How motivation can fix public systems | Abhishek Gopalka

Prevodilac: Ivana Krivokuća Lektor: Kristina Radosavljević

Take a minute

Hajde na trenutak

and think of yourself as the leader of a country.

zamislite da ste vođa neke zemlje.

And let's say one of your biggest priorities

I recimo da je jedan od vaših najvećih prioriteta

is to provide your citizens with high-quality healthcare.

da svojim građanima pružite visokokvalitetnu zdravstvenu zaštitu.

How would you go about it?

Kako biste to uradili?

Build more hospitals?

Da li biste izgradili više bolnica?

Open more medical colleges?

Otvorili više medicinskih fakulteta?

Invest in clinical innovation?

Ulagali u kliničke inovacije?

But what if your country's health system was fundamentally broken?

Ali šta ako je zdravstveni sistem u vašoj zemlji suštinski poremećen?

Whether it's doctor absenteeism,

Bilo da se radi o odsustvu lekara,

drug stock-outs or poor quality of care.

nedostatku lekova ili lošem kvalitetu nege.

Where would you start then?

Odakle biste počeli?

I'm a management consultant,

Ja sam konsultant u menadžmentu,

and for the last three years,

i protekle tri godine

I've been working on a project

radim na projektu

to improve the public heath system of Rajasthan,

poboljšanja sistema javnog zdravlja u Radžastanu,

a state in India.

državi u Indiji.

And during the course of the project,

Za vreme trajanja ovog projekta,

we actually discovered something profound.

otkrili smo nešto vrlo značajno.

More doctors, better facilities, clinical innovation --

Veći broj doktora, bolje ustanove, kliničke inovacije -

they are all important.

sve to je bitno.

But nothing changes without one key ingredient.

Ali ništa se ne menja bez jednog ključnog sastojka.

Motivation.

Motivacije.

But motivation is a tricky thing.

Ali motivacija je nezgodna stvar.

If you've led a team, raised a child or tried to change a personal habit,

Ako ste predvodili tim, odgajali dete ili pokušali da promenite ličnu naviku,

you know that motivation doesn't just appear.

znate da se motivacija ne javlja tek tako.

Something has to change to make you care.

Nešto mora da se promeni da bi vas nateralo da vam bude stalo.

And if there's one thing that all of us humans care about,

A ako postoji nešto do čega je nama ljudima stalo,

it's an inherent desire to shine in front of society.

to je urođena želja da zablistamo pred društvom.

So that's exactly what we did.

Zato smo upravo to uradili.

We decided to focus on the citizen:

Rešili smo da se fokusiramo na građane:

the people who the system was supposed to serve in the first place.

ljude kojima je sistem prvenstveno namenjen da služi.

And today, I'd like to tell you

Danas bih hteo da vam ispričam

how Rajasthan has transformed its public health system dramatically

kako je Radžastan drastično transformisao svoj sistem javnog zdravlja

by using the citizen to trigger motivation.

tako što je iskoristio građane da podstakne motivaciju.

Now, Rajasthan is one of India's largest states,

Danas je Radžastan jedna od najvećih država Indije,

with a population of nearly 80 million.

sa populacijom od skoro 80 miliona.

That's larger than the United Kingdom.

To je više nego u Ujedinjenom Kraljevstvu.

But the similarities probably end there.

Ali tu verovatno svaka sličnost prestaje.

In 2016, when my team was called in

Godine 2016, kada su moj tim pozvali

to start working with the public health system of Rajasthan,

da počne da radi na sistemu javnog zdravlja u Radžastanu,

we found it in a state of crisis.

našli smo ga u stanju krize.

For example, the neonatal mortality rate --

Na primer, stopa neonatalnog mortaliteta -

that's the number of newborns who die before their first month birthday --

to je broj novorođenčadi koja umre pre nego što napuni mesec dana -

was 10 times higher than that of the UK.

bila je 10 puta veća nego u UK.

No wonder then that citizens were saying,

Nije ni čudo što su građani govorili:

"Hey, I don't want to go to a public health facility."

