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Strategic Leadership for Health System Strategic Leadership for Health System TransformationTransformation
W. Henry Mosley W. Henry Mosley
Where do leaders operate?Where do leaders operate?
Beyond Imagination
That’s Impossible
Looks Difficult
Easy to do
What is difficult? Impossible? What is difficult? Impossible? Beyond imagination?Beyond imagination?
Our best thinking got us here.Our best thinking got us here.
The problems that we face cannot be The problems that we face cannot be solved by the same level of thinking solved by the same level of thinking that created them.that created them.
Albert EinsteinAlbert Einstein
The Present Health System Is The Present Health System Is Perfectly Perfectly DesignedDesigned to Produce the Present Results to Produce the Present Results
If we want If we want the same the same results, let us results, let us keep the keep the present present
system!system!
If We Want New Results, We Need to If We Want New Results, We Need to RedesignRedesign Our Health Production Our Health Production SystemSystem
bvl/l eadov 4/19/99 2Center for Communication ProgramsCenter for Communication Programs
U N I V E R S I T Y U N I V E R S I T Y
OHNS HOPKINS OHNS HOPKINS J J
Relationship between income and Relationship between income and malnutritionmalnutrition
The “disconnect” between income and malnutrition
Alternatively,
Malnutrition “falls” independent of “rises” in income(among the lowest income countries)
Interestgroups
Policymakers,planners
Managers,providers
Communities, households
MIS
Evaluations
Research,pilot projects
Leadership the old wayThe “Blueprint” Strategy
Health
ProjectBlueprints
Mental Models Mental Models SustainingSustaining the the Blueprint StrategyBlueprint Strategy
Highly placed professionals have sufficient Highly placed professionals have sufficient knowledge to prescribe interventions that knowledge to prescribe interventions that will work in any social contextwill work in any social context
Knowledge from “evidence-based” intervention Knowledge from “evidence-based” intervention research done in specific contexts have research done in specific contexts have universal applicabilityuniversal applicability
Time-limited, pre-designed, inflexible projects Time-limited, pre-designed, inflexible projects are the best means of introducing innovative are the best means of introducing innovative health interventions in any settinghealth interventions in any setting
Mental Models Mental Models SustainingSustaining the the Blueprint Strategy (cBlueprint Strategy (continued)ontinued)
The institutions, personnel and services of National The institutions, personnel and services of National Ministries of Health constitute the “health Ministries of Health constitute the “health system” of a countrysystem” of a country
Short-term material investments and focused Short-term material investments and focused technical assistance to the MOH will produce technical assistance to the MOH will produce sustainable improvements in a country’s healthsustainable improvements in a country’s health
Using outside “experts” to gather, analyze, interpret Using outside “experts” to gather, analyze, interpret and publish data is an effective means of gaining and publish data is an effective means of gaining an understanding of the realities in the field an understanding of the realities in the field
Interestgroups
Policymakers,planners
Managers,providers
Communities, households
MIS
Evaluations
Research,pilot projects
The “Blueprint” StrategyA fundamental flaw
Health
Learning Action
ProjectBlueprints
Disconnects learning
from action
Social Consequences of Blueprint ProjectsSocial Consequences of Blueprint Projects
No (or limited) learningNo (or limited) learning by the front-line health by the front-line health workers – who are the members of the workers – who are the members of the households and communities where the households and communities where the action is taking placeaction is taking place
Therefore, Therefore, no fundamental changesno fundamental changes in in behaviors and behaviors and no sustainabilityno sustainability after the after the project is completedproject is completed
EvidenceEvidence – Look at the health disparities among – Look at the health disparities among developing countries and the inequities developing countries and the inequities within countries within countries after 50 yearsafter 50 years of top down of top down projectsprojects
Donor Aid in Developing Countries Too Donor Aid in Developing Countries Too Often Produces Little Sustainable BenefitsOften Produces Little Sustainable Benefits
The twin tragedies of global povertyThe twin tragedies of global poverty11
So many people in developing countries are So many people in developing countries are seemingly fated to live horribly stunted lives seemingly fated to live horribly stunted lives and die such early deathsand die such early deaths
After 50 years and more than $2.3 trillion in aid After 50 years and more than $2.3 trillion in aid from the West, there is shockingly little to from the West, there is shockingly little to show for it.show for it.
11Paraphrased from: William Easterly, Paraphrased from: William Easterly, The White The White Man’s Burden. Why the West’s efforts to aid the Man’s Burden. Why the West’s efforts to aid the rest have done so much ill and so little good. rest have done so much ill and so little good. Penguin Press, NY, 2006Penguin Press, NY, 2006
So what do we need to change?So what do we need to change?
