The Origins (Part 3: Determination)
This is the last of a three-part series on how I got started on this Big Hairy Audacious Goal. It discusses my learning journey since Jeeon, and how I'm approaching my work/activism going forward.
This is going to be another long post, so here’s a 1-minute tl;dr version:
Burnout and New Beginnings: Post-COVID, an opportunity to build a global health portfolio for Endless came my way. I embarked on it with extensive research and triangulation to zoom out and broaden my horizons. My first-principles analysis eventually landed me on some key insights about persisting gaps in Global health, that I am setting as my North Star orientation.
Key persisting gaps in Global Health from a people-centered lens:
People-Centered Health Systems: We need people-centered, responsive health care that meets people where they are, i.e. through robust and holistic care at people’s homes and communities. Need a true paradigm shift, not just HCD as a checkbox item. 4 underlying gaps I’m focusing on going forward:
Integration of Care: Horizontal fragmentation of care across sectors and providers causes disjointed care experiences and poor health outcomes.
Quality of Care: Despite widespread access today (at least when you count all types of providers), poor quality care persists due to knowledge gaps, fragmented, uncoordinated services and misaligned incentives among providers.
Provider alignment with patient experiences and outcomes: Misaligned and perverse incentives and lack of feedback mechanisms from a patient-centered perspective contribute to poor alignment with long-term, comprehensive and outcome-focused care that people need and want.
Self-care: In the context of public health, self-care is a fairly new and emerging topic, although people spend a vast majority of their health-focused time on self-care compared to provider interactions. This is a huge opportunity for innovation, especially in the context of AI.
I do hope you find the time to read, reflect and comment on the full post.
By mid 2022, I was an emotional wreck. Although the economy and society were starting to recover from COVID, I was utterly burnt out from two grueling years of pandemic response work. Jeeon’s financial runway was dwindling down to its final months, and I had to face the reality that there was no path back to a commercial trajectory. On top of this, there was an immense void in my personal life as well, since my family had relocated to Baltimore in the middle of the pandemic for my wife’s graduate studies, and staying away from my two kids for months at a time (and alternately, trying to manage the company remotely across a 12-hour time difference) was unbelievably painful.
To support my wife through her final months of studies and to give myself a break, I took a four-month sabbatical in the US for reflection and healing. (I wrote a series of posts in a blog titled “The Recovering Entrepreneur” at this time — if you ever find yourself in an existential/identity crisis, you may find a kindred spirit there).
During this period, I first considered moving to the US full-time. This meant dissociating with my primary identity as a social entrepreneur in Bangladesh, which was daunting. Fortunately, an opportunity to help Endless build a global health portfolio unexpectedly came my way.
We will write about Endless’s vision and mission in an official blog post on our website (and link to it when it’s up), but here, I want to document the incredible learning journey I have gone through in the past ~20 months since taking that leap of faith, and how I have come to orient my compass with respect to my convictions and activism around global health today.
Broadening my horizons
My deep immersion in rural Bangladesh through Jeeon taught me a lot about the gaps in public health programs driving people to private providers, the relationships between informal providers and their communities, the challenges of introducing technology, and the power of incentives in shaping behaviors. If you haven’t read the earlier post, it goes into a lot more gory detail here:
However, after nearly 10 years immersed in one ecosystem, I became tunnel-visioned and lost sight of the global health landscape. I needed to zoom out, recalibrate, and understand how global health (and digital health in particular) had evolved and how different contexts compared to rural Bangladesh.
I did that first through a thorough literature review, voraciously reading as many (hundreds) papers, publications and reports I could get my hands on which seemed relevant to our broader mission of ensuring high-quality comprehensive care to billions (I can’t thank my wonderful colleague Bridgette enough for supporting me through that painful process). I then started synthesizing the recurring themes and triangulating them against my own experiences from mPower and Jeeon. I also started to reach out to my community of expert mentors (many of whom are in this distro - you know who you are! 🙏🏾) to validate and find gaps in my learnings, and distill it down into a set of key challenges that are fundamental yet unsolved. Finally, I conducted some field visits (both in Bangladesh and neighboring West Bengal) to ground-truth and stress-test these hypotheses with various frontline health organizations.
