How motivation can fix public systems | Abhishek Gopalka

翻译人员: Shengmin Huang 校对人员: Yolanda Zhang

Take a minute

花上一分钟，

and think of yourself as the leader of a country.

把自己想象成一国领袖。

And let's say one of your biggest priorities

假如你最首要的任务

is to provide your citizens with high-quality healthcare.

是为贵国公民提供 高质量的医疗保健。

How would you go about it?

你会如何着手？

Build more hospitals?

建立更多医院？

Open more medical colleges?

开办更多医学院？

Invest in clinical innovation?

投资医疗创新？

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

但如果贵国的健康系统 已经烂到根子里了，

Whether it's doctor absenteeism,

医生玩忽职守，

drug stock-outs or poor quality of care.

药物供不应求， 亦或是护理质量堪忧。

Where would you start then?

你将从何下手？

I'm a management consultant,

我是一名管理咨询师，

and for the last three years,

在过去三年里，

I've been working on a project

我一直致力于一项

to improve the public heath system of Rajasthan,

改善印度拉贾斯坦邦

a state in India.

公共健康系统的项目。

And during the course of the project,

而在项目进行过程中，

we actually discovered something profound.

我们确实发现了一些深刻的问题。

More doctors, better facilities, clinical innovation --

更多医生、更好的设施、 医疗创新——

they are all important.

这些都重要。

But nothing changes without one key ingredient.

但这些东西都缺少了一项 能发挥作用的关键要素。

Motivation.

发自内心的动力。

But motivation is a tricky thing.

但动力是个棘手的玩意儿。

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

如果你带过团队、养过孩子 或是试图改变个人习惯，

you know that motivation doesn't just appear.

你就会明白 动力不会凭空出现。

Something has to change to make you care.

有些事情得改变了 你才会去在意。

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

要说有什么事 我们全人类都在意，

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

就是对自己能被社会瞩目 发自内心的渴望。

So that's exactly what we did.

于是我们借此入手。

We decided to focus on the citizen:

我们决定聚焦于本国公民——

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

那些本就应该由 机关系统服务的人。

And today, I'd like to tell you

而今天，我将告诉你们

how Rajasthan has transformed its public health system dramatically

拉贾斯坦公共健康系统 的急剧转型，

by using the citizen to trigger motivation.

其动力是如何由公民激发的。

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

拉贾斯坦是当今印度 最大的邦州之一，

with a population of nearly 80 million.

有着近八千万的人口。

That's larger than the United Kingdom.

比英国全国还多。

But the similarities probably end there.

但可比之处仅此而已。

In 2016, when my team was called in

当我的团队在2016年受邀

to start working with the public health system of Rajasthan,

到拉贾斯坦开始参与 公共健康系统工作时，

we found it in a state of crisis.

我们发现它已 处于危机状态了。

For example, the neonatal mortality rate --

就拿记录了未满一个月就夭折

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

的新生儿死亡率来说，

was 10 times higher than that of the UK.

该数字高出英国新生儿 死亡率十倍之多。

No wonder then that citizens were saying,

难怪本国公民会说：

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

“嘿，我可不想去公立医疗场所。”

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

在印度，你如果要到 公立医疗场所看病，

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

你就得去“PHC”， 也就是“初级保健中心”。

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

一所初级保健中心应有能力 每天接待至少40名来访病人。

But in Rajasthan, only one out of four PHCs

而拉贾斯坦的初级保健中心 每四所里只有一所

was seeing this minimum number of patients.

能达到这个病人接待量的下限。

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

换句话说，人们对该系统 已然不抱希望。

When we delved deeper,

当我们更深入地进行研究时，

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

我们意识到问责机制的缺失 正是问题的核心。

Picture this.

想象一下，

Sudha, a daily-wage earner,

苏达，一名日薪工作者，

realizes that her one-year-old daughter

发现她一岁大的女儿

is suffering from uncontrollable dysentery.

闹了痢疾令她束手无策。

So she decides to take the day off.

于是她决定请一天假。

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

这将损失大约350卢比， 也就是5美元的日薪。

And she picks up her daughter in her arms

而当她怀抱着她的女儿

and walks for five kilometers to the government PHC.

徒步五千米来到 政府的初级保健中心，

But the doctor isn't there.

却发现医生不在。

So she takes the next day off, again,

所以第二天她也得请假，

and comes back to the PHC.

再次来到初级保健中心。

This time, the doctor is there,

这一次，医生在是在，

but the pharmacist tells her

但药剂师告诉她，

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

由于他们忘了及时订药，

because they forgot to reorder them on time.

她有权免费领取的 药物已经用完了。

So now, she rushes to the private medical center,

于是现在，她赶忙跑向 私立医疗中心，

and as she's rushing there,

而在她快马加鞭的同时，

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

还要眼看着女儿的病情 随着时间流逝而恶化。

she can't help but wonder

她不禁会想，

if she should have gone to the private medical center

自己是否在一开始就该直接去

in the first place

私立医疗中心，

and payed the 350 rupees for the consultation and drugs.

并支付350卢比的 门诊与医药费。

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

这无人负责的 耸人的系统失职

Costing time, money and heartache to Sudha.

