How motivation can fix public systems | Abhishek Gopalka

譯者: Lilian Chiu 審譯者: Tammy Yuting Chiang

Take a minute

花點時間，

and think of yourself as the leader of a country.

想像自己是國家領導人。

And let's say one of your biggest priorities

假設你的首要任務

is to provide your citizens with high-quality healthcare.

是提供高品質健康照護給你的人民。

How would you go about it?

你會如何著手？

Build more hospitals?

建造更多醫院？

Open more medical colleges?

開設更多醫學院？

Invest in clinical innovation?

投資醫療創新科技？

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

但，如果國家醫療體制在根本上 就出問題了呢？

Whether it's doctor absenteeism,

可能是醫生缺勤、

drug stock-outs or poor quality of care.

藥品缺貨，或照護品質不佳。

Where would you start then?

那你又該從何開始下手？

I'm a management consultant,

我是管理顧問，

and for the last three years,

過去三年，

I've been working on a project

我都在進行一個專案計畫，

to improve the public heath system of Rajasthan,

致力於改善印度拉賈斯坦邦的

a state in India.

公共醫療體制。

And during the course of the project,

在這個計畫的過程中，

we actually discovered something profound.

我們有了重大發現。

More doctors, better facilities, clinical innovation --

更多醫生、更好的設施、 醫療創新科技，

they are all important.

這些都很重要。

But nothing changes without one key ingredient.

但若少了一個關鍵要素， 體制就不會有任何改變。

Motivation.

動機。

But motivation is a tricky thing.

但動機的產生很微妙。

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

如果你曾經領導過團隊、 養育過孩子，

或嘗試過改變個人習慣，

you know that motivation doesn't just appear.

你就會知道動機不會無故出現。

Something has to change to make you care.

唯有某種改變發生， 你才會開始重視這件事。

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

如果有一件事是生而為人所重視的，

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

那就是在社會上出人頭地的渴望。

So that's exactly what we did.

所以，我們就這麼做了。

We decided to focus on the citizen:

我們決定專注於人民身上，

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

即照護系統最根本應該服務的對象。

And today, I'd like to tell you

今天，我要跟各位分享

how Rajasthan has transformed its public health system dramatically

拉賈斯坦邦的公共醫療體制 是如何大幅地

by using the citizen to trigger motivation.

透過人民來激發改變動機。

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

拉賈斯坦邦是印度最大的邦之一，

with a population of nearly 80 million.

人口近八千萬。

That's larger than the United Kingdom.

比英國人口還多。

But the similarities probably end there.

但兩地相似處可能就只有這樣了。

In 2016, when my team was called in

2016 年，當我的團隊應邀

to start working with the public health system of Rajasthan,

開始著手改善拉賈斯坦邦的 公共醫療體制時，

we found it in a state of crisis.

我們發現這個系統的狀況很危急。

For example, the neonatal mortality rate --

舉例來說，新生兒的死亡率──

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

即出生不到一個月就夭折的嬰兒數──

was 10 times higher than that of the UK.

比英國高了十倍。

No wonder then that citizens were saying,

也難怪人民都會說：

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

「嘿，我不想去公共醫療機構。」

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

在印度，如果你想去 公共醫療機構看醫生，

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

你會去 PHC，即基層健康中心。

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

估計一間 PHC 每天會有 至少 40 個病人。

But in Rajasthan, only one out of four PHCs

但在拉賈斯坦邦， 只有四分之一的 PHC

was seeing this minimum number of patients.

病人數有達到這個低標。

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

換言之，人民不再信任這個體制了。

When we delved deeper,

當我們更深入探究，

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

我們發現核心問題在於 權責制度的缺失。

Picture this.

想像一下。

Sudha, a daily-wage earner,

蘇德哈賺取的是日薪，

realizes that her one-year-old daughter

她發現她的一歲女兒

is suffering from uncontrollable dysentery.