Initially, I felt quite lost to distill the immense volume of information. Ultimately though, through this iterative process over ~6 months, I arrived at this deceptively simple summary of the most critical problems to solve in global health, taking a first-principles lens:
Each of these areas deserves its own post to cover the research and emerging solutions. Here, let’s frame and articulate these gaps and their intersections in just a bit more detail:
People-centered health systems (or lack thereof)
At an overarching, philosophical level, I realized that we have not really walked our talk about “people-centeredness” within our health systems. Human Centered Design (HCD), promising as a methodology as it was, became yet another jargon within an ever-expanding checklist to tick-off when pitching funders for money. We hardly internalized it as a philosophy, and stopped short of embracing as a core value that it is important to yield power and voice to our clients (or as they are tellingly termed in global health, “beneficiaries”).
However, if you genuinely approach healthcare from a people-centered lens, by definition you would have to design health services and systems that meet people where they are. This is why we designed Jeeon the way we did, leveraging people’s existing touchpoints and trust with pharmacies, as I wrote in my last post. Contrast that with the 18,000 community clinics built in Bangladesh spending billions, which are so clueless about people’s needs that they remain open (in the ~50% of cases they open at all!) from 10 AM - 2 PM, when most people are either tending the fields or cooking their meals. The busiest hours of pharmacies are usually before 11 AM and after 5 PM.
Meeting people where they are from a health system design perspective means investing in robust, responsive, comprehensive and effective healthcare systems that reach into their homes and communities. This is hardly news — we have known since Alma Ata that well-functioning primary care systems should be the centerpiece of any country’s health system, can address 90% of a community’s health needs, and save 60 million additional lives per year. Yet, in our single-minded —and dare I say, outdated— focus as a global health ecosystem to eradicate fatal infectious diseases, and the inertia of the resource allocation processes we have developed around it, we have categorically failed to address this fundamental need (and indeed, human right) of communities.
[We need] a fundamental shift in the way health services are funded, managed and delivered. [We envision] a future in which all people have equal access to quality health services that are co-produced (care […] delivered in an equal and reciprocal [long-term] relationship between professionals, people using care services, their families and the communities) in a way that meets their life course needs and respects their preferences, are coordinated across the continuum of care and are comprehensive, safe, effective, timely, efficient, and acceptable and all carers are motivated, skilled and operate in a supportive environment. (emphasis added)
— WHO Framework for Integrated People-centered health systems adopted in 2016,
falling largely on deaf ears
During my research, I was honestly pleasantly surprised to find the WHO (along with numerous other voices) advocating for the same people-centered philosophy I have always believed in, and equally horrified that there was so little departure from the status quo in the last eight years since the adoption of the Framework.
In terms of bang-for-buck, I therefore decided that continuing to lend my voice to this chorus — and focus my energy and efforts towards mainstreaming a people-centered paradigm in healthcare — still made the most sense.
***
When you double-click into that HUGE box and look beyond the philosophical and into the operational, however, there’s at least three big, interrelated and largely unsolved challenges that needs addressing, each of which is emphasized within the WHO’s vision, and which I had also personally run into at Jeeon many times over during the past 10 years:
1. Integration of care
Due to fragmented public health programs and the multitude of providers in mixed health systems, people receive disjointed and uncoordinated care. I concluded that we have done slightly better with vertical integration of care (within certain disease silos) than horizontal integration across various vertical programs and sectors, but that huge gaps persist in both dimensions:
Vertical integration: We have done relatively well in this area, especially within the disease-focused silos of most global health programming. In order to combat the HIV epidemic, for example, systems needed to be designed to screen, confirm, treat, and follow-up on the same patients effectively and over time (as represented in the 95-95-95 goal for 2030). However, as soon as you go beyond the handful of priority diseases, this integration breaks down completely. The same person found to be diabetic during an unrelated visit to a public hospital might therefore be rediscovered years later by a CHW belonging to the same public healthcare system. Few countries have well-designed triage+refer mechanisms or data sharing (especially for open-ended general health conditions) between the various providers even within the public sector, let alone across sectors. Last but not least, there is often no mechanism for reverse referrals, i.e. the ongoing follow-up and monitoring of care at the community level after one completes a visit or procedure at a facility, such as for post-operative care or chronic diseases.
While building Jeeon, we were faced numerous times with the dilemma of a patient who needed to be treated at a facility, but without a 1:1 agreement and data sharing arrangement set up with each referral facility (which was resource and time intensive), there was no guarantee that the patient would be treated (and treated well) and referred back to us for ongoing follow-ups.
