Public Health as Service Industry

Below, Josh Ruxin answers our final question.

Hands down, the application of private sector management solutions to health care, particularly in developing countries, is vital, and, almost utterly unfinanced. The focus of public health systems continues to be on training and retraining personnel, and identifying gaps in specific administrative systems. There's a raft of research on drug procurement systems, billing systems, and electronic patient medical records. The industry has come to resemble the three blind men each touching a different part of the elephant and trying to describe the animal each has in hand. Why have we gotten to this point?  Quite simply, because we've addressed public health as a uniquely scientific endeavor when in fact, it's an extremely complex service industry.

Five years ago in Rwanda, my colleague, Dr. Blaise Karibushi, and I, took a close look at everything various donors and NGOs were doing in Rwanda, and came to the conclusion that the vast majority were focusing on clinical quick fixes (training in a specific surgical procedure for example) rather than a holistic and cross-cutting approach. In hundreds of health centers we found the overutilization of some services and personnel and underutilization of others. In nearly all cases, young people with some advanced training in nursing were also being asked to manage accounting, human resources, and the physical plants of health centers designed to serve tens of thousands of people. â¨Other centers had similar characteristic features of non-management: failures to have daily schedules, having one person serve as accountant and cashier, and related breakdowns in every area of execution. The traditional approach to this sort of broad-spectrum failure is to pick an area where immediate improvement or diagnosis of the problem can be had, and follow it up with a one-off fix. Of course, that rarely results in the comprehensive change that benefits patients. On a nearly weekly basis, various organizations offer retreats for one sort of training or another. The training might be great, but when nurses and docs return to their facilities, plagued by institutional failure, it's nearly impossible for them to apply their learning.â¨

The right response to the cascading problems that originate with non-management is core training in management and delivery. Through our work on The Access Project, we found that by providing on-the-ground, in-center training to health center leadership, the worst health centers could quickly make improvements that led to increased income and resources available for solving the day-to-day problems which had plagued them. Better-run health centers can afford more staff, and ultimately address their most systemic problems. We have found that with just six months of careful on-site training, centers that were seeing merely a couple dozen patients per day, began seeing on average 100 patients daily. Word travels fast when quality and efficiency increase!

The problem is, the appropriate management training is not offered by most donor programs and is certainly not offered in public health schools around the world. MBA programs come much closer - investing in financial modeling and case-based studies. Even better is the training that comes from working at well managed companies, though few health centers or hospitals in developing countries are looking outside of professional medical staff for management. Sadly, donors continue to focus on the medicalization of the workforce and ironically, that's not what is most urgently needed for good medicine. For clinical work, pure and simple medicine need not be combined with other disciplines. But when it comes to health service delivery, a cross-disciplinary approach is essential.