Ourselves first – We need to:Ourselves first – We need to:
Break down the walls between all our formal Break down the walls between all our formal institutions and institutions and learnlearn to communicate with each to communicate with each otherother
Engage the people from the community and all Engage the people from the community and all sectors of government in a sectors of government in a learninglearning processprocess to to deepen our understanding of the realities of deepen our understanding of the realities of human developmenthuman development
To change the way we act, we must To change the way we act, we must first change the way we thinkfirst change the way we think
A first step is to change our “Mental A first step is to change our “Mental Model” of what constitutes the “health Model” of what constitutes the “health system” of a countrysystem” of a country
You are the Minister of Agriculture. You are the Minister of Agriculture. You are asked by a reporter from You are asked by a reporter from CNN to describe the CNN to describe the agricultural agricultural systemsystem in your country. in your country.
What is your answer?What is your answer?
Do You Really Know What Are the Production Systems of Your
Country?
Mental Models Define Our “Reality” and Mental Models Define Our “Reality” and Pre-determine the Choices We Make and the Pre-determine the Choices We Make and the Actions We TakeActions We Take
Who “produces crops” Who “produces crops” in your in your mental modelmental model of the agricultural of the agricultural system?system?
How does your answer How does your answer determine the roles determine the roles and functions of the and functions of the Ministry of Ministry of Agriculture?Agriculture?
You are the Minister of Health. You are You are the Minister of Health. You are asked by a reporter from CNN to asked by a reporter from CNN to describe the describe the health systemhealth system in your in your country.country.
What is your answer?What is your answer?
Do You Really Know What Are the Production Systems of Your
Country?
Mental Models Define Our “Reality” and Pre-Mental Models Define Our “Reality” and Pre-determine the Choices We Make and the determine the Choices We Make and the Actions We TakeActions We Take
Who “produces Who “produces health” in your health” in your mental modelmental model of of the health system?the health system?
How does your How does your answer determine answer determine the roles and the roles and functions of the functions of the Ministry of Health?Ministry of Health?
The Household Production of The Household Production of Health Health
Premises
1. Households are the primary units for the production of health.
HouseholdsHouseholds
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 The Household Production of Health Health
Premises (continued)
2. Households, like every social institution, have three basic capabilities for the production of the desired outputs
ResourcesPracticesValues
Material money housing possessions utilitiespropertyequipmenttechnologies
Non-material
gender
time
health
ethnicity/language
beliefs/knowledge/skills
reputation
social status
social networks
self-image/motivation
ResourcesResources
Productive CapabilitiesProductive Capabilities
FormalSanctioned by laws, religion,
regulations, relating to:• marriage/divorce• property rights• interpersonal relationships
gender/sexual/violence• personal mobility• labor force participation
InformalThe 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 CapabilitiesProductive Capabilities
PracticesPractices
Productive CapabilitiesProductive Capabilities
ValuesValuesProgress resistantHierarchical
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
Progress PromotingEgalitarian
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
Households
ValuesValues
PracticesPractices ResourcesResources
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?
ValuesValues
PracticesPractices ResourcesResources
A culture is the product of the interactionsof:
Culture Culture The DNA of Social InstitutionsThe DNA of Social Institutions
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?
Values
Practices Resources
Values
Practices Resources
The Household Production of The Household Production of Health Health
Premises Premises (continued)(continued)
33. Households produce health in . Households produce health in the context of the local community the context of the local community and the wider society – which is a and the wider society – which is a nation’s nation’s health production systemhealth production system..
HouseholdsHouseholds
GovernmentGovernment CommunitiesCommunities
The Health Production SystemThe Health Production System
The The Health Production SystemHealth Production System
Households
Government Communities
ValuesValues
PracticesPractices ResourcesResources
ValuesValues
PracticesPractices ResourcesResources
ValuesValues
PracticesPractices ResourcesResources
Interestgroups
Policymakers,planners
Managers,providers
Communities, households
MIS
Evaluations
Research,pilot projects
The “Blueprint” StrategyWhat values dominate?
Health
Learning Action
ProjectBlueprints
Disconnects learning
from action
Productive CapabilitiesProductive Capabilities
ValuesValuesProgress resistantHierarchical
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
Progress PromotingEgalitarian
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? What Are the Health Production Capabilities? For every 1000 families* in an LDC, complete the followingFor every 1000 families* in an LDC, complete the following
RESOURCESRESOURCES GovernmentGovernment HouseholdsHouseholds
- Health providers- Health providers
- Funds/capita/year- Funds/capita/year
- Preventive skills- Preventive skills
- Curative skills- Curative skills
PRACTICESPRACTICES
- Hours/day- Hours/day
- Days/week- Days/week
VALUESVALUES
- Motivation- Motivation
<5 2000 – 4000+
<$10 >$400
High Low
High Low
~8 24
~5 7
Low High
*About 5,000 persons
The Burden of Disease The Burden of Disease What are the health problems in the population, and What are the health problems in the population, and
how do they come about?how do they come about?
Source: WHO, World Health Report 2002. Reducing Risks, Promoting Healthy Life
What are the “household production” tasks What are the “household production” tasks that relate to the “burden of disease”?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 What are the “household production” tasks that relate to the Burden of Disease?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.