害苏达损失了时间、金钱， 还令她备受煎熬。

And this is something that just had to be fixed.

要查补的正是此类漏缺。

Now, as all good consultants,

作为合格的咨询师，

we decided that data-driven reviews

我们认为必须以 由数据导向的审查

had to be the answer to improve accountability.

来应对问责机制的改善问题。

So we created these fancy performance dashboards

所以我们创建了这些 花哨的绩效展示牌

to help make the review meetings of the health department

去帮助健康部门能更高效地

much more effective.

展开审查会议。

But nothing changed.

可无济于事。

Discussion after discussion,

一次又一次的讨论、

meeting after meeting,

一场又一场的会议，

nothing changed.

全都无济于事。

And that's when it struck me.

这才给了我当头棒喝。

You see, public systems

要知道，一直以来

have always been governed through internal mechanisms,

各项公共系统都是 由这些审查会议之类的

like review meetings.

内部机制来监管。

And over time,

而长此以往，

their accountability to the citizen has been diluted.

外界公民对他们问责的 作用就被淡化了。

So why not bring the citizen back into the equation,

如果能通过公民承诺， 让公民们再次起到作用，

perhaps by using the citizen promises?

又有何不可呢？

Couldn't that trigger motivation?

这样不就可以激发人们的动力了吗？

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

我们的启动方案 被我称为“咖啡店策略”。

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

你们应该在咖啡店里 见过这样的指示牌，

which says,

上面写着：

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

“如果您没收到收据， 咖啡就算您免费。”

Now, the cashier has no option

这样一来，收银员就不得不

but to give you a receipt each time.

在每次结账时都要给你开收据。

So we took this strategy and applied it to Rajasthan.

因此我们将此策略 应用在了拉贾斯坦。

We worked with the government

我们与政府合作了一项

on a program to revive 300 PHCs across the state,

在全州范围内恢复300家 初级保健中心的计划，

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

还让他们将每一条公民承诺 都清清楚楚地印在了墙上。

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

“我们向您保证 您每次都能看上医生。”

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

“我们向您保证您每次都能 领取到您的免费药物。”

"We assure you

“我们向您保证

that you will get your free diagnostics each time."

您每次都能接受免费诊断。”

And finally, we worked with elected representatives

最后，我们还与民选代表合作，

to launch these revived PHCs,

帮这些恢复的 初级保健中心重新开业，

who shared the citizen promises with the community

让它们大张旗鼓地 将这些公民承诺

with a lot of fanfare.

推广至社区。

Now, the promise was out there in the open.

现在，这些承诺已世人皆知。

Failure would be embarrassing.

食言就意味着蒙羞。

The system had to start delivering.

机关系统必须开始出力。

And deliver it did.

他们也确实出力了。

Doctor availability went up,

医生出勤率有所上升，

medicines came on hand,

药物一应俱全，

and as a result,

而结果就是

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

不到一年，病人来访率 就提升了两成。

The public health system was getting back into business.

公共健康系统正在重回正轨。

But there was still a long distance to go.

然而前路漫漫，

Change isn't that easy.

改变并非一蹴而就。

An exasperated doctor once told me,

曾有一位恼怒的医生告诉我，

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

“我是真心希望改变 我们社区的妇产保健，

but I just don't have enough nurses."

但苦于护士人手不足。”

Now, resources like nurses

目前，像护士这类资源

are actually controlled by administrative officers

实际由行政官员掌握，

who the doctors report to.

医生也得向他们汇报。

And while the doctors were now motivated,

现在医生们是有动力了，

the administrative officers simply weren't motivated enough

这些行政官员 却没有足够的动力

to help the doctors.

去帮助医生。

This is where the head of the public health department,

对此，公共健康部门负责人

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

维努·笈多女士提出了一条妙计。

A monthly ranking of all districts.

所有地区每月都要排名。

And this ranking would assess the performance of every district

该排名会对各地区 在每项重大疾病

on each major disease

和每次重要执行程序上的

and each major procedure.

绩效做评估。

But here's the best part.

而最妙的是：

We made the ranking go public.

我们公开了排名。

We put the ranking on the website,

我们将排名放到了互联网上，

we put the ranking on social media,

放到了社交媒体上，

and before you knew it, the media got involved,

不等你反应过来， 媒体就都参与进来了，

with newspaper articles on which districts were doing well

通过报刊文章

点评着各地区表现孰好孰坏。

and which ones weren't.

And we didn't just want the rankings

我们不只是希望这些排名

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

能影响表现最好 与最次的地区，

We wanted the rankings to motivate every district.

我们希望它能激起 所有地区的动力。

So we took inspiration from soccer leagues,

于是我们从足球联赛中获取灵感，

and created a three-tiered ranking system,

创建了一套有着三级排名 的排名系统，

whereby every quarter,

每个季度，

if a district's performance were to decline,

如果某个地区的绩效下降了，

you could get relegated to the lower tier.

那就将其排名降低。

But if the district's performance were to improve,

而如果一个地区的绩效上升了，

you could get promoted to the premiere league.

