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