Each year the Skoll Centre invites a small number of Oxford students to the annual Skoll World Forum on Social Entrepreneurship. Each year they share their unique perspectives of the sessions and events that unfold during this magical time in Oxford.
This session conducted by the leadership team of Partners in Health was scheduled for 7 am on the 10th of April. Hence by design it self-selected for individuals who were extremely motivated to learn from the experience of Partners in Health in Global Health Delivery.
Partners in Health (PIH) is a Boston-based
nonprofit health care organization founded in 1987 by Paul Farmer, Ophelia
Dahl, Thomas J. White, Todd McCormack, and Jim Yong Kim.
The organization’s goals are “to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair.” It provides healthcare in the poorest areas of developing countries. It builds hospitals and other medical facilities, hires and trains local staff, and delivers a range of healthcare, from in-home consultations to cancer treatments.
The session delved into a nuance in global
health delivery which are often ignored. Dr. Mukherjee asserted that the
successful delivery of healthcare ought to be reviewed through three lenses.
A justice framework
Human rights framework
Social determinants of health framework
The first two are not given their due share
of discussion since perhaps as healthcare professionals we feel this is beyond
our scope of work however, they are essential to an equitable delivery of good
health for all.
The justice framework requires
retrospective reflection. Many of the inequities we observe as global health
delivery agents are not just because people who we aim to benefit do not know
better or that there is lack of will to correct the structural problems that
exist. Instead, the source of these issues come from a history of colonization,
practices of slavery and exploitation of certain regions by others. The damage
from these unfortunate parts of our collective history is immense. While these
chapters of history cannot be undone, it would not be prudent to completely
forget about these issues as important causative factors towards why certain
regions struggle to this day with diseases that the developed world has long
overcome. Hence, keeping them in our purview as we think about global health
would ensure such injustices are never repeated.
The second framework is the human rights framework. Today we live in a world where almost everything we do, any service we receive or any item we own has input from many different regions. This is especially more applicable to the socioeconomic strata attending this forum or can read this narrative that I write today. When we live in a globalized world of commerce then a question that arises is why our human rights are different depending on national borders. What would be considered exploitation in one country would be considered fair trading practices in another. The world is much more comfortable with utilitarian notions of healthcare service delivery for the poor but not the same yardstick is applied to the wealthy. These are deep-seated, class-based biases that ought to be brought out in the fore and the repercussions of these biases need to be corrected or else the inequities we wish to overcome will always plague us in some way or form. This philosophy of healthcare delivery is reflected in the work of Partners in Health throughout the world. They believe all that they interact within their ecosystems are owed a similar chance towards healthcare services.
Finally, the social determinants of health were
also discussed. This is an area quite often discussed and debated on in Global
Health conversations. The impact of where you are born, your gender, your
education and such all impact health outcomes. This has been researched and
well documented. Dr. Mukherjee added a nuance to this conversation though. She proposed
that instead of calling it social determinants of health we should label this
effect the social forces of health
since these socioeconomic markers are not just a correlation but have vector
component to them as well hence the relabeling to a “force” would more
accurately depict the relationship.
One of the key takeaways from this session was that healthcare is clearly a political and a social issue. And in our respective communities, to enable meaningful healthcare change we must interact deeply with the social and political forces. Meaningful change requires mobilization and that’s only possible once we put our skin in the game by operating beyond our healthcare facilities and embed ourselves intimately with the wider community.
About the Author
Mohsin Mustafa is an Oxford MBA candidate, a Skoll Scholar and Weidenfeld-Hoffmann Trust Scholar. He is also an entrepreneur who is passionate about the provision of quality primary healthcare. He sees the provision of quality healthcare as a way of enabling social justice and that’s what fuels his passion for work. Mohsin is the co-founder and managing director of Clinic5, an affordable healthcare delivery service for communities in Pakistan. He is currently a Skoll Scholar, Weidenfeld-Hoffman Scholar and MBA candidate at the Saïd Business School.
Each year the Skoll Centre invites a small number of Oxford students to the annual Skoll World Forum on Social Entrepreneurship. Each year they share their unique perspectives of the sessions and events that unfold during this magical time in Oxford.
Achieving universal health care through collaboration between funders, social entrepreneurs, and government
Frustrating. Slow. Fundamental. Scale. These were the words that came to mind to attendees when Erin Worsham of the Center for the Advancement of Social Entrepreneurship asked them to describe working with government. The balance between the challenges of working with government, and the potential impact and scale that could be achieved through collaboration was immediately apparent.