„Hej, neću da idem u zdravstvenu ustanovu.“

In India, if you wanted to see a doctor in a public health facility,

U Indiji, ako biste hteli da odete kod lekara u ustanovi javnog zdravlja,

you would go to a "PHC," or "primary health center."

išli biste u „PZC“ ili „primarni zdravstveni centar“.

And at least 40 patients are expected to go to a PHC every day.

Predviđeno je da najmanje 40 pacijenata svakoga dana dolazi u PZC.

But in Rajasthan, only one out of four PHCs

Ali u Radžastanu samo jedan od četiri PZC-a

was seeing this minimum number of patients.

primi taj minimalni broj pacijenata.

In other words, people had lost faith in the system.

Drugim rečima, ljudi su izgubili veru u sistem.

When we delved deeper,

Kada smo zašli dublje,

we realized that lack of accountability is at the core of it.

shvatili smo da je nedostatak odgovornosti u srži svega toga.

Picture this.

Zamislite ovo.

Sudha, a daily-wage earner,

Sudha, nadničarka,

realizes that her one-year-old daughter

shvata da njena godinu dana stara ćerka

is suffering from uncontrollable dysentery.

boluje od uznapredovale dizenterije.

So she decides to take the day off.

Zato reši da uzme slobodan dan.

That's a loss of about 350 rupees or five dollars.

To je gubitak od oko 350 rupija ili pet dolara.

And she picks up her daughter in her arms

Podiže ćerku u naručje

and walks for five kilometers to the government PHC.

i pešači pet kilometara do državnog PZC-a.

But the doctor isn't there.

Ali doktor nije tamo.

So she takes the next day off, again,

Zato ona ponovo uzima slobodan dan

and comes back to the PHC.

i vraća se u PZC.

This time, the doctor is there,

Ovoga puta je doktor tu,

but the pharmacist tells her

ali joj farmaceut saopštava

that the free drugs that she's entitled to have run out,

da je nestalo besplatnih lekova na koje ona ima pravo,

because they forgot to reorder them on time.

jer su zaboravili da ih naruče na vreme.

So now, she rushes to the private medical center,

Tako ona sada juri u privatni medicinski centar,

and as she's rushing there,

i dok žuri tamo

looking at her daughter's condition worsening with every passing hour,

i gleda kako se stanje njene ćerke pogoršava sa svakim satom,

she can't help but wonder

ne može da se ne zapita

if she should have gone to the private medical center

da li je trebalo da odmah ode u privatni medicinski centar

in the first place

and payed the 350 rupees for the consultation and drugs.

i plati 350 rupija za pregled i lekove.

No one is held accountable for this incredible failure of the system.

Niko ne snosi odgovornost za ovaj neverovatan neuspeh sistema.

Costing time, money and heartache to Sudha.

A to Sudhi oduzima vreme i novac i povređuje je.

And this is something that just had to be fixed.

To je prosto moralo da se popravi.

Now, as all good consultants,

Kao svi dobri konsultanti,

we decided that data-driven reviews

odlučili smo da prikazi zasnovani na podacima

had to be the answer to improve accountability.

moraju biti odgovor za poboljšanje odgovornosti.

So we created these fancy performance dashboards

Tako smo napravili sofisticirane table učinka

to help make the review meetings of the health department

kako bi inspekcijski sastanci odeljenja za zdravlje

much more effective.

postali mnogo efikasniji.

But nothing changed.

Ali ništa se nije promenilo.

Discussion after discussion,

Rasprava za raspravom,

meeting after meeting,

sastanak za sastankom,

nothing changed.

ništa se nije menjalo.

And that's when it struck me.

Tada mi je sinulo.

You see, public systems

Vidite, javnim sistemima

have always been governed through internal mechanisms,

se oduvek upravljalo kroz unutrašnje mehanizme

like review meetings.

kao što su inspekcijski sastanci.

And over time,

Vremenom,

their accountability to the citizen has been diluted.

njihova odgovornost prema građanima je oslabila.

