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How to understand public healthcare challenges

The Skoll Centre’s Apprenticing with a Problem awards support individuals to engage in experiential learning and deep immersion around the challenges that they seek to tackle.

Oxford MBA alumna, Melissa McCoy, is a 2016-17 awardee whose apprenticeship took her to South Africa to learn about the real challenges faced in the healthcare system, from those who experience it first-hand.

About two years ago, I started trying to solve South African public healthcare challenges before setting foot in the country. For my Oxford MSc Computer Science thesis project, I built a low bandwidth-optimised online telehealth platform and a machine-learning based triage tool for South African patients to solve issues of doctor scarcity and misdistribution. While this sounds logical, I jumped into creating a solution before truly understanding the problem space.

The Skoll Centre’s Global Challenge competition, which resulted in an Apprenticing with a Problem grant, was a huge blessing. It gave me the resources and thought space to understand South African healthcare challenges from several angles and ensure I was tackling the problems in the right way.

The resulting research that my team and I completed focused on visiting 15 healthcare facilities, spanning several characteristic types:

  1. Primary, secondary, and tertiary levels of healthcare
  2. Gauteng, Western Cape, North West, and Mpumalanga provinces
  3. Remote rural, rural, and urban geographies.

The research also focused on speaking with four types of stakeholders (doctors, nurses, facility managers, ICT professionals) that represent the various healthcare system perspectives.

While our findings around the problem space were extremely valuable (and are fully detailed in our report), we also took away some surprising insights:

  1. Willingness to embrace change: Contrary to our initial beliefs, people in the public healthcare system in South Africa do not enjoy the status quo. They are cognisant of the challenges and inefficiencies in the system. They also believe that while there is a lot that rests on the powers that be, there is a lot that they can do themselves to bring about change. Our visits were viewed with optimism and most facilities were hopeful and confident that our suggestions would be beneficial for them. A system that is not cynical and is open to feedback is bound to see progress in due course of time. The positive attitude of practitioners and the administration alike towards embracing technological improvements was a huge motivational factor for us.
  2. Bottom-up, Organic Tech Solutions: While many facilities lacked digital infrastructure to allow for referrals and sharing information, healthcare facilities & professionals devised their own ways to facilitate these processes. Doctors had created WhatsApp groups to discuss difficult patient cases. Nurses had equally formed networks among themselves and would send SMS messages to each other to communicate bed occupancy and information about referred patients.
  3. Learning from field interviews is hard: We came into the research with several pre-conceived ideas around the core problems and the appropriate solutions to solve them. We wanted to validate if our hypotheses were correct without biasing interviewees in the process. In Rob Fitzpatrick’s book, The Mom Test (which we referenced often), he summarises the challenges of this process well: ‘Trying to learn from field conversations is like excavating a delicate archaeological site. While each blow with your shovel gets you closer to the truth, you’re liable to smash it into a million little pieces if you use too blunt an instrument. I see a lot of teams using a bulldozer and crate of dynamite for their excavation. They use heavy-handed questions like “do you think it’s a good idea” and shatter their prize. At the other end of the spectrum, some founders are using a toothbrush to unearth a city, flinching away from digging deep and finding out whether anything of value is actually buried down there.’ We botched at least a dozen conversations with stakeholder, by either introducing our concept of interest too early or never bringing it up and getting their true thoughts. This was a skill we gradually improved upon with every interaction.

Overall, the exploration was invaluable and one-of-a-kind. It set the stage for how our company, ConnectMed, planned to work with the South African public healthcare system, as well as how we now think about engaging the Kenyan system.

Melissa recently completed her MSc Computer Science and MBA at University of Oxford on a Rhodes Scholarship and is now working on a Africa-focused digital health venture, ConnectMed, in South Africa and Kenya. She previously worked in the Americas and Africa as an engineer, entrepreneur, and consultant.

Follow @melissa_mccoy

Download Melissa’s Apprenticing with a Problem report.

Read more about Apprenticing with a Problem on the Skoll Centre website.

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Who wants to be sexy, anyway? How ignoring the boring bits of global health costs lives

Global Health: Getting from Innovation to Implementation panel

Forging Common Ground – Series of Oxford Student Insights to the Skoll World Forum 2017.

