Changes in Global Health

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COMMENTARY

The Science of Large-Scale Changein Global HealthC. Joseph McCannon, BA

Donald M. Berwick, MD, MPP

M. Rashad Massoud, MD, MPH

INNOVATION IN HEALTH CARE INCLUDES IMPORTANT CHAL-lenges: to find or create technologies and practices thatare better able than the prevailing ones to reduce mor-bidityandmortalityandto make those improvementsubiq-

uitousquickly. In many respects in thepursuit ofglobalhealth,

the secondchallengetherapid spreadof effective changesseems to be the greater. Many sound (even powerful) solu-tions exist, such as new medicines and innovations in healthcare delivery, but their adoption is unreliable and slow. Of-ten, they remain hidden in pockets around the globe, flour-ishing locally without reliably reaching those in need else-where. Some such solutions come from biomedical research,but even more takeshape at the point ofcare, in settings wherelocal problem solverscreate effective new approachesto prob-lems that others who live far away face as well.

Failure to deploy improved technologies and practiceswidely and quickly is a form of waste that donors, research-ers, clinicians, and, most of all, communities in developing

nations cannot afford. It behooves those who sponsor bio-medical science to make commensurate investments in op-erational sciences that can inform and energize the activedissemination of new solutions. This is a crucial, but as yetlargely neglected, global project: to rapidly spread effectiveprototypes to entire populations. Scaling up should be-come a major and sustained enterprise in the global healthcommunity. It has its own scientific foundations.

Current Prevailing Paradigm

At present, innovators in global health, especially scien-tists, often operate with an implicit theory of spread: thetheory that good ideas demonstrated in successful proto-

type projects will reach audiences through publication, mar-ket forces, or communication networks. Putting their faithin journals, Web sites, and conferences, innovators duti-fully generate guidelines, normative reports, descriptive rec-ommendations, and clinical training programs, hoping thatfront-line practitioners and health care organizations willfind successful innovations, adapt them, and adopt them.

That theory is weak; good ideas, even when their value isthoroughly demonstrated in oneplace,will notreliably spread

into actionthroughnormalcommunication channels at a pacetruly responsive to theenormous healthcare challenges in re-source-poor settings.A significant barrier is overload: the sheervolume of new studies, interventions, and reports over-whelms all but the most conscientious clinicians. Even whenhealth care system leaders or clinicians become aware of apromising innovation, their ability to introduce it is often se-verely constrained by limitations of time, resources, and skill.Those in potentially adopting sites face the difficult work oftransitioning fromlearning about a conceptto meaningful ac-

tion in their own local setting, which requires leadership, so-ciological sophistication, and attentive management. Most in-novative technologies (such as sound antiretroviral therapies)and most innovative clinical processes (such as new roles forcommunity health workers) must be actively, not passively,spread, or they may not spread at all.1

Successful,informative examples of introducingchange ona largescaledo exist in global health.2 For example,some ma-jor public health projects have changed the profile of diseasein entire populations (eg, smallpox eradication, the controlof polio, and the work of the Bangladesh Rural AdvancementCommittee to reduce morbidity from diarrhea3); some inno-vations in roles forthe workforce, such asnurse-based scale-up

of antiretroviral therapies in Zambia, have moved from ex-periments to prevalent norms4; some countries have broadlyintroduced and adapted enhanced-care guidelines (eg, NigerandEcuadorhaveobserved significantreductions in birth com-plications in programs sponsored by the US Agency for In-ternational DevelopmentsQuality AssuranceProject5,6); andsome of our own programs, supported by the Centre for Ru-ral Health (University of KwaZulu-Natal, Durban), the Re-productive Health Research Unit (University of the Witwa-tersrand, Johannesburg), and the Institute for HealthcareImprovement, havesuccessfully expanded antiretroviral treat-ment in several provinces in South Africa.7

The best of these initiatives, even when targeting a spe-

cific disease, have operated within existingpublic healthcarestructures, building system-wide skill at rapidly adoptingbetter practice that can be applied to themanagement of otheracute and chronic diseases. Each of these projects soughtnot only to spread the news of best practice or to demon-

Author Affiliations: Institute for Healthcare Improvement, Cambridge, Massa-chusetts.CorrespondingAuthor: C. JosephMcCannon,Institutefor Healthcare Improvement,20 University Ave, Seventh Floor, Cambridge, MA 02138 ([email protected]).