Horizontal integration: At each level (primary, tertiary, etc.), there are often a variety of providers to choose from, sometimes even from different sectors (public, private, faith-based, non-profit, informal, etc.). At the community level, for example, there are typically public/social sector community health workers (CHW)/nurses/midwives, private pharmacies, faith-based healers, and even friends-and-family as informal providers of care. People typically make choices on a case-by-case basis based on availability, urgency, cost, and a mental model of who-is-good-for-what. For example, within the window of a single pregnancy, a woman would typically opt for routine ANC/PNC visits by the health worker, handle acute symptoms like bloating or back-ache with pills “suggested” by the local drug shop, share depressive or mood disorders with peers or the local priest, and seek nutrition and lifestyle counseling from the mother-in-law.
Without data sharing and integration of care across these various sectors and types of providers, continuity of care breaks down completely, causes confusion, and leads to duplication and inefficiencies. I have seen this first-hand in Bangladesh, where different providers (two departments within the Ministry of Health, as well as BRAC and other NGOs) might send CHWs to the same households for largely overlapping tasks around a pregnancy. At Jeeon, we were catering to many of these same pregnancies (e.g. for pregnancy-induced back-pain or gestational diabetes), but there was no data sharing or coordination between our systems, so these discreet but related encounters remained completely invisible to each other.
Horizontal fragmentation is no doubt perpetuated and exacerbated by the fragmentation of global health funding, which might introduce thick walls and “not-my-problem” dynamics between providers. As a result, each program might screen for a particular condition it is designated for, but fail to account for or refer to adjacent ones.
Not only is this fragmentation a frustrating and confusing experience for patients, it also directly causes poor quality care and health outcomes. And it is intricately linked with the incentive structures that animate each individual provider and/or system.
2. Quality of care
We have long obsessed about access as our primary goal. This could be true in some contexts where low density of rural populations might mean long distances to any sort of care (although studies in India have shown otherwise). However, as I experienced viscerally in rural Bangladesh, people often don’t suffer because of lack of access, they suffer despite it. Once you count all the various types of providers ignored by the health system, people more often than not have access to some health provider within 15 minutes from their house. Many informal providers even do house calls, and will readily show up at 3 am in the morning when your child is sick.
If it isn’t access that is causing the problem, what is? According to the flagship 2018 report by the Lancet Commission on Quality, up to 15% of all deaths (8 million people) in the developing world are attributable to poor quality of care.
“Poor-quality care is now a bigger barrier to reducing mortality than insufficient access. 60% of deaths from conditions amenable to health care are due to poor-quality care, whereas the remaining deaths result from non-utilisation of the health system.”
— Lancet Commission on High Quality Health Systems (paper), 2018
A few data points may be illustrative as to how this typically plays out:
The average doctor consultation in Bangladesh lasts 48 seconds, which is the lowest among 67 countries surveyed. The closest second was India, at ~2 minutes! (study)
In Madhya pradesh (India), as many as 63% of interactions in PUBLIC sector clinics happened with providers who had no medical qualifications! Moreover, there were only minor differences between trained and untrained providers in terms of following clinical guidelines. (paper)
Indian public sector doctors spend 65% more time with patients, diagnose them better, and are more likely to offer correct treatment in their private practice than THEIR OWN day jobs at public clinics. (study)
70% of primary care interactions in Bangladesh happen with the informal private sector, which is completely unregulated, untrained/unaccredited, and operate in a vacuum with no support or oversight. 95% of health providers in Bangladesh are in the informal sector. (Bangladesh Health Watch)
So an extremely simplified version of the story is this: public sector care in these countries are often poor quality, which drives people to seek care in the unregulated private sector, which offers equally poor clinical quality but more convenience and generally a better experience, which people find worthwhile enough to pay for out-of-pocket.
Indeed there is a gap in the number of qualified medical professionals in the absolute sense, which causes some of this quality gap, but that is clearly not the entire story. Firstly, qualified physicians tend to crowd urban areas and rarely visit their rural postings (“absenteeism”) causing huge density variances. But it is not even clear that qualifications translate to clinical skills, and that those skills translate to effort. In other words, many providers, even qualified ones, don’t know well how to treat patients (or to treat patients well). Lastly, even when providers know what to do, they often don’t do it. This will lead us to the problem of incentives in the next section.
What complicates the quality problem further is that measurement of quality is not directionally consistent. In education, reading scores are good when going up, and bad when down. In healthcare, contrastingly, no medicines might mean poor quality (inadequate care) in one case, while excessive medicines may indicate poor quality in another. One imperfect solution to this may be to rely more on subjective patient experience and self-reported outcomes. However, although the Lancet Commission on quality strongly advocates for including such measures in health system performance assessments, to the best of my knowledge there are still no well-validated and consistent indicators measuring patient experience that can be applied universally.