得了無法控制的痢疾。

So she decides to take the day off.

所以她當天決定請假。

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

損失的薪水是 350 盧比， 相當於 5 美金。

And she picks up her daughter in her arms

她抱起女兒，

and walks for five kilometers to the government PHC.

走了五公里路，到了政府的 PHC。

But the doctor isn't there.

但醫生不在。

So she takes the next day off, again,

所以她隔天又再次請假，

and comes back to the PHC.

再回到 PHC。

This time, the doctor is there,

這次，醫生在那裡，

but the pharmacist tells her

但藥師告訴她，

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

她可以領取的免費藥品缺貨了，

because they forgot to reorder them on time.

因為他們忘了即時補貨。

So now, she rushes to the private medical center,

因此，她趕去私人醫療中心，

and as she's rushing there,

路途中，

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

每過一小時，女兒病情就越來越糟，

she can't help but wonder

她忍不住會想，

if she should have gone to the private medical center

她是不是應該一開始就直接 去私人醫療中心，

in the first place

and payed the 350 rupees for the consultation and drugs.

花 350 盧比看醫生和買藥。

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

體制敗壞到這種程度， 也沒有人需要負責。

Costing time, money and heartache to Sudha.

蘇德哈因此必須付出 時間、金錢和心力。

And this is something that just had to be fixed.

這是必須要處理的問題。

Now, as all good consultants,

和所有的優質顧問一樣，

we decided that data-driven reviews

我們認為應該要從數據導向的檢討

had to be the answer to improve accountability.

來著手改善權責制度，

So we created these fancy performance dashboards

所以我們建立了這些 很炫的績效儀表板，

to help make the review meetings of the health department

來協助讓醫療部門的檢討會議

much more effective.

變得更有效率。

But nothing changed.

但，沒有任何改變。

Discussion after discussion,

討論了又討論，

meeting after meeting,

開會了又開會，

nothing changed.

什麼都沒有改變。

And that's when it struck me.

此時，我突然有了個想法。

You see, public systems

要知道，公共體制

have always been governed through internal mechanisms,

一直都是透過內部機制在管理，

like review meetings.

比如，檢討會議。

And over time,

隨著時間過去，

their accountability to the citizen has been diluted.

他們對人民應負的責任就被稀釋了。

So why not bring the citizen back into the equation,

那為什麼不把人民放回公式裡？

perhaps by using the citizen promises?

比如，用公民承諾？

Couldn't that trigger motivation?

那會不會激發改變動機？

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

我們用所謂的咖啡廳策略開始著手。

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

各位可能有看過咖啡廳的這種標牌，

which says,

上面寫著：

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

「如果你沒有拿到收據， 咖啡就免費。」

Now, the cashier has no option

收銀員因此別無選擇，

but to give you a receipt each time.

只能每次都乖乖地給你收據。

So we took this strategy and applied it to Rajasthan.

我們把這項策略用在拉賈斯坦邦。

We worked with the government

我們和政府合作進行一個計畫，

on a program to revive 300 PHCs across the state,

希望讓全邦的三百間 PHC 能夠重生，

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

我們要求他們在牆上 清清楚楚地寫出公民承諾。

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

「我們保證您每次來時 都一定會有醫生在。」

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

「我們保證您每次來時 都一定能拿到免費藥品。」

"We assure you

「我們保證您每次來時 都一定能接受免費診斷。」

that you will get your free diagnostics each time."

And finally, we worked with elected representatives

最後，我們和票選出來的 人民代表合作，

to launch these revived PHCs,

重新開幕這些整治過的 PHC，

who shared the citizen promises with the community

他們大張旗鼓地向社區鄰里 提出公民承諾。

with a lot of fanfare.

Now, the promise was out there in the open.

這些承諾現在已經眾所周知，

Failure would be embarrassing.

沒做到就會很丟臉。

The system had to start delivering.

這個體制因此必須要開始履行責任。

And deliver it did.

