Doctors Without Orders

To improve global health, what we need isn’t just Bill Gates’ billions, but Microsoft’s managers.

Two years ago, I saw a line of 30 people waiting for services at Nyamata Hospital in Bugesera, a rural region in southern Rwanda. Its approximately 300,000 residents live clustered around small villages. It was the epicenter of the 1994 genocide and remains one of the poorest districts in the nation.

The hospital is on a charming plot of land, and its infrastructure is welcoming, impressive, and modern. It has some 60 professional staff and half a dozen doctors, an adequate number of personnel for a district facility. But while a line of 30 people seems long to Americans, it’s not to Rwandans. I was surprised to find so few lined up for the sort of high-quality care that this hospital promised, on the surface, to deliver.

When my team asked why so few patients were there, the staff, the patients, and the community all pointed to the same cause: a malfeasant and incompetent director. “People go to that hospital to die because the director doesn’t care,” they told us. Apparently, his attitude and style was such that it seeped into the rest of the staff. No one else cared either, even with state-of-the-art equipment and new facilities.

I wasn’t fully convinced of how poisonous the culture had become until two incidents a few weeks later. A nurse, who worked for one of my projects and volunteered at the hospital, told me she was appalled by the shoddy and rancid-smelling mattresses in the patient rooms. After pushing the issue with the staff, she learned that brand-new mattresses had been in a storage room awaiting use for years. Soon after, I bumped into an extremely poor woman who had recently had an emergency caesarean delivery at the hospital. When I asked her when she was returning home, she explained that she had been ready for four days, but that the hospital director insisted on her paying for the ambulance to travel the 30 kilometers to her home. The price demanded was higher than her monthly income, and no one at the hospital seemed willing to figure out how to resolve the dilemma.

Not surprisingly, performance and opinions changed rapidly when a new director arrived. This new manager cleaned up the hospital’s accounting, queried staff on major management and resource needs, fired incompetent and corrupt employees, and figured out how to respond in a timely, thoughtful manner to key challenges. Within two months, there were working X-ray machines for the first time in two years. Staff morale improved dramatically. Today the hospital sees more than 100 patients a day, and the community views it as a center for healing, not dying.

The lesson? In public health, just as in any other collective endeavor, management matters. It seems like an obvious point, and yet at the heart of some of the world’s worst public health crisis zones, it is one that has yet to sink in–with dire consequences for millions.

The history of public health in the twentieth century can be characterized as a losing battle for resources against a rising tide of epidemics and pandemics. In spite of some breakthrough solutions to massive problems like childhood disease and pandemics like polio, the failure to construct viable public health systems in the developing world has helped create the conditions for the pandemics of today: tuberculosis, AIDS, and cardiovascular disease, among many others. To make things worse, massive health problems predating these remain, from extraordinarily high maternal mortality rates to the scourge of malaria. The numbers are so breathtaking that they obscure the heartbreaking stories each represents. Globally, there are still an estimated 500 million episodes of malaria every year that claim at least one million lives, and in Africa more than 250,000 women die in childbirth annually. Over the past two decades, these grim statistics have scarcely budged, and in many countries, they have worsened.

If public health planners were business people objectively examining the sector’s progress today–particularly in sub-Saharan Africa, where average life expectancy is now 46 years, versus 67 in the rest of the world–the answer would clearly point to a change of strategy. Many international public health programs are so poorly run–or at least achieve such poor results–that they resemble the management quality of a local lemonade stand rather than an Apple or Google.

It’s not that public health workers don’t have their hearts in their work. It’s that the global public health workforce has long had to make do with small initiatives that were perpetually under-funded and training that valued a flair for squeezing results out of miniscule funding. However, we live in an age when immense public and private resources are suddenly available. From major programs like the Global Fund to Fight AIDS, Tuberculosis and Malaria to bilateral ones like the U.S. President’s Emergency Plan for AIDS Relief, along with major efforts led by nonprofits like the Bill and Melinda Gates Foundation, global public health is now discussed for the first time in history as a venture warranting and receiving billions.

With so much money being committed and so many lives at stake, it’s time to revolutionize global public health. We need less do-goodism, and more do-it-rightism; we need more managers, not more doctors. The billions of dollars in new funds must propel an infusion of new management talent and practices based on private sector experience. We must upgrade the entire health system in countries–and in poor countries with few doctors, that means taking medical doctors out of management positions and replacing them with professional managers. It means encouraging nongovernmental organizations (NGOs) to cast their nets wider when recruiting public health workers in order to pull leaders from the private sector rather than the public sector, and teaching the management of health delivery to soon-to-be minted public health graduates. And it means building new initiatives like we would a business, with rational accounting and delivery systems, while likewise reforming existing efforts.

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