Leadership in Health System Transformation The Household Production of Health W. Henry Mosley Johns...

Leadership in Health System Leadership in Health System TransformationTransformation

The Household Production of HealthThe Household Production of Health

W. Henry Mosley Johns Hopkins Bloomberg W. Henry Mosley Johns Hopkins Bloomberg School of Public HealthSchool of Public Health

CCIH ConferenceCCIH ConferenceMay 26, 2007May 26, 2007

First PrinciplesFirst Principles

• “Development can be neither given nor received; it must be generated from within.”

Jamshid Gharajedaghi

Key issues confronting the production Key issues confronting the production of health in developing countries 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 First, We Need to Change the Way the Way WeWe Think 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 Laws” of Mental ModelsMental Models

1. Mental models* are the lenses through

which we observe reality

* Also called “perceptions”, “world views”, “paradigms”, etc.

QuestionQuestion – How many have ever – How many have ever seen the sun rise in the morning and seen the sun rise in the morning and

set in the evening?set in the evening?

Who Who cares whether the earth is the whether the earth is the center of the universe, or just one planet center of the universe, or just one planet

among billions?among billions?

Our mental models of the universe do not shape the reality of the physical laws of nature

““Laws” of Mental ModelsLaws” of Mental Models(Continued)(Continued)

2. In human relations and social

institutions, our mental models are our reality

A Societal Belief/Knowledge 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 MentalLaws” of Mental ModelsModelsContinuedContinued

3. Misconceptions about reality are self-fulfilling prophecies

Realities or Mental Models?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?

• 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?

Systems Thinking – 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 Pre-determine the Choices We Make and

the Actions We Takethe 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?

•

• 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?

Systems Thinking – 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 Pre-determine the Choices We Make and

the Actions We Takethe 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? 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

RESOURCES Government Households

- Health providers

- Funds/capita/year

- Preventive skills

- Curative skills

PRACTICES

- Hours/day

- Days/week

VALUES

- Motivation

10 - 20 2000 – 4000+

<$10 >$300

High Low

High Low

~8 24

~5 7

Low High

*About 5,000 persons

The Household Production of Health The Household Production of 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 Health 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 CapabilitiesProduction Capabilities

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?

ValuesValues

Production CapabilitiesProduction Capabilities

Practices are the actions taken that Practices are the actions taken that involve relationships with others. They involve relationships with others. They may be - may be -

Formal – guided by laws, rules, procedures, religious prescriptionsInformal – guided by the functional values of individuals and institutions

PracticesPractices

Production CapabilitiesProduction Capabilities

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

ResourcesResources

ValuesValues

PracticesPractices ResourcesResources

A culture is the product of the interactionsof:

Culture Culture The DNA of The DNA of SocialSocial Institutions Institutions

Values

Practices Resources

Culture is self-replicating from generation to generation Like DNA, a cultural system is resistant to change

Values

Practices Resources

Values

Practices Resources

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?

The Burden of Disease The Burden of Disease What are the health problems in the population, What are the health problems in the population,

and how do they come about?and how do they come about?

Source: WHO, World Health Report 2002. Reducing Risks, Promoting Healthy Life

What are the “household production” What are the “household production” tasks that relate to the “burden of tasks that relate to the “burden of

disease”?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” What are the “household production” tasks that relate to the Burden of tasks that relate to the Burden of

Disease?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.

• 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

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 options– procure and administer treatments

How about sickness care?

*Source: WHO, World Health Report 2002. Reducing Risks, Promoting Healthy Life

The Household Health The Household Health Production SystemProduction 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.

HouseholdsHouseholds

GovernmentGovernment CommunitiesCommunities

The Health Production The Health Production SystemSystem

CommunitiesCommunities

Clan/ethnic affiliationsClan/ethnic affiliationsReligious Religious organizationsorganizationsCooperativesCooperativesLabor unionsLabor unionsBusiness enterprisesBusiness enterprisesNon-government Non-government organizationsorganizationsPolitical partiesPolitical partiesTrade associationsTrade associationsGovernment Government institutionsinstitutions

SchoolsSchoolsHealth centersHealth centersExtension services, Extension services, etc.etc.