In the next hour and a half, we heard candid conversations from two partnerships between social entrepreneurs and governments. One was between Last Mile Health and the Government of Liberia. The other was between Partners in Health and the Kingdom of Lesotho. Through these conversations, there were three themes that kept coming up:
Collaborative target setting and evaluation between social enterprises and governments
Demonstrating impact to inspire scale up
Funding for comprehensive primary health care, rather than particular diseases
Collaborative target setting and evaluation
Thabelo Ramatlapeng of the Kingdom of Lesotho kicked off this theme when she mentioned one of the major challenges for governments was working with organizations who brought their own missions, and their own objectives, and were inflexible about setting these objectives collaboratively. In both partnerships, there was a concerted effort made to understand the government’s priorities and ambitions, and design the work and evaluation according to these, rather than organizational agendas.
Lisha McCormick of Last Mile Health drove this home when she mentioned that in her experience, the Government of Liberia wasn’t concerned with RCTs, and evaluation; they had very practical questions- how do we implement, and how do we pay for it?
Demonstrating impact to inspire scale up
Another recurring theme was social enterprises demonstrating impact to government in smaller use cases, and government building on this momentum to scale up what is proven to work. Partners in Health by building seven comprehensive primary care clinics in the most isolated and difficult to reach areas of Lesotho, and Last Mile Health by implementing a community health worker model in three counties of Liberia. Each have now scaled rapidly in close collaboration with government, with comprehensive primary healthcare now reaching 40% of the population of Lesotho, and community health workers operating in 15 counties of Liberia.
This to me, seems like the ultimate theory of change around working with government. Innovators prove that work can be done differently and more effectively, and the value of government is in recognizing and scaling this innovation so that it has massive impact. The innovation would not have been recognized, however, if the respective teams hadn’t engaged government in setting the objectives and defining success at the very earliest stages.
Delivering comprehensive primary healthcare
There was a third stakeholder in the conversation between panelists that wasn’t a speaker, but whose presence was felt- the funders. A major challenge emphasized by Abera Leta of Partners in Health was that funding for health is often in verticals, designated to treat HIV vs. malaria vs. a vaccination, rather than funding that can be used for comprehensive care that treats communicable and noncommunicable diseases, and makes true universal healthcare access a reality.
Again, the importance of following the government’s lead was emphasized. In countries like Rwanda that insist on autonomy in how they use donor money to fund healthcare, comprehensive primary healthcare can be prioritized. Just like with social enterprises, when funding reinforces and enables the government agenda around comprehensive primary healthcare, rather than trying to force its own, the potential of this collaborative relationship is realized. Every speaker, from the government and the social enterprises, was unanimous in calling for funding that could be used to build the primary healthcare systems that countries need.
As we think about these themes, it’s important to keep the individuals at the center, who are the reason that all three players- governments, social entrepreneurs, and funders- do this work. S. Olasford Wiah of the Government of Liberia brought us back to these individuals when he shared what inspires him to work in community health. He shared the story of one of his former patients. A woman who had a healthy pregnancy, but experienced complications during the delivery. Her community came together to try and bring her to a health center, walking and carrying her for hours in a hammock, but by the time they reached the center, she had passed away.
This is the injustice experienced by the 50% of the world that doesn’t have access to essential health services. And addressing this injustice is what motivates us and demands that we collaborate to achieve a world with universal access to health care.
About the Author
Puja Balachander is a social impact designer following the lead of vulnerable communities to help solve their most intractable problems. Throughout her career so far, she has worked on designing sustainable, equilibrium-shifting solutions with end-users. Puja believes in working with end-users in their language and in their community, therefore she practices and teaches design in French, Hindi, and Tamil, and has worked all over the US, India, and Madagascar. Currently undertaking her MBA degree at Saïd Business School, she is also co-founding Devie, a social enterprise that aims to improve access to quality early childhood development.
Mohsin Ali Mustafa is our 2018-19 Skoll Scholar on the Oxford MBA. Mohsin is also a Weidenfeld-Hoffman Scholar, co-founder and managing director of Clinic5 – an affordable health delivery service in Pakistan.
I write this blog post as a letter to my younger self. We don’t have a time machine (yet) but what we do have is an ability to communicate ideas through our written word and I see my life as part of a larger continuum, so this blog is an effort to speak to that young man or woman who is brimming with enthusiasm to go out and “change the world.”