So why not bring the citizen back into the equation,

Pa zašto ne bismo vratili građane u jednačinu,

perhaps by using the citizen promises?

možda pomoću obećanja građanima?

Couldn't that trigger motivation?

Zar to ne bi moglo da pokrene motivaciju?

We started with what I like to call the coffee shop strategy.

Počeli smo nečim što volim da zovem strategijom kafića.

You've probably seen one of these signs in a coffee shop,

Verovatno ste videli neki od ovih znakova u kafiću

which says,

koji kaže:

"If you don't get your receipt, the coffee is free."

„Ako ne dobijete račun, kafa je besplatna.“

Now, the cashier has no option

Sada kasir nema izbora

but to give you a receipt each time.

nego da vam svaki put da račun.

So we took this strategy and applied it to Rajasthan.

Uzeli smo tu strategiju i primenili je na Radžastan.

We worked with the government

Radili smo sa vladom

on a program to revive 300 PHCs across the state,

na programu oživljavanja 300 PZC-a širom zemlje,

and we got them to paint very clear citizen promises along the wall.

i rekli smo im da po zidu nacrtaju vrlo jasna obećanja građanima.

"We assure you that you will have a doctor each time."

„Uveravamo vas da će vas doktor primiti svaki put.“

"We assure you that you will get your free drugs each time."

„Uveravamo vas da ćete svaki put dobiti svoje besplatne lekove.“

"We assure you

„Uveravamo vas

that you will get your free diagnostics each time."

da ćete svaki put dobiti besplatno dijagnostikovanje.“

And finally, we worked with elected representatives

I najzad, radili smo sa izabranim predstavnicima

to launch these revived PHCs,

na pokretanju tih oživljenih PZC-a,

who shared the citizen promises with the community

a oni su pred zajednicom iznosili obećanja građanima

with a lot of fanfare.

uz mnogo pompe.

Now, the promise was out there in the open.

Sada je obećanje stajalo na otvorenom.

Failure would be embarrassing.

Neuspeh bi bio sramotan.

The system had to start delivering.

Sistem je morao da počne da ispunjava obećanja.

And deliver it did.

I tako je i bilo.

Doctor availability went up,

Doktori su bili više dostupni,

medicines came on hand,

lekovi su bili pri ruci,

and as a result,

i, kao rezultat toga,

patient visits went up by 20 percent in less than a year.

broj poseta pacijenata se povećao za 20 procenata za manje od jedne godine.

The public health system was getting back into business.

Sistem javnog zdravlja bio je ponovo u akciji.

But there was still a long distance to go.

Ali još je ostalo preći dug put.

Change isn't that easy.

Sprovesti promene nije tako lako.

An exasperated doctor once told me,

Jedan ogorčeni doktor mi je jednom rekao:

"I really want to transform the maternal health in my community,

„Zaista želim da transformišem zdravstvenu zaštitu majki u zajednici,

but I just don't have enough nurses."

ali prosto nemam dovoljno medicinskih sestara.“

Now, resources like nurses

Resurse kao što su medicinske sestre

are actually controlled by administrative officers

zapravo kontrolišu administrativni službenici

who the doctors report to.

kojima doktori podnose izveštaj.

And while the doctors were now motivated,

I mada su lekari sada bili motivisani,

the administrative officers simply weren't motivated enough

administrativni službenici jednostavno nisu bili dovoljno motivisani

to help the doctors.

da pomognu doktorima.

This is where the head of the public health department,

Ovde je šef odeljenja za javno zdravlje,

Ms. Veenu Gupta, came up with a brilliant idea.

gđica Vinu Gupta, došla na briljantnu ideju.

A monthly ranking of all districts.

Mesečno rangiranje svih okruga.

And this ranking would assess the performance of every district

A to rangiranje bi procenjivalo učinak svakog okruga

on each major disease

vezan za svako veće oboljenje

and each major procedure.

i svaku veću proceduru.

But here's the best part.

Ali evo šta je najbolji deo.