Community Institutional ResourcesCommunity Institutional Resources

Social CapitalSocial Capital

GovernmentGovernment

INSTRUMENTINSTRUMENT INFLUENCEINFLUENCEInformation Information - - inform/persuadeinform/persuadeLaws, regulations - Laws, regulations - compel/coerce compel/coerce Taxes, pricesTaxes, prices - - incentives/disincentives incentives/disincentives Direct investments -Direct investments - provide/facilitate provide/facilitate Research Research - - discover/developdiscover/develop

Government has many agencies but only five “Policy Instruments” to

influence household and community behavior

(Health, education, agriculture, (Health, education, agriculture, finance, social welfare, defense, finance, social welfare, defense, interior, commerce, transport, interior, commerce, transport, telecommunications, etc.) telecommunications, etc.)

The The Health Production SystemHealth Production System has has multiple (competing) culturesmultiple (competing) cultures

Households

Government Communities

ValuesValues

PracticesPractices ResourcesResources

ValuesValues

PracticesPractices ResourcesResources

ValuesValues

PracticesPractices ResourcesResources

What are some essential features of What are some essential features of this “mental model” of the this “mental model” of the householdhousehold

health productionhealth production systemsystem??

It is already decentralized – made up of multiple, independent, interacting “sub-

systems” involving households, communities and government agencies

It is already self-sustaining – every sub-system has a self-replicating “culture”

Local and Global Local and Global Driving ForcesDriving Forces Are Are Major Sources of ChangeMajor Sources of Change

HouseholdsHouseholds

GovernmentGovernment CommunitiesCommunities

Local & GlobalDrivingForces

Driving Forces for ChangeDriving Forces for ChangeWhat are they?What are they?

Local &GlobalDrivingForces

PoliticalPoliticalEconomicEconomicSocialSocialTechnologicalTechnologicalEnvironmentalEnvironmental

The Health Development The Health Development LeadershipLeadership ChallengeChallenge

• 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 What Is the Traditional Method of Introducing Innovation and Introducing Innovation and

Change in the Health Production Change in the Health Production System?System?

• The “blueprint” approach

What does this mean?

Interestgroups

Policymakers,planners

Managers,providers

Communities, households

MIS

Evaluations

Research,pilot projects

The top–down, or “blueprint” project strategy

Health

Learning Action

ProjectBlueprints

disconnects learning from

action

Households

Government Communities

ValuesValues

PracticesPractices ResourcesResources

ValuesValues

PracticesPractices ResourcesResources

ValuesValues

PracticesPractices ResourcesResources

Distrustful, traditional, patriarchal

Partisan, religious, feudal

Scientific, bureaucratic, competitive

But blueprint projects are not sustainable when “cultures” are in conflict

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 What is the solution to initiate and sustain fundamental changes in the sustain fundamental changes in the

health production system?health production system?

• Leadership - to generate a Shared Vision

• Action Learning Organizations - to Enable People to Act

Policymakers,planners

Managers,providers

Communities, households

Needs

Tasks

Outputs

Competencies

Dem

and

Dec

isio

ns

The “Learning Organization” Strategy

Interestgroups

Learning

Health Link Action to Learning

1 2

3

1. Learning to fit1. Learning to fit

• 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

Decisionprocess

DemandexpressionCommunities,

householdsPolicymakers,planners

Blueprint Project - Can the Blueprint Project - Can the community participate here? community participate here?

• Strategic objective - Reduce MMR by 20% (500/100,000 to 400/100,000) in 5 years.

Shared Vision - Can the Shared Vision - Can the community participate here? 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 fit2. Learning to fit

• 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

OutputsNeedsCommunities, households

Managers,providers

Local solutions solve local Local solutions solve local problems best.problems best.

Action Learning PrincipleAction Learning Principle

• People… “benefit more from their own mistakes than by consuming development plans made for them.”

Jamshid Gharajedghi

3. Learning to fit3. Learning to fit

• 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

Distinctivecompetencies

TaskrequirementsPolicymakers,

planners

Managers,providers

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 the If we want the same results, let same results, let us keep the us keep the present systempresent 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

What do you want What do you want to happen?to happen?

Vision

Shared Vision - Resourceful Shared Vision - Resourceful households and a households and a

responsive health care responsive health care systemsystem

Elitism

redesignreallocateadd resources

Bureaucratic inertia

Professional standards

Territoriality

Culture

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

Credo for DevelopmentCredo for Development– 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