Strategic Leadership for Health System Transformation W. Henry Mosley

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