Transcript Strategic Leadership in Population and Reproductive Health

Strategic Leadership for Health System
Transformation
W. Henry Mosley
Where do leaders operate?
Beyond Imagination
That’s Impossible
Looks Difficult
Easy to do
What is difficult? Impossible?
Beyond imagination?
Our best thinking got us here.
The problems that we face cannot be
solved by the same level of thinking
that created them.
Albert Einstein
The Present Health System Is Perfectly
Designed to Produce the Present Results
If we want
the same
results, let us
keep the
present
system!
If We Want New Results, We Need to
Redesign Our Health Production System
JJOHNS HOPKINS
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Center for Communication Programs
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Relationship between income and
malnutrition
The “disconnect” between income and
malnutrition
Alternatively,
Malnutrition
“falls”
independent
of “rises” in
income
(among the
lowest
income
countries)
Leadership the old way
The “Blueprint” Strategy
Interest
groups
Policymakers,
planners
MIS
Evaluations
Research,
pilot projects
Project
Blueprints
Managers,
providers
Communities,
households
Health
Mental Models Sustaining the
Blueprint Strategy
Highly placed professionals have sufficient
knowledge to prescribe interventions that
will work in any social context
Knowledge from “evidence-based” intervention
research done in specific contexts have
universal applicability
Time-limited, pre-designed, inflexible projects
are the best means of introducing innovative
health interventions in any setting
Mental Models Sustaining the
Blueprint Strategy (continued)
The institutions, personnel and services of
National Ministries of Health constitute the
“health system” of a country
Short-term material investments and focused
technical assistance to the MOH will produce
sustainable improvements in a country’s
health
Using outside “experts” to gather, analyze,
interpret and publish data is an effective
means of gaining an understanding of the
realities in the field
Interest
groups
The “Blueprint” Strategy
A fundamental flaw
Policymakers,
planners
MIS
Evaluations
Project
Blueprints
Managers,
providers
Communities,
households
Research,
pilot projects
Learning
Disconnects
learning
from action
Health
Action
Social Consequences of Blueprint Projects
No (or limited) learning by the front-line health
workers – who are the members of the
households and communities where the
action is taking place
Therefore, no fundamental changes in
behaviors and no sustainability after the
project is completed
Evidence – Look at the health disparities among
developing countries and the inequities
within countries after 50 years of top down
projects
Donor Aid in Developing Countries Too
Often Produces Little Sustainable Benefits
The twin tragedies of global poverty1
So many people in developing countries are
seemingly fated to live horribly stunted lives
and die such early deaths
After 50 years and more than $2.3 trillion in aid
from the West, there is shockingly little to
show for it.
1Paraphrased
from: William Easterly, The White
Man’s Burden. Why the West’s efforts to aid the rest
have done so much ill and so little good. Penguin
Press, NY, 2006
So what do we need to change?
Ourselves first – We need to:
Break down the walls between all our formal
institutions and learn to communicate with each
other
Engage the people from the community and all
sectors of government in a learning process to
deepen our understanding of the realities of
human development
To change the way we act, we must
first change the way we think
A first step is to change our “Mental
Model” of what constitutes the “health
system” of a country
Do You Really Know What Are the
Production Systems of Your
Country?
You are the Minister of Agriculture.
You are asked by a reporter from
CNN to describe the agricultural
system in your country.
What is your answer?
Mental Models Define Our “Reality” and
Pre-determine the Choices We Make and the
Actions We Take
Who “produces
crops” in your
mental model of
the agricultural
system?
How does your
answer
determine the
roles and
functions of the
Ministry of
Agriculture?
Do You Really Know What Are the
Production Systems of Your
Country?
You are the Minister of Health.
You are asked by a reporter from
CNN to describe the health
system in your country.
What is your answer?
Mental Models Define Our “Reality” and Predetermine the Choices We Make and the
Actions We Take
Who “produces
health” in your
mental model of the
health system?
How does your
answer determine
the roles and
functions of the
Ministry of Health?
The Household Production of
Health
Premises
1. Households are the primary
units for the production of
health.