它也真的做到了。

Doctor availability went up,

醫生的出席率提升，

medicines came on hand,

藥品不再短缺，

and as a result,

因此，

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

不到一年，病人就診率就提升兩成。

The public health system was getting back into business.

公共醫療體制又重回正軌了。

But there was still a long distance to go.

但還有很長的路要走，

Change isn't that easy.

改變沒有那麼容易。

An exasperated doctor once told me,

曾經有位很惱火的醫生告訴我：

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

「我真的很想改善社區孕產期保健，

but I just don't have enough nurses."

但我就是沒有足夠的護理師。」

Now, resources like nurses

像護理師這些資源

are actually controlled by administrative officers

其實是由行政官員控制的，

who the doctors report to.

醫生要向他們報告。

And while the doctors were now motivated,

雖然現在醫生有動機想改變了，

the administrative officers simply weren't motivated enough

但行政官員還沒有足夠的動機

to help the doctors.

來協助醫生。

This is where the head of the public health department,

此時，公共醫療部門的部長

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

維努古塔女士

想出了一個極佳的點子。

A monthly ranking of all districts.

針對所有地區進行每月排行。

And this ranking would assess the performance of every district

這個排行榜會評估每個地區

on each major disease

在每一種主要疾病上

and each major procedure.

及每一個主要程序上的績效表現。

But here's the best part.

但，以下才是最棒的部分。

We made the ranking go public.

我們會把排行榜公開。

We put the ranking on the website,

我們把排名放在網站上，

we put the ranking on social media,

我們把排名放在社群媒體上，

and before you knew it, the media got involved,

接著，媒體就會自動介入了，

with newspaper articles on which districts were doing well

報紙就會開始刊登

哪些區域表現出色、

and which ones weren't.

哪些表現不佳。

And we didn't just want the rankings

我們不只希望排名

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

會影響到表現最佳和最差的區域。

We wanted the rankings to motivate every district.

我們希望排名能激勵每一個區域。

So we took inspiration from soccer leagues,

所以我們採用來自足球聯盟的靈感，

and created a three-tiered ranking system,

設計出了一個三層式的排名系統，

whereby every quarter,

在每一季的排行榜上，

if a district's performance were to decline,

如果某區域的表現變差，

you could get relegated to the lower tier.

它就會被降級到下一層。

But if the district's performance were to improve,

但如果該區域的表現有改善，

you could get promoted to the premiere league.

就會被提升到最高等級。

The rankings were a big success.

這個排名方法非常成功，

It generated tremendous excitement,

大幅激勵了大家，

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

各區域開始彼此競爭，想成為模範。

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

仔細想想，這個概念其實很簡單。

If the performance data is only being reviewed by your manager

如果績效表現數據

只會被機關內部上層、經理檢討，

in internal settings,

it simply isn't motivating enough.

改善的動機就不會足夠。

But if that data is out there,

但如果這些數據能擺出來，

in the open, for the community to see,

對外公開，讓社會能看見，

that's a very different picture.

就是完全不同的情況了。

That just unlocks a competitive spirit

那會解放出我們每個人 與生俱來的競爭魂。

which is inherent in each and every one of us.

So now, when you put these two together,

所以，把兩者結合，

the coffee shop strategy and public competition,

咖啡廳策略和公開競爭，

you now had a public health system

就能讓公共醫療體制

which was significantly more motivated to improve citizen health.

有更強烈的動機去改善人民的健康。

And now that you had a more motivated health system,

現在，醫療體制有了更多改變動機，

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

面對各方支援，也因此 有了更完善的準備，

Because now, there is a pull for the support,

因為，現在大家搶著要提供支援，

whether it's resources, data or skill building.

舉凡資源、數據或技能建立。

Let me share an example.

讓我舉個例子。

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

有一次，我去阿傑梅爾縣 參加區域會議。

This is one of the districts that had been rising rapidly

它是排名快速爬升的其中一個區域。

in the rankings.

