Rabin Martin CEO Jeff Sturchio on A question of design: The role of donations in advancing greater access to health for all
Over the course of two days last week, at the 2018 Global Health Policy Forum, PQMD had the pleasure of exploring a variety of new perspectives and approaches to some of the most challenging issues facing the global drug, device, and service donations community, affecting health system strengthening, human mobility & refugees, and the unintended consequences of donations, among others.
Rabin Martin’s President & CEO Jeff Sturchio provided the keynote address on the role of donations in advancing greater access to health for all on the morning of Wednesday, April 11. Below is an edited transcript of his remarks.
Jeff Sturchio Keynote Address
Yesterday’s Executive Forum gave us great food for thought on the role of donations in advancing greater access to healthcare, the overall theme of our meeting, as PQMD Executive Director Elizabeth Ashbourne reminded us. The discussion yesterday rightly focused on what needs to be done to avoid dependency and to foster sustainability in response to both natural disasters and humanitarian emergencies, neither of which is in short supply.
These remarks sketch an overarching framework focusing on the idea of resilience, which will be helpful in framing our collective conversation today. I realize that there are centuries of relevant experience gathered in this room, so I’m just hoping to suggest some themes that will resonate with you and catalyze discussion.
In a fascinating presentation to the Arthur W. Page Society recently, Tim Brown, the head of IDEO Design, outlined the design process that he and his colleagues use to generate creative solutions to complex problems. He cited Nobel Laureate Herbert Simon, whose definition of design was “whenever we are shaping the world to meet our needs,” which seems relevant to the task before PQMD members. To do this successfully, Brown said, one begins by talking to people and understanding their needs. Often, we then jump immediately to thinking of solutions to meet those needs. But the critical first step, he argued, is to frame the central question in the right way, then build prototype solutions, test them out, and learn through this process until you find something that works.
So, let me start by trying to frame the central question for us, based in part on yesterday’s excellent conversation. This is where I think the notion of resilience provides important perspective. Margaret Kruk of the Harvard School of Public Health and Michael Myers of the Rockefeller Foundation and their colleagues have defined five key characteristics of resilient health systems, based in part on the global response to the 2014 Ebola outbreak in West Africa.
They define health system resilience as “the capacity of health actors, institutions and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it.” Resilient health systems deliver “improved performance in both bad times and good.” Resilient health systems are aware, diverse, self-regulating, integrated and adaptive.
The last of these characteristics seems particularly important for our purposes today. Adaptive systems can adjust and enhance performance in times of crisis as well as in normal times. They offer the opportunity of respond to a wide range of conditions, including the health needs of refugees and internally displaced persons, as well as a path for institutionalizing benefits for populations after crises have passed.
This perspective on resiliency seems appropriate for our thinking about how the PQMD network can improve the impact you’re having in responding to critical needs, building stronger health systems and improving population health.
One final definition that I think is also helpful. In a 2016 commentary on health system strengthening, universal health coverage, health security and resilience in the Bulletin of the World Health Organization, Joseph Kutzin and Susan P. Sparkes cite the definition from the 2008 Talinn Charter on health systems for health and wealth: a health system is “the ensemble of all public and private organizations, institutions, and resources mandated to improve, maintain or restore health.”
I was struck by their insistence that health systems involve both public and private organizations working together to achieve the goal of better health for all. That perspective – one that encourages us to think of health systems as ecosystems of different actors bringing complementary skills and resources together to achieve more than the sum of the parts – is also critical to the work that PQMD does to help create sustainable health systems.
So, let’s pose the central framing question as: How can we best design resilient and sustainable health systems that draw on all available resources and expertise to improve health for all? I’d offer three critical themes to achieve this goal:
Among the issues discussed in yesterday’s Executive Forum was the often-fragmented nature of response to natural disasters or humanitarian emergencies and the disparities in access – to medicines, to information, to other health care resources – that often characterize the countries in which PQMD members work. To address those disparities and fragmentation, we need to take a systems approach to thinking about solutions to the problems that medical donations are intended to help solve. The empty “second shelf” doesn’t sit in a vacuum – it is the outcome of a connected chain of policies, practices and players that deliver health care to those who need, with greater or lesser efficiency. But I sometimes feel that we’re like the blind person confronted with an elephant – everyone touches a different part of the animal, but we don’t really understand the problem we’re facing in full.
Thinking more systematically about the interconnectedness of health systems will help us understand how to address disparities in access to achieve more equitable outcomes, how to use incentives to encourage more useful behaviors and better allocation of scarce resources, and how to encourage more effective cross-sectoral coordination and collaboration to improve the resilience of the system’s response to stress and crisis. It’s not coincidental that the Global Health Security Agenda has started with its Joint External Evaluations to analyze the strengths and weaknesses of each country’s public health system – the foundation for enhanced prevention, detection and response to pandemics and other emerging health crises.