Congratulations on graduating from medical school, I am proud to see the passion to serve in you is thriving to the point where you want to work as medic on the front lines of the war in Pakistan. I know right now you want to do a Che Guevara and change the world. I remember you mentioned that you wish to end the war that’s raging in your country by working as a Disaster Response Medic. I’d like to share a few things I learnt over the course of the last few years that might help you along the way. I am cautious as I write this since the words of age can strike as pessimism to the youth so take from this what makes sense to you.
First – patience, Rome wasn’t built in a day. Climate change did not start last year, the war that rages all over the world is not a product of inequities of the past few days. The big problems that you want to tackle are insidious and hence their solutions would also require time, patience and effort. This is a marathon and not a sprint pace yourself or you will burn yourself out. Keep your eyes on the prize, this will be your life’s work – take the long-term approach. Do not let small losses here or there dissuade you from the end goal.
Second, find a mentor; life at 24 seems impossible to navigate at times, a mentor who works in the space or inspires you with their professional and personal attributes can transform your worldview. I know I got direction from my mentor or else I might have ended up completely misdirected. A mentor encourages you and anchors you in life with their wisdom.
Third – balance, this world needs young people like you, but remember you’re not the only one in this. I know right now you can’t see it with everyone that you know taking the path that’s safe and comfortable but let me assure you there are thousands of troops fighting the same battle as you. It is important that in your struggle to change the world you don’t forget yourself. Remember the relationships that make who you are, spend time with them; remember the passion for trekking in the mountains, do it occasionally; remember your love for sushi, have it once in a while. Don’t blindside yourself in the effort to change the world and in the process forget what made you, you.
The last and the most important one, love. Don’t forget to love, you were driven on this path out of the love for a patient, a patient you lost on your watch in the ER, I know you shed tears that night and vowed to fix the systemic problems that caused it, don’t forget that passion. Protect that flame in your heart. Winds will blow to put it out, sometimes under the guise of practicality, other times in the guise of rewards.
Remember, your heart will harden to cope with all the sorrows you will experience, and it would seem like a wise thing to let it harden as that hurts less. That’s a cop out young man – don’t be weak and give in to that urge. A good way to judge this is by observing how you treat everyone closest to you. If you notice you’re becoming harsher with the people in your life, you’re doing something wrong. This one is the hardest to maintain and let me be honest with you, it’s still a constant struggle in my life despite the few years I have over you.
That’s enough for today, I know you’re a young man with a short attention span so I kept it short but trust the path you have taken, who knows this path might even lead you to the leading center of learning in the world where you would be sharing your experience with colleagues from all over the world. When that happens remember to treat that privilege with humility and purpose.
I have a hunch life will be a rewarding adventure on your chosen path and you will go places you did not even imagine you would.
I am immensely grateful to the Skoll Centre and the Weidenfeld-Hoffman Trust for enabling my education at the Saïd Business School. I am cognizant of the privilege and will do my utmost to deliver on the promise. I pledge to return to my organization Clinic5 at the end of this academic year to scale our work in healthcare in partnership with schools in Pakistan.
Mohsin Mustafa (pictured right) with young girls attending his clinic in a Pakistani classroom.
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:
Primary, secondary, and tertiary levels of healthcare
Gauteng, Western Cape, North West, and Mpumalanga provinces
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:
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.
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.
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.
By Julian Cottee, Skoll Centre Research & Insights Programme Manager
Our previous blog looked at ‘Six Reasons Why Research Matters for Social Entrepreneurship’, ranging from gaining a deep understanding of problem and solution landscapes, to innovation, and a critical birds-eye view of the sector. The Skoll Centre has since been exploring research for social entrepreneurship through a series of seminars led by impact-focused early career researchers from across Oxford University. Each has discussed their own research experiences and drawn out lessons for better aligning research with the needs of the social innovators.
Evidence and impact
Evidence and impact evaluation are top of the list for many practitioners when asked how research can help their work. Anna Custers, a Skoll Centre Early Career Research Fellow, explored this topic in depth through her experiences with a number of randomised controlled trials (RCTs) assessing the impact of poverty reduction measures in the Global South. The RCT methodology, originally designed for evaluating the impact of medical interventions, is now becoming more widely used outside of clinical settings. Social scientists in a range of fields are adopting RCT approaches, and while many policymakers view them as a ‘gold standard’ for evidence of impact, they are not uncontroversial. RCTs are complex, lengthy and expensive to set up, and they can only be used to evaluate a narrow gamut of interventions. Their strength in demonstrating the counterfactual – what happens in groups not receiving the intervention – also raises significant ethical questions. If demonstrating impact through RCTs were to become a routine part of the funding and policymaking landscape for social entrepreneurship, the range of projects would be curtailed, the speed of implementation would be reduced, and additional research funding would be needed. Further discussions revolve around the question of how much evidence is ‘enough’ to demonstrate impact, and to what extent this differs depending on the scale of the initiative being assessed. An expensive RCT might be appropriate for a highly scalable ‘big bet’ intervention that can be widely replicated if impact can be robustly demonstrated, but many, if not most, projects are smaller and more locally specific.