Mothers are the primary managers and
implementers of the household health production
tasks, and women and children are the major
“beneficiaries/victims”
Therefore gender relations and status of
women are key determinants of health in the
developing world
The Household Production of
Health
Premises (continued)
2. Households, like every social
institution, have three basic
capabilities for the production of the
desired outputs
Resources
Practices
Values
Productive Capabilities
Resources
Material
money
housing
possessions
utilities
property
equipment
technologies
Non-material
gender
time
health
ethnicity/language
beliefs/knowledge/skills
reputation
social status
social networks
self-image/motivation
Productive Capabilities
Practices
Formal
Sanctioned by laws, religion,
regulations, relating to:
•marriage/divorce
•property rights
•interpersonal relationships
gender/sexual/violence
• personal mobility
•labor force participation
Informal
The customary ways of
making decisions, taking
actions relating to:
•gender roles
•marital relations
child marriage/violence
•sexual relations
•health care provision
•money management
•freedom of mobility
Productive Capabilities
Values
Progress resistant
Progress Promoting
Hierarchical
Status based on birth/gender
Knowledge from traditions
Conformity honored
Destiny due to fate
Past/present oriented
Closed minded, arrogant
Suspicion of “others”
Success by relationships
Egalitarian
Status by achievement
Learning by trial and error
Creativity, innovation honored
Destiny from self-reliance
Future oriented
Open minded, self-critical
Mutual trust
Success based on merit
Values
Practices Resources
1. Which health production capabilities are
more important – material or non-material?
Which do we measure? Why?
2. What do we mean when we say that a
person or household is “resourceful”?
Can we measure it? How?
A culture is the product of the
interactions
of:
Values
Practices
Resources
Culture
The DNA of Social Institutions
Values
Practices
Resources
Values
Practices
Resources
Values
Practices
Resources
 Culture is self-replicating from generation to
generation
 Like DNA, a cultural system is resistant to
change
Externally driven development programs
typically ignore culture – Why?
The Household Production of
Health
Premises (continued)
3. Households produce health in
the context of the local community
and the wider society – which is a
nation’s health production system.
The Health Production System
The Health Production System
Values
Households
Practices Resources
Values
Values
Government
Communities
Practices Resources
Practices
Resources
Interest
groups
The “Blueprint” Strategy
What values dominate?
Policymakers,
planners
MIS
Evaluations
Project
Blueprints
Managers,
providers
Communities,
households
Research,
pilot projects
Learning
Disconnects
learning
from action
Health
Action
Productive Capabilities
Values
Progress resistant
Progress Promoting
Hierarchical
Status based on birth/gender
Knowledge from traditions
Conformity honored
Destiny due to fate
Past/present oriented
Closed minded, arrogant
Suspicion of “others”
Success by relationships
Egalitarian
Status by achievement
Learning by trial and error
Creativity, innovation honored
Destiny from self-reliance
Future oriented
Open minded, self-critical
Mutual trust
Success based on merit
What Are the Health Production Capabilities?
For every 1000 families* in an LDC, complete the following
RESOURCES
Government
- Health providers
<5
<$10
High
High
2000 – 4000+
>$400
Low
Low
~8
~5
24
7
Low
High
- Funds/capita/year
- Preventive skills
- Curative skills
Households
PRACTICES
- Hours/day
- Days/week
VALUES
- Motivation
*About 5,000 persons
The Burden of Disease
What are the health problems in the population, and
how do they come about?
Source: WHO, World Health Report 2002. Reducing Risks, Promoting Healthy Life
What are the “household production” tasks
that relate to the “burden of disease”?
Undernutrition – food production/purchase
and storage; dietary selection and meal
preparation; family food allocation;
dietary practices in pregnancy and
postpartum; breastfeeding and
complementary feeding practices; etc.
What are the “household production” tasks
that relate to the Burden of Disease?
Unsafe sex – negotiating gender roles and
sexual relationships, “protecting” unmarried
daughters (and sons), delaying sexual debut,
arranging marriages, secluding women,
limiting sexual partners, practicing
contraception, obtaining abortions, utilizing
condoms, etc.
What are the “household production” tasks that
relate to the Burden of Disease?
Unsafe water, sanitation and hygiene –
collection, storage, utilization of water; bathing,
washing clothing, bedding, utensils, use of
soap; food preparation (incl. infant formula) and
storage; latrine practices and waste disposal;
etc.
Indoor smoke from solid fuel – collection of
biomass for fuel; use of open indoor fires; lack
of windows, etc
How about sickness care?