Jane Nelson (Director, Corporate Responsibility Initiative at Harvard Kennedy School and Senior Fellow, Brookings Institution) made this point eloquently yesterday, and I completely agree about the importance of building coalitions and partnerships to implement cross-sectoral solutions that bring new thinking, new resources and new solutions to bear in ways that accomplish more together than individual members of a coalition can do on their own.
One of the most important lessons we’ve learned from a generation of work by PQMD members is that the most effective donation programs are those that are delivered through broad coalitions of partners, each of whom has a specified role within the network, all focused on achieving a common objective. Think for a minute about the Mectizan Donation Program, or the International Trachoma Initiative, or the Global Alliance to Eliminate Lymphatic Filariasis, or the effort to eliminate guinea worm, or polio eradication, to take just a few salient examples. These efforts have succeeded at a scale and scope, and level of sustainability, that skeptics predicted would never be possible – and they did so because they involve broad-based, cross-sectoral coalitions of partners in a coordinated effort to address key public health challenges.
Finally, a word about affected communities. Yesterday, Jeff Jordan, President & CEO of the Population Reference Bureau, asked an important question: Are we leaving the people out? That was provocative and right on target. At the end of the day, the ambitious efforts that PQMD members undertake to improve resilience and create more sustainable systems to respond to natural disasters and humanitarian emergencies won’t succeed unless they’re grounded in the needs and everyday realities of the communities that we hope to serve.
I’m reminded of a body of work among development economists like Esther Duflo, who wrote Poor Economics with her colleague Abhijit Bhanerji, and the book Portfolios of the Poor, by Daryl Collins and colleagues, which start from the principle that poor people have agency and are just as creative and resourceful about finding resources and making choices to meet their needs for food, shelter and health care as those with greater access to resources. We should be humble about learning from their experiences, exploring their solutions to the challenges they face in everyday life, and designing interventions that can bring additional tools and resources to bear in solving the needs they express – but not assume that our view, often from half a world away, is more likely to lead to sustainable change.
Again, this is a lesson learned from a generation of best practice by PQMD members and your partners, so in a sense I’m just highlighting something you already know. But it’s such a fundamental principle of the collective work we do that I thought it important to emphasize here.
I hope that these perspectives have been helpful to think about the big questions you face in trying to optimize the impact of your work to advance greater access to healthcare through humanitarian action, shared values and health systems strengthening. The role of cross-sector networks like PQMD is absolutely central to making the world a better place and helping us move toward more resilient and sustainable health systems.
Let me close with a quotation from Jonathan Quick, until recently the CEO of Management Sciences for Health, and the author of a new book on The End of Epidemics, which I recommend highly. Jono offers a set of seven principles for improving the pandemic preparedness, which offer a vade mecum of hard-won wisdom. I won’t list all seven – which include the importance of innovation and collaborative transformation, as well as investing in resilience. But I love his first principle: “Lead as though the house is on fire!” That captures perfectly the mix of urgency and passion that I know characterizes how each of you approach the challenges you face in your work. It also captures the indispensable role that PQMD plays in helping the global community meet the challenge of designing resilience into more sustainable health systems that will improve health outcomes not just for the many in need today, but also for generations to come.
 For more on Tim Brown’s views on design, see his talk at TED Global 2009, “Designers – think big!” at https://www.ted.com/talks/tim_brown_urges_designers_to_think_big/transcript; Tim Brown and Jocelyn Wyatt, “Design thinking for social innovation,” Stanford Social Innovation Review, 8, no. 1 (Winter 2010): 29-43; and Tim Brown, Change by Design: How Design Thinking Transforms Organizations and Inspires Innovation (New York: Harper Business, 2009).
 Margaret E. Kruk, Michael Myers, S. Tornorlah Varpilah, Bernice T. Dahn, “What is a resilient health system? lessons from Ebola,” The Lancet, 385 (9 May 2015): 1910 – 1912; see also Margaret E. Kruk et al., “Building resilient health systems: a proposal for a resilience index,” BMJ (Clinical Research edition), 357 (23 May 2017): j2323: doi.org/10.1136/bmj.j2323
 Joseph Kutzin and Susan P. Sparkes, “Health systems strengthening, universal health coverage, health security and resilience,” Bulletin of the World Health Organization, 94 (February 2016): 2.
 E. Bell, J. W. Tappero, K. Ijaz et al. “Joint External Evaluation—development and scale-up of a global multisectoral health capacity evaluation process,” Emerging Infectious Diseases, 2017;23(13). doi:10.3201/eid2313.170949.
 Abhijit V. Banerjee and Esther Duflo, Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty (New York: Public Affairs, 2011); Daryl Collins, Jonathan Morduch, Stuart Rutherford, and Orlanda Ruthven, Portfolios of the Poor: How the World’s Poor Live on $2 a Day (Princeton, NJ: Princeton University Press, 2009).
 Jonathan D. Quick, with Bronwyn Fryer, The End of Epidemics: The Looming Threat to Humanity and How to Stop It (New York: St. Martin’s Press, 2018).