Leadership in Health System
Transformation
The Household Production of Health
W. Henry Mosley Johns Hopkins Bloomberg
School of Public Health
CCIH Conference
May 26, 2007
First Principles
• “Development can be neither given nor
received; it must be generated from
within.”
Jamshid Gharajedaghi
Key issues confronting the production
of health in developing countries
• 1) How can we make our investments in
health interventions more effective and
efficient?
• 2) How can we ensure greater equity in
access to the knowledge, skills and
technologies that facilitate the production
of health?
• 3) How can we assure sustainable health
improvements?
First, We Need to Change
the Way We Think
•
We need to open our minds in order
to learn - the greatest barrier to
learning is the “IK IK” syndrome
•
We need to learn how to see reality
objectively – in order to know what is
true
We need to break out of the “prisons” of our mental models
“Laws” of Mental Models
1. Mental models* are the lenses
through which we observe reality
* Also called “perceptions”, “world views”, “paradigms”,
etc.
Question – How many have ever
seen the sun rise in the morning and
set in the evening?
Who cares whether the earth is the
center of the universe, or just one planet
among billions?
Our mental models
of the universe do
not shape the reality
of the physical laws
of nature
“Laws” of Mental Models
(Continued)
2. In human relations and social
institutions, our mental models are
our reality
A Societal Belief/Knowledge
“Women are intrinsically inferior to
men.”
• Is this a “reality” or a mental model?
• What are the “right” and “wrong” choices
and actions that are predetermined in
societies that “know” this to be a reality?
“Laws” of Mental Models
Continued
3. Misconceptions about reality are
self-fulfilling prophecies
Realities or Mental Models?
• The greatest constraints to
improving reproductive health in the
poor developing countries are
because the health systems lack:
–
–
–
–
–
financial resources
physical facilities
technologies
personnel
motivated workers
– True or False?
Systems Thinking – 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?
Systems Thinking – 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
Pre-determine 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?
What Are the Health Production Capabilities?
For every 1000 families* in an LDC, complete the following
RESOURCES
Government
- Health providers
- Funds/capita/year
- Preventive skills
- Curative skills
10 - 20
<$10
High
High
Households
2000 – 4000+
>$300
Low
Low
PRACTICES
- Hours/day
- Days/week
~8
~5
24
7
VALUES
- Motivation
Low
High
*About 5,000 persons
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
– Values
– Practices
– Resources
Production Capabilities
Values
Values are individual and institutional.
Personal values answer the questions –
Who am I, what am I worth?
What is my purpose in life?
What is the basis for deciding if my choices
and actions are right or wrong?
What are my rights and my responsibilities
to myself and others?
Production Capabilities
Practices
Practices are the actions taken that
involve relationships with others. They
may be Formal – guided by laws, rules,
procedures, religious prescriptions
Informal – guided by the functional
values of individuals and institutions
Production Capabilities
Resources
Resources facilitate the production
processes. These are Material – money, housing, utilities,
property, equipment, technologies
Non-material – gender, time, health,
ethnicity, language(s), knowledge, skills,
reputation, status, social networks
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
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?
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, female genital mutilation, male
circumcision, 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/ventilation, 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
The Household Health
Production System
• 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
Community Institutional Resources
Social Capital
Clan/ethnic affiliations
Religious organizations
Cooperatives
Labor unions
Business enterprises
Non-government
organizations
Political parties
Trade associations
Government institutions
Schools
Health centers
Extension services, etc.
Government has many agencies but only five
“Policy Instruments” to influence household and
community behavior
INSTRUMENT
INFLUENCE
Information inform/persuade
Laws, regulations compel/coerce
Taxes, prices incentives/disincentives
Direct investments - provide/facilitate
Research
discover/develop
(Health, education, agriculture, finance,
social welfare, defense, interior,
commerce, transport,
telecommunications, etc.)
The Health Production System has
multiple (competing) cultures
Values
Households
Practices Resources
Values
Values
Government
Communities
Practices Resources
Practices
Resources
What are some essential features of
this “mental model” of the household
health production system?
It is already decentralized
– made up of multiple, independent, interacting “subsystems” involving households, communities and
government agencies
It is already self-sustaining
– every sub-system has a self-replicating “culture”
Local and Global Driving Forces Are
Major Sources of Change
Driving Forces for Change
What are they?
Political
Economic
Social
Technological
Environmental
Local &
Global
Driving
Forces
The Health Development
Leadership Challenge
• How can we enhance and expand
the resourcefulness of the
primary producers of health so
that they can more effectively and
efficiently produce favorable health
outcomes?
What Is the Traditional Method of
Introducing Innovation and
Change in the Health Production
System?
•
The “blueprint” approach
What does this mean?
The top–down, or “blueprint”
project strategy
Interest
groups
Policymakers,
planners
MIS
Project
Blueprints
Managers,
providers
Communities,
households
Evaluations
Research,
pilot projects
Learning
Health
disconnects
learning from
action
Action
But blueprint
projects are
not sustainable
when
“cultures” are
in conflict
Distrustful,
traditional,
patriarchal
Values
Practices Resources
Values
Values
Practices Resources
Practices Resources
Scientific,
bureaucratic,
competitive
Partisan, religious,
feudal
Development Failures
• “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 the solution to initiate and
sustain fundamental changes in the
health production system?
• Leadership - to generate a
Shared Vision
• Action Learning Organizations - to
Enable People to Act
The “Learning Organization” Strategy
Communities,
households
Link
Action to
Learning
1
Health
2
Learning
3
Policymakers,
planners
Competencies
Interest
groups
Tasks
Managers,
providers
1. Learning to fit
Communities,
households
Demand
expression
Decision
process
Policymakers,
planners
• The task – learning how to engage all
stakeholders in a creative partnership with
shared values that will generate a Shared
Vision leading to policies, strategies and
cooperative programs that will promote
and support the household production of
health
Blueprint Project - Can the
community participate here?
• Strategic
objective Reduce MMR
by 20%
(500/100,000 to
400/100,000) in
5 years.
Shared Vision - Can the
community participate here?
Shared Vision - No
mother dies from child
birth in this
community.
Should we do it alone?
Or through the Learning
Organization?
2. Learning to fit
Communities,
households
Needs
Outputs
Managers,
providers
• The task – learning how to understand
the household’s needs and constraints,
and how to introduce new values,
practices, knowledge, skills, and
technologies to help households and
communities become more resourceful
in the production of health
Local solutions solve local
problems best.
Action Learning Principle
• People… “benefit more from their own
mistakes than by consuming development
plans made for them.”
Jamshid Gharajedghi
3. Learning to fit
Policymakers,
planners
Distinctive
competencies
Task
requirements
Managers,
providers
• The task – learning how to change
the organizational culture so that
planners can develop the
organizational competencies to do
the tasks required to design,
implement and be accountable for
programs that promote the household
production of health
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
What do you want
to happen?
Vision
Shared Vision - Resourceful
households and a
responsive health care
system
Culture
Elitism
Territoriality
Professional
standards
Bureaucratic
inertia
JJOHNS HOPKINS
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Center for Communication Programs
bvl/l eadov 4/ 19/99 2
Credo for Development
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Go to the people
Live among the people
Learn from the people
Plan with the people
Work with the people
Start with what the people know
Build on what the people have
Teach by showing, learn by doing
Not a showcase but a pattern
Not odds and ends but integrated approach
Not to conform but to transform
Not relief but release
International Rural Reconstruction Movement