We made the ranking go public.

Rangiranja su javno objavljivana.

We put the ranking on the website,

Okačili smo rangiranja na veb-sajt,

we put the ranking on social media,

stavili ih na društvene mreže,

and before you knew it, the media got involved,

i za tren oka su se angažovali mediji

with newspaper articles on which districts were doing well

sa novinskim člancima o tome kojim okruzima ide dobro,

and which ones weren't.

a kojima ne.

And we didn't just want the rankings

Nismo samo hteli da rangiranja

to impact the best- and the worst-performing districts.

utiču na okruge sa najboljim i najgorim učinkom.

We wanted the rankings to motivate every district.

Želeli smo da rangiranja motivišu svaki okrug.

So we took inspiration from soccer leagues,

Zato smo preuzeli inspiraciju od fudbalskih liga

and created a three-tiered ranking system,

i napravili sistem rangiranja sa tri nivoa,

whereby every quarter,

pri čemu biste svakog kvartala,

if a district's performance were to decline,

ako se smanji učinak okruga,

you could get relegated to the lower tier.

mogli da padnete na niži nivo.

But if the district's performance were to improve,

Ali ako se učinak okruga poboljša,

you could get promoted to the premiere league.

možete biti unapređeni u premijer ligu.

The rankings were a big success.

Rangiranja su ostvarila veliki uspeh.

It generated tremendous excitement,

Stvorila su ogromno uzbuđenje,

and districts began vying with each other to be known as exemplars.

a okruzi su počeli da se međusobno nadmeću kako bi se utvrdili kao uzorni primeri.

It's actually very simple, if you think about it.

To je zapravo vrlo jednostavno, ako razmislite o tome.

If the performance data is only being reviewed by your manager

Ako podatke o učinku pregleda samo vaš menadžer

in internal settings,

u internim uslovima,

it simply isn't motivating enough.

to jednostavno ne motiviše dovoljno.

But if that data is out there,

Ali ako su podaci o tome predstavljeni

in the open, for the community to see,

na otvorenom, tako da zajednica može da ih vidi,

that's a very different picture.

stvari su sasvim drugačije.

That just unlocks a competitive spirit

To oslobađa takmičarski duh

which is inherent in each and every one of us.

koji je urođen svima nama.

So now, when you put these two together,

Kada spojite ta dva,

the coffee shop strategy and public competition,

strategiju kafića i javno nadmetanje,

you now had a public health system

dobili ste sistem javnog zdravlja

which was significantly more motivated to improve citizen health.

koji je znatno motivisaniji da poboljša zdravlje građana.

And now that you had a more motivated health system,

I sada kada imate motivisaniji sistem zdravstva,

it was actually a system that was now much more ready for support.

to zapravo postaje sistem koji je mnogo spremniji da pruži podršku.

Because now, there is a pull for the support,

Jer sada postoji sila koja navodi na podršku,

whether it's resources, data or skill building.

bilo da se radi o resursima, podacima ili razvijanju veština.

Let me share an example.

Izneću jedan primer.

I was once at a district meeting in the district of Ajmer.

Jednom sam bio na okružnom sastanku okruga Adžmer.

This is one of the districts that had been rising rapidly

To je jedan od okruga koji je brzo napredovao

in the rankings.

na rang-listama.

And there were a group of passionate doctors

Tu je bila grupa strastvenih doktora

who were discussing ideas on how to better support their teams.

koji su razmatrali ideje o tome kako da bolje podrže svoje timove.

One of the doctors had up-skilled health workers

Jedan od lekara je dokvalifikovao zdravstvene radnike

to tackle the problem of nurse shortages.

da bi rešio problem nedostatka medicinskih sestara.

Another doctor was using WhatsApp in creative ways

Drugi doktor je koristio Votsap na kreativne načine

to share information and ideas with his frontline workers.

da bi delio informacije i ideje sa svojim radnicima.

For example,

Na primer,

where are the children who are missing from immunization?

gde su deca koja su propustila vakcinaciju?

