Lessons from Global Health Development: Sustainable Change Contrarian

By Rob Thames

Part 1 of a three-part series

 “We cannot solve our problems with the same level of thinking that created them.”― Albert Einstein

 In the U.S., some refer to healthcare system change as an oxymoron. It is complicated. It is hard. And while progress has been made, we have a long way to go.

 But if such change in healthcare is challenging in the richest nation, then imagine it in low resource countries. In many sub-Saharan African countries, healthcare must compete with investment in other more impactful determinants of health such as education, food security, and sanitation that, if present, are weakly established. Layer in different governments, languages/dialects, and cultures; include frontier rural locations, tribal influences and religious differences and the challenge to improve health and healthcare in countries such as Tanzania, Madagascar, and Nigeria can feel truly overwhelming.

Historically, the traditional approach to both change in U.S. healthcare and global development

has been to identify needs and direct resources, typically money, at the perceived needs. This pattern has resulted in little success and in many cases, regression, harm and/or increased costs. In global development, despite over a trillion dollars channeled to low resource countries in the past two decades, little progress – and often regress – has resulted (Taylor, Empowerment On An Unstable Planet). In U.S. healthcare, it has created and perpetuated a medical industrial system that is three times as expensive as other countries for almost median outcomes. The lesson? Funds are zero sum limited; human energy is not. And the only real empowerment is self-empowerment.

 Why? A Contrarian Approach

Four lessons are paramount, according to Taylor, et.al. First, donors begin with their perception of needs in a low resource country. While well-intended, this approach emphasizes what does not work in the community and thus leads to a focus on its weakness - what the community has not been able to sustain. Lessons from global health development evidence suggest the contrary: sustainable change starts with an emphasis on past successes or strengths, i.e., what the community is good at. Similarly, in the U.S., a well-meaning tendency to only focus on what is wrong and channeling resources toward it, often has disappointing results. In contrast, learning from, and playing through, the organization’s strengths, more often produces success.

 Second, donor-directed funds come with donor-directed criteria for measurement and external accountability for a country’s progress. But when the community does not own the change, the change is not sustained. Despite good intentions, what has been enabled is dependency, not ownership. In U.S. healthcare, when well-intended governance and/or management directs goals and outcomes without empowering and enabling local physicians and colleagues to shape and own them, the result is the opposite of empowerment. Progress, if any, is typically not sustained and regress is not uncommon.  

Third, a top-down approach, regardless of intentions, does not work. However, a sound understanding of context that leads to a trinitarian partnership of local owners with top-down funders and policy support, and an outside-in third party that provides catalytic expertise around process and exposure to new ideas, has been found to produce favorable global health development results. Many U.S. healthcare organizations recognize the value of balancing a top-down and bottom-up process. But much progress remains to better partner laterally, e.g., with physicians, community organizations, coaches/advisors and insights from organizations in other markets who have demonstrated progress in a targeted area; it can also provide an antidote for “NIH” (not invented here) and group-thinking.

 Finally, an overemphasis on outcome measures in too-short of a period of time has tended to choke or truncate progress. When dealing with sustainable health change, outcome measures are most helpful over longer periods of time, e.g., a decade or more. Successful sustainable change in global development begins with an initial focus on measuring behavior change as a leading indicator. U.S. healthcare organization adherence to an arbitrary 30-day reporting period, while a helpful discipline for monitoring some appropriate metrics, can inadvertently result in inappropriate decisions for evaluating health outcome metrics. Similarly, this approach to reacting too quickly to emotional blowback that is inevitable from some in the early stages of any large-scale change, has contributed to the well-known healthcare leadership change “merry-go-round,” as some doctors refer to it.

 So What?

Clearly the above is an overly simplified summary of lessons from global health development. But the intent is to serve as a reminder and a call to healthcare leaders in three ways. First, demonstrate the courage to look beyond the conveniently tempting but well-tread, conventional/traditional areas for improvement ideas (the closed loops in our own industry, etc.); and seek out different fields and experiences for inspiration and insight for evidenced-based and experience-based change. Second, take the time to invest in process that stimulates and supports the true empowerment that is required for sustainability. Finally, invest the time to challenge and replace the well-intended, reflexive thinking that has created our current problems.