And there were a group of passionate doctors

有一群很有熱情的醫生，

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

他們在討論有什麼點子可以 讓他們的團隊得到更好的支援。

One of the doctors had up-skilled health workers

其中一位醫生讓受過 技能提升訓練的醫護人員

to tackle the problem of nurse shortages.

來解決護理師短缺的問題。

Another doctor was using WhatsApp in creative ways

另一位醫生有創意地 運用 WhatsApp，

to share information and ideas with his frontline workers.

和前線醫護人員分享資訊和想法。

For example,

比如，

where are the children who are missing from immunization?

沒有接受預防接種的孩子在哪裡？

And how do you convince the mothers

要如何說服母親

to actually bring their children for immunization?

確實地帶孩子去做預防接種？

And because their teams were now significantly motivated,

因為他們的團隊現在已經 有很強烈的改變動機了，

they were simply lapping up the support,

他們會欣然接受支援，

because they wanted to perform better and better.

因為他們想要表現得更好。

Broken systems certainly need more resources and tools.

出問題的體制肯定需要 更多資源和設備支援。

But they won't drive much impact

但光有資源和設備是不夠的，

if you don't first address the motivation challenge.

如果動機這項難題沒有先被解決。

Once the motivation tide begins to shift,

一旦動機被激發了，

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

資源和設備才能真正發揮效用。

But I still haven't answered a key question.

但我還沒有回答一個關鍵問題。

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

拉賈斯坦邦的公共醫療體制 後來表現得如何？

In 2016, when our work began,

2016 年，當我們開始 進行體制改造時，

the government of India and the World Bank

印度政府和世界銀行

came out with a public health index.

提出了一個公共衛生指標。

Rajasthan was ranked 20th out of 21 large states.

在 21 個大邦中， 拉賈斯坦邦排名 20。

But in 2018,

但到了 2018 年，

when the next ranking came out,

下一次的排行榜出來時，

Rajasthan showed one of the highest improvements

拉賈斯坦邦是印度所有大邦中

among all large states in India,

改善最大的邦之一。

leapfrogging four positions.

躍升了四名。

For example, it showed one of the highest reductions

比如，該邦的新生兒死亡率 有最大幅度的下降。

in neonatal mortality,

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

每年多拯救了三千個新生兒。

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

一般來說，公共衛生需要 花很長的時間改善，

甚至數十年。

But this approach had delivered results

但這個方法，

只花兩年就展現出成果。

in two years.

But here's the best part.

但，最棒的是

我們所學到的這個方法， 並不是只能用在拉賈斯坦邦。

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

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

事實上，這個利用人民 來激發改變動機的方法

is not even limited to public health systems.

甚至不只限於公共醫療體制。

I sincerely believe that if there is any public system,

我真心相信，

如果任何國家有任何公共體制

in any country,

that is in inertia,

過度安於現況，

then we need to bring back the motivation.

那麼我們就需要把改變動機找回來。

And a great way to trigger the motivation

而激發動機的一個好方法，

is to increase transparency to the citizen.

就是增加讓人民看見的透明度。

We can do this with education

教育可以這麼做， 衛生也可以這麼做，

and sanitation and even political representation.

甚至政治代表都可以這麼做。

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

公立學校能公開競爭招募學生，

Cities and towns, on the basis of cleanliness.

城市和鄉鎮可以推出清潔競賽。

And politicians on the basis of a scorecard

還可以用計分卡來計算政治人物 對改善民生的貢獻，

of how exactly they're improving citizen lives.

藉此來讓他們競爭。

There are many broken systems out there in the world.

世界上有許多出問題的體制，

We need to bring back their motivation.

我們必須要把它們的動機找回來，

The citizen is waiting.

人民都在等著，

We must act today.

我們現在就必須採取行動。

Thank you very much.

非常謝謝。

(Applause)

（掌聲）