From 70 – 90% of all sickness care takes place in
the home*
Household members, especially mothers:
make the primary diagnoses of illnesses
assess the severity and likely outcomes
select among available providers and treatment
options
procure and administer treatments
*Source: WHO, World Health Report 2002. Reducing Risks, Promoting Healthy Life
Leadership Challenges in Health
1. How do you get all the diverse actors
in a “multi-minded” health production
system to move together in towards a
common goal?
2. How do you overcome the barriers to
change generated by long-standing,
self-sustaining institutional cultures at
every level?
Leadership Skills for Change
Catalytic - Shared Vision of a health
future that people want to create
Enabling - Teamwork with trust, openmindedness, transparency and mutual
accountability for all outcomes
Learning – Generating new knowledge to
mobilize the vast resources of ordinary
people for change
Leadership the New Way “Learning Organization” Strategy
Communities,
households
3
Learning
Health
1
Linking
Action to
Learning
2
Policymakers,
planners
Competencies
Interest
groups
Tasks
Managers,
providers
“Learning Organization” Strategy
What values dominate?
Communities,
households
3
Learning
Health
1
Linking
Action to
Learning
2
Policymakers,
planners
Competencies
Interest
groups
Tasks
Managers,
providers
Productive Capabilities
Values
Progress resistant
Progress Promoting
Hierarchical
Status based on birth/gender
Knowledge from traditions
Conformity honored
Destiny due to fate
Past/present oriented
Closed minded, arrogant
Suspicion of “others”
Success by relationships
Egalitarian
Status by achievement
Learning by trial and error
Creativity, innovation honored
Destiny from self-reliance
Future oriented
Open minded, self-critical
Mutual trust
Success based on merit
Maternal Mortality - Blueprint Project
Can the community participate here?
Strategic objective –
Reduce MMR by 20%
- from (500/100,000
to 400/100,000) in
5 years.
Maternal Mortality - Shared Vision
Can the community participate here?
Shared Vision - No mother
dies from child birth in
our community.
Should we do it alone?
Or through the Learning
Organization?
Bureaucratic Perceptions
4% MMR reduction/year is “easy to do.”
10% MMR reduction/year is “difficult!”
25% MMR reduction/year is “impossible!”
Elimination of MMR is “beyond imagination!”
Where do leaders operate?
Beyond Imagination
That’s Impossible
Looks Difficult
Easy to do
Does your country have a Shared
Vision?
Government goal - reduce MMR by 4%
every year!
Community goal - Zero MMR!
Household goal - Zero MMR!
Question
Should a vision be achievable under
present conditions?
Shared vision asks:
What do we want to happen? Or What
do we want to create?
NOT
What is feasible given present
conditions?
Should visions be based on
situation analysis?
Should we want only what we can have
given the current situation?
Should we aim for what we truly want and
change the current situation?
A few questions
1. Do you have a national shared vision for
reproductive health?
2. Do you have a shared vision for RH in your
organization?
3. Can everyone describe what the shared
vision is?
4. If you don’t have a shared vision, what is
the reason?
Key question
Do families, the primary producers of health,
participate in shaping the reproductive
health vision for their community?
Exciting and Sustaining Action by
Every Team Member
Does every frontline worker know:
•
•
•
•
what the goal is?
what the score is in their community?
what their part is on the team?
how well they are performing?
Resourcefulness
“Development can be neither given nor
received – it must come from within….
What the less developed have been most
deprived of is not the fruits of
development, but the opportunity to
develop themselves.”
Jamshid Gharajedaghi
What is difficult? Impossible?
Beyond imagination?
Leadership – Helping People Be More
“Resourceful” in Producing Health
Old way
New way
Professionals in facilities
providing services
Resourceful households
producing health
Transforming the health system
THE WISDOM OF TAO
XVII RULERS
Of the best rulers
The people only know that they exist,
The next best they love and praise,
The next they fear,
And the next they revile.
When they do not command the people's faith,
Some will lose faith in them,
And then they resort to oaths!
But of the best, when their task is accomplished, their work done,
The people all remark, "We have done it ourselves."
Source: The Wisdom of China and India by Lin Yuntang
Where do leaders operate?
Beyond Imagination
That’s Impossible
Looks Difficult
Easy to do