And how do you convince the mothers

I kako ubediti majke

to actually bring their children for immunization?

da dovedu decu na vakcinisanje?

And because their teams were now significantly motivated,

A pošto su njihovi timovi sada bili značajno motivisani,

they were simply lapping up the support,

prosto su jedva dočekali podršku,

because they wanted to perform better and better.

jer su hteli da postignu što više.

Broken systems certainly need more resources and tools.

Lošim sistemima svakako treba više resursa i alata.

But they won't drive much impact

Ali to neće imati mnogo uticaja

if you don't first address the motivation challenge.

ako se najpre ne pozabavite problemom motivacije.

Once the motivation tide begins to shift,

Kada plima motivacije počne da se menja,

that's when you get the real returns off resources and tools.

tada zgrćete pravi dobitak od resursa i alata.

But I still haven't answered a key question.

Ali i dalje nisam odgovorio na ključno pitanje.

What happened to the performance of Rajasthan's public health system?

Šta se dogodilo sa učinkom sistema javnog zdravstva u Radžastanu?

In 2016, when our work began,

Godine 2016, kada smo počeli sa radom,

the government of India and the World Bank

vlada Indije i Svetska banka

came out with a public health index.

prikazali su indeks javnog zdravlja.

Rajasthan was ranked 20th out of 21 large states.

Radžastan je bio na 20. mestu od 21 velike države.

But in 2018,

Ali 2018. godine,

when the next ranking came out,

kada je objavljena sledeća rang-lista,

Rajasthan showed one of the highest improvements

Radžastan je pokazao jedno od najboljih poboljšanja

among all large states in India,

među svim većim državama u Indiji,

leapfrogging four positions.

skočivši za četiri mesta.

For example, it showed one of the highest reductions

Na primer, pokazao je jedno od najvećih smanjenja

in neonatal mortality,

neonatalnog mortaliteta,

with 3,000 additional newborn lives being saved every year.

pri čemu se svake godine spasi dodatnih 3 000 novorođenčadi.

Typically, public health transformations take a long time, even decades.

Transformacije u javnom zdravstvu obično traju dugo, čak decenijama.

But this approach had delivered results

Ali ovaj pristup je ostvario rezultate

in two years.

za dve godine.

But here's the best part.

A evo najboljeg dela.

There is actually nothing Rajasthan-specific about what we learned.

U ovome što smo naučili nema ničeg što posebno važi samo za Radžastan.

In fact, this approach of using the citizen to trigger motivation

Zapravo, ovaj pristup korišćenja građana za pokretanje motivacije

is not even limited to public health systems.

nije čak ni ograničen na sisteme javnog zdravlja.

I sincerely believe that if there is any public system,

Iskreno verujem da, ako postoji neki javni sistem,

in any country,

u bilo kojoj zemlji,

that is in inertia,

koji je u stanju inercije,

then we need to bring back the motivation.

moramo uvesti motivaciju.

And a great way to trigger the motivation

A sjajan način za pokretanje motivacije

is to increase transparency to the citizen.

jeste povećanje transparentnosti za građane.

We can do this with education

To možemo primeniti u obrazovanju, sanitarnim merama,

and sanitation and even political representation.

pa čak i sa političkim predstavnicima.

Government schools can compete publicly on the basis of student enrollment.

Državne škole se mogu javno takmičiti na osnovu upisa učenika.

Cities and towns, on the basis of cleanliness.

Veći i manji gradovi to mogu na osnovu čistoće.

And politicians on the basis of a scorecard

A političari na osnovu rezultata

of how exactly they're improving citizen lives.

koji tačno pokazuju kako poboljšavaju živote građana.

There are many broken systems out there in the world.

Mnogo je loših sistema u svetu.

We need to bring back their motivation.

Moramo im vratiti motivaciju.

The citizen is waiting.

Građani čekaju.

We must act today.

Moramo nešto preduzeti danas.

Thank you very much.

Mnogo vam hvala.

(Applause)

(Aplauz)