Ideas around the role of research in evidence provision were further developed by Dr Jenny Tran, speaking about a recent Skoll Centre-funded research project that interviewed 31 policymakers, funders and practitioners in the field of social innovation in healthcare in low- and middle- income countries. The interviews probed attitudes and beliefs relating to evidence within these three groups. Among practitioners for instance, responses ranged from seeing research and evidence as an accountability mechanism – “Research is a tool of justice…how are we holding ourselves accountable to our patients?” – to something that just needs to be done to satisfy the expectations of funders – “We do what we have to do”. The funders interviewed also had mixed attitudes towards evidence, with some admitting candidly that gut feeling was as important as data in making funding decisions. Organisations spoke of a lack of time and expertise to collect good data on their impact. One theme that clearly emerged from the interviews was a lack of consensus on how to operationalise a model of data generation and use amongst all three groups that is of an appropriate scale in terms of the time and resources demanded, as well as being robust and rigorous. RCTs were rarely seen to be the answer. Tran’s paper recommends a number of future pathways for improving research in this space, including further elaboration of the concept of ‘lean research’ striking the balance between appropriate scale and rigour; better technical education; and changing the way evidence generation is funded. All of these are ripe for future exploration. In addition, there is little or no attention currently paid to how organisations measure negative impacts, or their incentives for doing so. This too is an area that deserves further study and the development of practical tools for the generation of objective impact measurement.
Two other seminars in the series focused on the role of research not in the generation of evidence, but in others kinds of knowledge creation, through embedded partnerships between academics and practitioners. Kate Roll, Senior Research Fellow at Saïd Business School, spoke on the Oxford-Mars Mutuality in Business project, a large multi-year research project exploring the idea of mutuality as an organising principle for business. The project is unusual in that it is carried out by an academic team in collaboration with the Mars in-house think-tank, Catalyst. The allure of the set-up is clear from the point of view of carrying out research guided by real-world priorities – there is potential for unique access to knowledge, skill and legitimacy on both sides – yet challenges are also many. In particular, spanning the research-practice boundary brings to the fore different perspectives on questions such as:
When is work finished? (medium-rare or well done)
With whom can we meet? (negotiating internal access)
What is a good output? (collaboration, consultancy, opportunism)
Who needs to be involved? (setting boundaries in joint research)
Drawing on the theory of organisational hybridity, Kate explains such collaborations as a case of striving to effectively bring together differing ‘institutional logics’: “as the degree of incompatibility between logics increases, hybrid organisations face heightened challenges” (Pache and Santos 2013). In order to realise the unique opportunities for insight and impact, researchers are obliged to adopt the character of the ‘amphibious academic’. Even if they might be happier in water, like the frog, they too can cope ably on land.
Successful examples of such collaborations are not numerous. They require connections, funding and abundant engagement and amphibious capability from all partners. Alex Fischer and Heloise Greeff, members of the Skoll Centre’s Research for Action Network, spoke about Oxford’s Smart Handpumps project, a long-running collaboration with NGOs and government. While the project began by exploring the causes and impacts of broken water pumps in rural Kenya, it has since transitioned to address how broken pumps can be fixed quickly and cost-effectively. The project is now driving technological and systems innovation to the point that it has led to the creation of a social enterprise that will service the handpumps sustainably into the future using the technical and institutional knowledge generated in earlier phases. Alex and Heloise described a ‘research-action spiral’ in which innovation and research have circled around each other in a productive dance. These impactful outcomes of the project could not have been anticipated at the beginning of the research process – a powerful argument for research led by problems and not just solutions. Often, following intuitions and blind alleys was just as important for the development of the impact of the project as any planned research pathway. This highlights the value of flexible funding and creative leadership in action-research projects. Universities are an important ingredient in this kind of innovation and research, as they provide safe spaces for the exploration of novel ideas that may not otherwise be pursued. The role of PhD students too is of significant value – unlike research assistants or employed post-doc researchers, PhD students follow their own research agendas within the wider project, generating new ideas and possibilities.
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.