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strate it in pilot sites but also to devise detailed strategiesdeeply rooted in logistics and systems and network sci-ence8-10 to reach enormous numbers of people quickly.

Science-Based Models for the Spread of Change

The diffusion of innovation in social and technical systems

has been the object of decades of scholarship in numerousindustries and social sectors.11,12 The successful programslisted above, and others, have that scientific tradition at theirroots. They attend to 3 key questions: How does the poten-tially adopting community perceive the proposed changes?What is the nature of the social system in the potentiallyadopting community? And, which structural approach tospreading better practice will be used?

How Does the Potentially Adopting Community Per-ceive of theProposedChange? Rogers13 hasdescribed 5 char-acteristics of an innovation, as perceived by the potentiallyadopting community that are positively associated with therate of diffusion: (1) Relative advantagehow well does theinnovation appear to address needs as perceived by the po-

tential adopter? (2) Compatibilityhow closely does the in-novation (and its purveyor) appear to align with the exist-ing belief systems and contextual circumstances of thepotential adopter? (3) Simplicityhow simple and under-standable does the innovation appear to the potentialadopter? (4) Trialabilityto what extent does the poten-tial adopter have the opportunity to test the innovationunder a variety of conditionsbefore committing to it? (5)Observabilityhow transparent is the innovation and its re-sults from the viewpoint of the potential adopter?

Each of these perceived characteristics contributes to re-ducing what Rogers asserts is the fundamental obstacle tothe spread of change: the adopters perception of risk. Rog-

ers model is descriptive, not prescriptive, but it neverthe-less suggests tactics for the design and packaging of prom-ising innovations. Importantly, the extensive empiricalliterature that Rogers draws on includes several studies innon-Western and developing nations.13

What Is the Nature of the Social System in the Poten-tially Adopting Community? Effective spread agents payattention to thenature of thesocial network into which theywish to disseminate new practices. Is it reticent? Compli-ant? How often, where, and how do members of the socialsystem meet? Who are their first adopters and influentialleaders? How quickly can the adopting system absorb a newidea? Is it important to pilot on a smaller scale to build will?

Or, is it conceivable to go to full scale immediately? Everysocial system contains complexitystemming from inde-pendent, self-interested parties, competing ideas and rules,and resource constraints, which are particularly acute in de-veloping nations with inadequate supplies and infrastruc-ture and acute shortages of medical personnel.14,15 Success-ful dissemination projects view these as importantconsiderations, supporting efforts to remove or address bar-riers without using them as justifications for inaction.

Which Structural Approach to Spreading Better Prac-tice Will Be Used? Agents of dissemination can choose froma wide range of strategic designs for large-scale improve-ment all of which consider available resources and knownconstraints. Examples of such spread strategies include ex-ecutive mandates, which may be appropriate for a simple

change that can be immediately implemented in a hierar-chical system (eg, removing from pharmacy stocks a medi-cation newly found to be ineffective); campaigns, which maybe appropriate for relatively simple interventions that relyon broad will-building and learning networks16,17; collabo-rative improvement projects, which bring together teams fromnumerous, often interdependent facilities, for structuredlearning and exchange via a variety of media around sharedaims, measures, and goals18,19; and extension agent methods,which use itinerant health care workers or natural commu-nity leaders to spread ideas and best practice.3

How Leaders Can Support Large-Scale Change

No matter which structural design for spread is used, effec-

tive leaders of large-scale change understand the differencebetween simply raising awareness of a new practice and en-suring broad implementation. To get results, they attend to3 major streams of support: the cultivation of will, the sup-ply of ideas for change, and the day-to-day execution ofchange. This simpletriadwill, ideas, and executionoffers practical guideposts for action.20,21

Cultivation of will involves building and maintaining asense of purpose for improvement, including clearly iden-tifying why the status quo should no longer be an optionand creating optimism regarding the possibility of improve-ment. Key to successful will building are clear, quantifi-able, and ambitious aims articulated by leaders; consistent

attention to those aims22

; celebration of success; and ex-pressions of confidence in the creative potential and goodwill of the workforce.

