which are easily treatable but have been largely ignored. Nevertheless, the Rwandan experience and other nations’ progress continue to demonstrate that developing countries need an across-the-board upgrade of their health systems and that the management to get that job done does not yet exist.
What would a new, management-oriented approach to developing world public health look like? Ask Jim Yong Kim, a co-founder of Partners in Health, a public health NGO, and a professor at both the Medical School and School of Public Health at Harvard University. Kim has long been a fervent advocate for applying business acumen to the public health sector and to teaching public health much the way business is taught today: by case studies. He often jokes that there should be a collection of case studies on public health failures. He recently asked, “What can we learn from business and communications experts that will help us better deliver healthcare? How can we ensure that the lifesaving products and technologies are as available in poor countries as imported soft drinks?”
In response, Kim is putting together the Global Health Delivery Project (GHD), a new initiative out of Harvard in which global health meets the business world. Led by Kim, physician Paul Farmer, and business professor Michael Porter, GHD addresses the implementation gap between good plans and good execution by studying successes and failures in global health care delivery and the design and management of health care delivery systems in low-resource settings. According to them, “Practitioners of health care worldwide need effective care delivery models, support, training, information, and tools to utilize new resources in a way that will provide the best-possible care; yet no comprehensive effort currently exists to address their needs.” They plan to focus Harvard’s program in four key areas: education to teach effective methods of health delivery; interdisciplinary “communities of practice” to leverage the Internet to disperse these ideas; research to unite clinical research, operational research, and engineering science; and innovation centers, located across Africa, to provide on-the-ground research, learning, and teaching for Harvard’s affiliates and others.
This is, of course, just one effort, not a wholesale reform; on the other hand, there is no governing body of public health, and so any change will have to come through the effective demonstration of new approaches by groups like Kim’s. The key is figuring out the right curriculum and case studies to train the talent required today. The intersection of the private and public sectors is a challenge for any discipline, and public health implementation anywhere–the United States being a glaring example–has an extraordinarily difficult time getting it right. A true business approach in global public health demands that clear metrics, interventions, incentives, and feedback mechanisms be put in place to focus on health improvement just as the private sector focuses on profits. Practitioners need not have an understanding of the minutiae of health challenges. They simply need to be great managers, trained in the basics of public health, with superb strategic, organizational, and implementation skills. The next step for Kim and Harvard needs to be satellite programs across Africa; even with innovation centers, the project is still rooted in Cambridge. As Kim and others in GHD know first-hand, learning management techniques thousands of miles from the health centers of Africa risks irrelevance.
The Rwandan Model
In recent years Rwanda–not Harvard–has been at the forefront of bringing management techniques to its public health system. In light of its history of genocide and war, Rwanda seems an unlikely candidate for a rapidly expanding professionalized health care system. However, during the decades prior to the genocide, hundreds of thousands of Rwandans spread across the world in a massive Diaspora. They were exposed to new approaches and developed new expectations about health care, all the while longing to return and rebuild the nation. Their return in the 1990s coincided with the rise in international interest and, eventually, funding for specific diseases, particularly AIDS. Furthermore, the relatively transparent government, combined with its can-do attitude, has made it a haven for donor dollars seeking speedy results.
Millions of health dollars–from governments, the Global Fund, NGOs, and family foundations–began flowing in 2003, but the limitations of the country’s remote health centers often kept these resources from reaching a substantial portion of the country’s population. While funds for international health issues increased, on-the-ground success lagged behind. In response, the Access Project, an initiative to deliver management talent to far-flung health centers, began working in health centers in Rwanda with business-style metrics and private-sector expectations of sustainability and scalability.
The Access Project is just one local initiative, and yet its success illustrates the possibility for similar efforts elsewhere. This is not a stand-alone effort, but one that complements existing programs. Financed by technology maven and businessman Rob Glaser, the CEO of Real Networks, it builds on the Global Fund’s success by delivering on-the-ground assistance with its implementation. Blaise Karibushi–a medical doctor and MBA who currently directs the Access Project in Rwanda–insists that with proper guidance and systems, any health center can improve its operations to the point where it can sustainably deliver quality health care to the community. The interventions his team has implemented fall into ten categories of management, none of which sound as sexy as delivering AIDS drugs to desperately ill children, but all of which improve health–including management of data, planning and reporting, human resources management, and financial management, including local insurance schemes. This is the stuff that most donors want nothing to do with, but it is the stuff that the future of public health must be built on.
Unlike other organizations that immediately move into a health center and choose a specific need (X-ray machines, water, electricity, training), the Access Project begins by diagnosing the management needs of health centers. It has found centers where there are plenty of nurses, but because there is no proper scheduling, they are deployed inefficiently and as a result deliver terrible results. In other centers it has found that just three nurses are expected to manage the delivery of care to a population of 25,000, procure medicine, handle community insurance, and maintain the facility, all on a total budget of a few thousand dollars per year. The results are predictable: no health care delivered, low morale, and few patients. But with a proper management structure–merely by providing sufficient accounting systems, drug procurement guides, and basic management training–these centers have been able to get on their feet quickly. And while donors have proved hard to corral before Access Project begins work on a particular facility, once it has completed its overhaul, they tend to become suddenly interested in making investments. In one dramatic case, a health center that had been seeing five to 10 patients a day was seeing over 150 patients six months after management reforms were implemented, and as a result it qualified for other donor financing to offer AIDS services.
Global Health at a Crossroads
There is a true revolution in global public health funding going on. The Gates Foundation has become the most prominent force financially and ideologically in the sector, spending nearly $3 billion in 2008, but thousands of smaller foundations are also engaged. There are more than 71,000 foundations in the United States today, and with over $40 billion donated last year (albeit only a small percentage for global health), their giving is accelerating and great opportunities are in the offing.
This outpouring provides a window for action; many in the global public health community, from doctors to donors, are opening up to the idea of a managed, systems-wide approach. In 2006, having seen the limitations of disease-specific approaches particularly in countries with weak health systems, the Global Fund to Fight AIDS, Tuberculosis and Malaria announced that it would accept proposals for improvements in health systems. Advocates for anti-retroviral drugs (ARVs) are today at the forefront of demanding that health workers be trained and placed in the hills and deserts, not just in the urban and peri-urban areas where delivery of ARVs is easier. They are beginning to address health not by focusing on a limited slate of diseases, but rather by focusing on every aspect of life that contributes to health, from the management of care programs to agricultural productivity to telecommunications improvement and the provision of clean water.
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