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
What are the “household production” tasks that relate to the Burden of Disease?
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 optionsprocure and administer treatments
How about sickness care?
*Source: WHO, World Health Report 2002. Reducing Risks, Promoting Healthy Life
Leadership Challenges in HealthLeadership 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 ChangeLeadership Skills for Change
CatalyticCatalytic - - Shared VisionShared Vision of a health of a health future that people want to createfuture that people want to create
EnablingEnabling - - TeamworkTeamwork with trust, open- with trust, open-mindedness, transparency and mutual mindedness, transparency and mutual accountability for all outcomesaccountability for all outcomes
LearningLearning – – Generating new knowledgeGenerating new knowledge to to mobilize the vast resources of ordinary mobilize the vast resources of ordinary people for change people for change
Policymakers,planners
Managers,providers
Communities, households N
eeds
Tasks
Outputs
Competencies
Dem
and
Dec
isio
ns
Leadership the New Way - “Learning Organization” Strategy
Interestgroups
Learning
Health
31
2
Linking Action to Learning
Policymakers,planners
Managers,providers
Communities, households N
eeds
Tasks
Outputs
Competencies
Dem
and
Dec
isio
ns
“Learning Organization” StrategyWhat values dominate?
Interestgroups
Learning
Health
31
2
Linking Action to Learning
Productive CapabilitiesProductive Capabilities
ValuesValuesProgress resistantHierarchical
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
Progress PromotingEgalitarian
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 Maternal Mortality - Blueprint Project Can the community participate here? Can the community participate here?
Strategic objective – Strategic objective –
Reduce MMR by 20% Reduce MMR by 20% - from - from (500/100,000 to (500/100,000 to 400/100,000) in 5 400/100,000) in 5 years.years.
Maternal Mortality - Shared Vision Maternal Mortality - Shared Vision Can the community participate here? Can the community participate here?
Shared VisionShared Vision - No mother - No mother dies from child birth in dies from child birth in our community.our community.
Should we do it alone?Should we do it alone?
Or through the Or through the Learning Learning OrganizationOrganization? ?
Bureaucratic PerceptionsBureaucratic Perceptions
4% MMR reduction/year is “easy to do.”4% MMR reduction/year is “easy to do.”
10% MMR reduction/year is “difficult!”10% MMR reduction/year is “difficult!”
25% MMR reduction/year is “impossible!”25% MMR reduction/year is “impossible!”
Elimination of MMR is “beyond imagination!”Elimination of MMR is “beyond imagination!”
Where do leaders operate?Where do leaders operate?
Beyond Imagination
That’s Impossible
Looks Difficult
Easy to do
Does your country have a Shared Does your country have a Shared Vision?Vision?
Government goal - reduce MMR by 4% Government goal - reduce MMR by 4% every year!every year!
Community goal - Zero MMR!Community goal - Zero MMR!
Household goal - Zero MMR!Household goal - Zero MMR!
QuestionQuestion
Should a vision be achievable under Should a vision be achievable under present conditions?present conditions?
Shared vision asks:Shared vision asks:
What do we want to happen? Or What do What do we want to happen? Or What do we want to create?we want to create?
NOTNOT
What is feasible given present conditions?What is feasible given present conditions?
Should visions be based on Should visions be based on situation analysis? situation analysis?
Should we want only what we can have Should we want only what we can have given the current situation?given the current situation?
Should we aim for what we truly want Should we aim for what we truly want and and changechange the current situation? the current situation?
A few questionsA few questions
1.1. Do you have a national shared vision for Do you have a national shared vision for reproductive health?reproductive health?
2.2. Do you have a shared vision for RH in your Do you have a shared vision for RH in your organization?organization?
3.3. Can Can everyoneeveryone describe what the shared describe what the shared vision is?vision is?
4.4. If you don’t have a shared vision, what is If you don’t have a shared vision, what is the reason?the reason?
Key questionKey question
Do families, the primary producers of health, Do families, the primary producers of health, participate in shaping the reproductive participate in shaping the reproductive health vision for their community? health vision for their community?
Exciting and Sustaining Action by Exciting and Sustaining Action by Every Team MemberEvery Team Member
Does Does every every frontline workerfrontline worker know: know:
• what the what the goalgoal is? is?• what the what the scorescore is in their community? is in their community?• what their part is on the team?what their part is on the team?• how well they are performing?how well they are performing?
ResourcefulnessResourcefulness
“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? What is difficult? Impossible? Beyond imagination?Beyond imagination?
Leadership – Helping People Be More Leadership – Helping People Be More “Resourceful” in Producing Health“Resourceful” in Producing Health
Old wayOld wayProfessionals in facilities Professionals in facilities providing servicesproviding services
New wayNew wayResourceful households Resourceful households producing healthproducing health
Transforming the health system
THE WISDOM OF TAOTHE WISDOM OF TAOXVII 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?Where do leaders operate?
Beyond Imagination
That’s Impossible
Looks Difficult
Easy to do