Oxford DPhil candidate in Philosophy, Michael Plant, gives his perspective on the  Skoll World Forum session “Global Health: Getting from Innovation to Implementation”.

As you start the marathon, crowds cheer you on. They’re with you for the first mile. And the second mile. Now you’re at the 15th mile. You hit the wall. You need support to keep you going –  a glass of water, a single cheer – but no one’s there. Who wants to watch the middle of a long race? You know they’ll be crowds to cheer you across the line, but that seems very far away.

This, argued Barbara Bush, founder of Global Health Corps, is an uncomfortably apt analogy for the problems facing global health as it tries to move from innovation to implementation. People get excited about the start: creating a new vaccine. And people can get excited about the end: making sure that vaccine travels the last mile and gets to the child who needs it.

Yet, in the long distance between those two, cheerleaders are thin on the ground. It’s very hard to get people interested in improving health systems, scaling up interventions and finding better ways to distribute medicines around the world.

Why? Systems simply aren’t sexy, unsexy things get ignored, and so millions of people die or suffer from health conditions we already have the technology to solve.

Hence the question Barbara posed to the three experts on her discussion panel: if we want to improve the ‘unsexy middle’ of global health, what should we do?

Steve Davis, CEO of PATH, argued healthcare innovators should be designing with scale in mind and the road to scale is mostly clearly through health ministers, rather than patients or funders. For instance, there’s little point creating a new drug so expensive developing countries can’t afford it.

Yap Boum of MSF added progress is often slow because locals aren’t invited to be part of the innovation process. How much better could NGOs be if they had locals on their boards who understood the country?

Surgeon and public health researcher Atul Gawande agreed going from ‘zero to one’ – inventing something – was valued much more by funders than taking discoveries and bringing them into the existing systems. At least in part, this is because discoveries feel much more tangible. He suggested a way around this is for funders to focus on scaling an innovation by one order of magnitude at a time, seeing each as a serious and independent goal. Pioneering a new procedure in one clinic should be thought of as a victory. Getting that procedure from 1 to 10 clinics is different second achievement requiring different methods, getting it from 10 clinics to 100 a third, and so on.

As panel discussion moved to questions, the audience wanted to understand why there wasn’t more collaboration between all the different organisations. If so much of global health is just a co-ordination problem, why haven’t we solved it yet?

The problem, it seems, is people having priorities. If, as Atul shrewdly noted, the US can’t even agree on whether to provide subsistence healthcare in their own country, how could we reasonably expect NGOs, governments and donors to all be effectively pulling in the same direction on global health? He suggested we need a unified metric, or yardstick, to compare different potential health priorities and reveal the top priorities.

Two things struck me from the conversation today. The first was: if we’re worried we’re overlooking things because they’re not sexy, what else are we ignoring?

As someone who’s interested in how best to increase happiness – or put another way, how best to reduce misery – I had hoped mental illness would have been a bigger part of the discussion. Research suggests mental pain can, and often does, have a bigger effect on self-reported happiness scores than physical pain does. What’s more the way standard health metrics, such as ‘QALYs’ (Quality-Adjusted Life Years), are constructed fails to adequately capture the badness of mental illness (see Dolan and Metcalfe 2012). Perhaps due to the stigma, measurement issues, or the complexity of treating them, mental illness is the marathon almost no one is even watching.

Second, if we need to agree on a single metric so we can prioritise resources in global health, it seems obvious to me the right metric is happiness. I take it we don’t value health just for its own sake, but because it helps us live longer and enjoy our lives more. Not all health conditions make people unhappy and, where there’s a choice between reducing unhappiness or ill-heath, we should target misery. Whilst some may worry happiness is too ‘fluffy’, the evidence suggests ‘subjective well-being’, as it’s often called, can be reliable measured. The OECD now recommends countries collect data on it.

Neither improving healthcare systems or mental health care are particularly sexy, which is why they’ve been overlooked. However, as Steve Davis said at the close to the session: our outrage at avoidable deaths and suffering should drive us to do better.

Michael Plant is a DPhil Candidate in Philosophy, CEO and Co-Founder of Hippo. Read more from Michael at www.plantinghappiness.co.uk.

Follow Michael: @michaeldplant