Supplying sound ideas for change involves leaders em-powering local workforce and communities to look for andhear about innovations and for individuals to offer, with-out fear of criticism, their ideas about improvements. Lead-ers committed to ensuring the supply of ideas encourage lo-cal creativity and show respect for the challenges associatedwith accepting and adapting ideas from elsewhere.23

Attending to the details of execution involves the pro-cesses of day-to-day application and learning that allow aninnovation from somewhere else to take root in a new set-

ting. The best leaders of change know this, and they focusenergetically on logistics. They have patienceeven affin-ityfor the tedium of specifics, showing endless creativityin removing the bureaucratic or infrastructural barriers tochange. They capitalize on any available resource at everylevel of the care system (from tertiary centersto primary careclinics to the community). They recognize the need for dataon how changeis progressing andare skilled at creating toolsthat furnish actionable information to those driving local

COMMENTARY

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change. They encourage cooperation, dialogue, and trustamong groupspursuing common goals and emphasize speedand pace in the change process.24

Advancing the Science of Large-Scale Change

Health care system leaders around the world have much to

learn about how to spread effective interventions and bestpractices methodically. Global health leaders trying to man-age large-scale improvement projects need better opportu-nities to engage in ongoing conversationand learn faster andmore continually from each other. Equally important, thisdialogue should link to existing scientific foundations re-garding the spread of innovation and advance that sciencewith as much energy and intent as is seen in the advance-ment of biomedical science. Among activities that inter-ested donors and development agencies should considersponsoring are the following:

Building optimism and interest through rapid successbyestablishing examples of complete success, in an ex-tremely short time frame (eg, spreading a life-saving in-

tervention, such as antiretroviral therapy, across an en-tire nation that haslacked a recordof achievement at thatscale);

Building leadership capability by identifying a cadre ofleaders, managers, and clinicians at work on large-scaleimprovement in several nations and by bringing themtogetherperiodically, via electronic communities and face-to-face exchange, to analyze their ongoing activity andto deepen the science of large-scale change;

Fostering learning by analogy through systematic studyof other fields skilled at mobilizing large-scale change(eg, agriculture, military organizations, multinationalcorporations, and grassroots political organizations);

Developing a common lexicon, and decision-supporttools to assist leaders of large-scale change in identify-ing appropriate dissemination approaches at the locallevelsuitedto thenature of their intervention, thescaleof their project, and the level of their resourcesastheyplan and implement major programs;

Increasing investment in major projects that dissemi-nate best practices in scale-up and funding further, for-mal scientific exploration in the field.

The Future

The global health community, at least regionally and per-haps at a worldwide level, can pursue a goal of enormous

significance by ensuring that any new practice of merit beembraced, shared, and broadly implemented in a matter ofmonths or even days by skilled leaders, health systems man-agers, clinicians, and other health care workers. Such a goal,while surely seeming too optimistic to some, has 2 sup-ports strongly in its favor: a body of science regarding thediffusion and management of change that has generated use-ful lessons on systems improvement and that could, withinvestment, be even better; and the demand for justice in

global health, which is inconsistent with the toll paid whengreat innovations fail to reach all of those who could ben-efit from them.

Financial Disclosures: The authors report that they receive salary support fromthe Institute for Healthcare Improvement, which works on large-scale change ini-tiatives in several nations. More information on these activitiesis availableat http://www.ihi.org. Dr Massoud received prior salary support from the USAID Global

QA Project for the work in the Russian Federation that this commentary refer-ences.Other Contributions: We thank Jane Roessner, PhD, for her contribution to thepreparation of this article as part of her regular duties at the Institute for Health-care Improvement.

REFERENCES

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20. Nolan TW. Execution of StrategicImprovementInitiatives to ProduceSystem-Level Results. Cambridge, MA: Institute for Healthcare Improvement; 2007. In-novation Series white paper. http://www.ihi.org/IHI/Results/WhitePapers/ExecutionofStrategicImprovementInitiativesWhitePaper.htm.Accessed September4, 2007.21. Resar R. Will, ideas, and execution: their role in reducing adverse medicationevents. J Pediatr. 2005;147(6):727-728.22. Deming WE. Out of the Crisis. Cambridge, MA: MIT Press; 2000.23. Taylor C, Taylor D.Just and Lasting Change: When Communities Own TheirFutures. Baltimore, MD: Johns Hopkins University Press; 2002.24. Wenger E. Communities of Practice. Cambridge, England: Cambridge Uni-versity Press; 1998.

COMMENTARY

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