3. Misalignment of incentives driving poor quality and fragmentation
It should be fairly evident by now what I mean by incentive gaps. Just to clarify, I don’t mean just the tangible financial incentives that are misaligned, but also the softer elements of the “choice architecture” and non-financial motivations (reputational considerations, peer pressure, etc.) that providers are embedded in. Both the integration and quality gaps are ultimately fueled and perpetuated by a wide variety of incentive misalignments.
At the micro level, public providers, who are paid irrespective of performance (or even presence for that matter, lack incentives for quality care. Private providers, while better incentivized to deliver services, have other forms of perverse incentives, such as the informal provider above who would clearly make a huge margin from the 95 injectable drugs he prescribes and then sells. Complicating this further, patients themselves often don’t have a good mental model for clinical quality, equating more drugs with better care, and demanding the latest antibiotics as quick fixes. In my hometown of Jashore, Bangladesh, the most popular private provider by far is a pharmacist who injects a potent “secret recipe” concoction of antibiotics, steroids and painkillers to every patient, irrespective of their condition.
At the meso level, there is rarely any incentive or motivation for providers across organizations to collaborate and coordinate with each other in care delivery, leading to the fragmentation challenges. For-profit clinics will often try to vertically integrate to hold patients longer than specialize and link up with complementary service providers. Public health officials will often see private clinics as competition rather than potential collaborators in ensuring health of the population, in the absence of performance metrics that cover the breadth of the health system (not just services rendered within public facilities). Last but not least, there are no incentives to share knowledge and learnings for accelerating innovation, leading to many reinvented wheels and repeated mistakes.
At the macro level, funding silos and poor measures of health system performance are the main culprit. Global health financing, as discussed above, perpetuates silo’ed thinking around diseases and not integrated life-course oriented care for populations. Payments are also typically tied to outputs (people served, widgets delivered, etc.) rather than effective measures of quality and value creation. But funders don’t deserve all the blame. Governments themselves are largely driven by their own perverse incentives — 5-year election cycles that lead them to prioritize shiny objects like building hospitals rather than meaningful but invisible system strengthening investments that pay off long-term.
I wrote about incentive misalignments further in the context of Antimicrobial resistance in the following post:
In addressing the above challenges, below are some key strategic focus areas that could yield high leverage and that I think we must explore deeply and systematically as an ecosystem (certainly not exhaustive):
Technology and business model innovations: What can a modern, holistic and integrated primary care system look like that fully leverages 21st century technology? How might we be able to tackle NCDs proactively at a low cost? Can we anticipate the impending “singularities” that AI will engender, and exploit it for furthering these goals?
Measurement and financing innovations for incentive alignment: How could we create enabling environments for value-based care delivery? For co-opetition within and across sectors? For more patient-centered thinking and design of systems? For tackling AMR?
Integration architecture: How should we design our health data and systems to be safe, private, patient-driven and interoperable? What kind of infrastructure and institutions might enable public systems and large funders to easily identify, test out and scale new and promising innovations in #1 and #2?
Global health financing and resource allocation processes: Can we start to shift how large health funders think about resource allocation? Can we move the conversation from incremental reallocations (“diagonalization”) to dedicated and significant allocation for a comprehensive redesign of integrated and holistic primary health systems?
I’m certainly under no illusions that we can solve all these issues globally in my lifetime, or that I can make a meaningful dent on any of them, let alone all. Tackling these issues is a collective responsibility for all global health actors.
However, it is useful to have a North Star orientation at all times to figure out how best to contribute at any given time going forward, hopefully for the rest of my career in global health, whether it is in ecosystem roles like at Endless, or entrepreneurial ventures like mPower and Jeeon (or the next one!).
In (re-)setting this orientation for what has long been my professional mission, I am reminded of the following quote from an incredible book called “Mastery” that I am currently reading:
For a master, the rewards gained along the way are fine, but they are not the main reason for the journey. […] if the traveler is fortunate — that is, if the path is complex and profound enough — the destination is two miles further away for every mile he or she travels.
For a mission as long-term, complex, evolving and unpredictable as this, I will do well to remind myself to make this more about the journey than the destination.
Thanks for candidly sharing your story and inspiring us all to strive for a better future in public health!