就将其提升至最高档。

The rankings were a big success.

这套排名系统大获成功。

It generated tremendous excitement,

人心大振，

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

各地区开始相互竞争， 争当典范。

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

仔细想想，也不出奇。

If the performance data is only being reviewed by your manager

如果只是由你的上级 在内部环境里

in internal settings,

审核绩效数据，

it simply isn't motivating enough.

动力自然是不够的。

But if that data is out there,

但如果数据公开了、

in the open, for the community to see,

对外了、全社区都能看到了，

that's a very different picture.

事情就会大不一样。

That just unlocks a competitive spirit

这样一来释放了潜藏在

which is inherent in each and every one of us.

我们所有人体内的竞争精神。

So now, when you put these two together,

于是乎，当你们将

the coffee shop strategy and public competition,

咖啡店策略与公开竞争合二为一，

you now had a public health system

就有了一个对于提升公民健康

which was significantly more motivated to improve citizen health.

今非昔比、动力十足的 公共健康系统。

And now that you had a more motivated health system,

既然现在的公共健康系统 背后充满动力了，

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

它就比过去更需要获得支持。

Because now, there is a pull for the support,

因为现在，无论是系统的

whether it's resources, data or skill building.

资源、数据、还是技术积累， 相应的支持都要跟上来。

Let me share an example.

我来分享个例子。

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

有一次我在阿杰梅尔区 参加地区会议。

This is one of the districts that had been rising rapidly

这正是其中一个排名

飞速上升的地区。

in the rankings.

And there were a group of passionate doctors

会议上有一伙热忱的医生

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

在为如何更好地支持 他们的团队出谋划策。

One of the doctors had up-skilled health workers

其中一位医生 让业务娴熟的护工

to tackle the problem of nurse shortages.

来填补护士的短缺。

Another doctor was using WhatsApp in creative ways

另一位医生妙用 通讯软件WhatsApp

to share information and ideas with his frontline workers.

来分享一线医护人员 的消息与想法。

For example,

例如：

where are the children who are missing from immunization?

“尚未接种疫苗的孩子们都在哪儿？”

And how do you convince the mothers

“又要如何说服那些母亲们

to actually bring their children for immunization?

把自己的孩子带来接种疫苗？”

And because their teams were now significantly motivated,

正因为他们的团队 现在动力十足，

they were simply lapping up the support,

他们对支持来者不拒，

because they wanted to perform better and better.

以求绩效更上一层楼。

Broken systems certainly need more resources and tools.

支离破碎的系统 固然需要更多资源与工具，

But they won't drive much impact

但如果不先把动力点燃，

if you don't first address the motivation challenge.

那些东西只会收效甚微。

Once the motivation tide begins to shift,

一旦动力的浪潮开始涌动，

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

你才能真正获得 来自资源与工具的回报。

But I still haven't answered a key question.

但有个关键问题 我还没回答：

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

拉贾斯坦的公共健康系统 绩效如何？

In 2016, when our work began,

2016年，在我们的工作启动时，

the government of India and the World Bank

印度政府与世界银行

came out with a public health index.

给出了一份公共健康指标。

Rajasthan was ranked 20th out of 21 large states.

在21个大邦之中 拉贾斯坦排名第20位。

But in 2018,

但到了2018年，

when the next ranking came out,

次届排位公布时，

Rajasthan showed one of the highest improvements

拉贾斯坦一跃而上连升四位，

among all large states in India,

是印度各大邦中

leapfrogging four positions.

排名提升最大的邦。

For example, it showed one of the highest reductions

举个例子，其中一项 降低程度最大的指标

in neonatal mortality,

就是新生儿死亡率。

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

每年增加了3000个被拯救的新生儿。

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

一般来说，公共健康系统转型 旷日累时，可达数十年之久，

But this approach had delivered results

但这套方法仅两年

in two years.

就见效了。

But here's the best part.

而最棒的是，

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

我们研究的方法 并不仅限于拉贾斯坦。

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

实际上，这套利用公民 激发动力的方法

is not even limited to public health systems.

也并非仅限于公共健康系统。

I sincerely believe that if there is any public system,

我由衷地相信任何国家，

in any country,

任何公共系统，

that is in inertia,

如果缺乏活力，

then we need to bring back the motivation.

都需要找回其动力。

And a great way to trigger the motivation

为公民提高透明度

is to increase transparency to the citizen.

就是激发动力的不二法门。

We can do this with education

在教育，卫生

and sanitation and even political representation.

乃至政治代表方面 我们都能用上。

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

公立学校可以根据学生的 入学人数进行公开评比。

Cities and towns, on the basis of cleanliness.

城镇可以对比清洁度。

And politicians on the basis of a scorecard

而政客们可以 就他们提升公民

of how exactly they're improving citizen lives.

生活质量的程度评分。

There are many broken systems out there in the world.

世上支离破碎的系统还有很多。

We need to bring back their motivation.

我们要让它们重拾动力。

The citizen is waiting.

那里的公民望眼欲穿。

We must act today.

我们的行动刻不容缓。

Thank you very much.

非常感谢。

(Applause)

（掌声）