Abhishek Gopalka
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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.