Managing the International Health Crisis

Much of today’s media coverage of global health issues is misleading. News stories tend to focus on the controversies surrounding AIDS drug pricing or the amount of funding necessary to combat the epidemic successfully. Though these issues are important, they contribute to a myth that HIV/AIDS is the only looming catastrophe in international health and that cheaper drugs or a dramatic infusion of money could soon turn the tide.

Those who pay closer attention and read sources outside the mainstream get a more accurate picture. HIV/AIDS is only one health crisis among many facing the world’s poor, including maternal and child health, tuberculosis, and cardiovascular disease. Moreover, no amount of money could rapidly overcome all the other systemic barriers to fighting disease in developing countries, such as undeveloped infrastructure, weak political will, and a paucity of human resources. Yet even by reading widely, a concerned citizen in the U.S. might not appreciate one of the most critical obstacles to fighting health inequal-ities. When D. A. Henderson, leader of the successful World Health Organization campaign to eradicate smallpox, was asked at a press conference what disease the world should try to eliminate next, he surprised the audience by answering, “bad management.”

Two years ago, I went to Rwanda as part of a team dedicated to confronting the management problem. The leaders of Rwanda’s Ministry of Health, aware of our management support project at Columbia University’s Center for Global Health and Economic Development, asked the center for assistance in launching a new national HIV/AIDS program. We went about recruiting candidates who had expertise in strategic planning, quantitative analysis and communication—a nontraditional profile of skills for public health work. Occasionally, we had to struggle with the Columbia bureaucracy to convince senior officials that someone with an M.B.A. might be a better fit than someone with an M.P.H. In the end, we assembled a small team that included a management consultant, an accountant and a lawyer.

We arrived in Kigali, the capital city, in summer 2003. When someone first asked me about my overall impressions of the situation in Rwanda, I could think only of Mikhail Gorbachev’s famous comment about the Russian economy: “In a word, good. In two words, not good.” Rwanda has made remarkable progress since the genocide, particularly in the area of domestic security. The country feels completely safe, with very little violent crime or political turmoil, and corruption is relatively modest. At the same time, Rwanda remains a deeply illiberal democracy rooted in a culture of deference to authority. Moreover, as a landlocked country with few natural resources, Rwanda has little economic base outside of traditional subsistence agriculture. Nearly half of the population is under the age of 15, and the public education system cannot cope.

As we quickly learned, all of these problems directly contribute to weak management, which in turn hampers Rwanda’s ability to use the rapid influx of donor money intended to address the problems. For example, the government’s inability to pay adequate salaries to civil servants results in a perverse set of incentives. Rather than focusing on organizational objectives, health officials spend much of their time trying to supplement their meager salaries. For instance, officials often attend training sessions run by international nongovernmental organizations (NGOs) that offer per-diem payments for participation, even if the topic is wholly irrelevant. One particularly clever senior manager was almost never in Rwanda, aggressively seeking invitations to overseas conferences that paid him as much as $250 per day for hotel and food. He would quietly stay in hostels for $10 a night, and simply pocket the difference.

Poverty also translates into shortsighted thinking and planning. Investment in long-term improvements is a luxury seldom contemplated, as most Rwandans are accustomed to thinking about how to provide for their families. “In the medium term,” one Rwandan joked to me, “we’re all dead.” Everything operates on a short-term outlook. No one knows when public holidays will be observed, as the government tends to declare holidays at the last minute by national radio broadcast. If you find a car with a tank of gas more than a quarter full, you’ve likely found an expat’s car—Rwandans don’t invest in full tanks. This mindset endures even when capital becomes available. Significant funds for HIV/AIDS are arriving, yet the healthcare leadership does not tend to think about resolving the bottlenecks that will hamper scaled-up treatment three years from now, such as the critical need for more nurses, doctors and laboratory technicians. Despite $50 million in HIV/AIDS funding this year, not a single new nursing school is under construction.

Meanwhile, the deferential streak in the Rwandan temperament contributes to workplace environments in which very few middle managers feel empowered to take initiative and their supervisors tend to micromanage. The HIV/AIDS management unit that I was advising initially had a system that required any staff member to sign a sheet before leaving the office for any meeting or errand, justifying the need for the excursion. One colleague occasionally wasted entire days of work because he had run out of cell phone minutes to make business calls, could not find another available phone in the office, yet could not go into town to re-charge his cell phone because the boss was not there to approve his errand. In its extreme form, such deference to authority becomes almost comic. One day, a prison work crew was landscaping a public square in Kigali while the prison guard supervising them sipped from his bottle of vodka. The guard eventually passed out. Rather than making a break for it, the prisoners respectfully picked the guard up and carried him back to jail, then quietly returned to their cells.

My colleagues and I worked closely with our Rwandan counterparts to begin the slow process of transforming management culture in two key HIV/AIDS coordination offices. I was responsible for advising Dr. Blaise Karibushi, the leader of one of these units, and our first step was to overhaul the implementation plan for the new national HIV/AIDS program. We reversed the typical short-term approach to planning and began by agreeing to three-year goals. We then calculated the level of human resources and infrastructure necessary to achieve these goals, and worked backwards from there. Eventually, Blaise’s team designed a detailed workplan and budget for the first year of the program. This plan included investment in improvements that would not yield any immediate benefit but would alleviate anticipated constraints (such as a looming warehouse capacity problem) in years two or three.

As the project progressed, Blaise and I had more time to focus on the more complex challenges of changing performance culture and management style. First, we developed a completely new incentives scheme. We translated the organizational workplan into individual workplans and performance targets, and set aside a pool of money for performance-linked bonuses at the end of the year. To make the system work, we also instituted a series of regular performance reviews for each person reporting to Blaise and asked those people to create a similar process for monitoring their supervisees. In a dramatic departure from the Rwandan norm, Blaise also began to seek feedback from his subordinates. Though this was initially very uncomfortable both for him and those giving him feedback, the constructive criticism he received helped him rethink his management style.

Responding to this feedback, we experimented with new ways for Blaise to manage his team on a week-to-week basis. We discarded the system of daily sign-off on everyone’s intended activities. Instead, Blaise convened a weekly meeting of unit heads every Monday and agreed with them on their goals for the week. From that departure point, each unit head was empowered to make any decision necessary to achieve those goals. At the next weekly meeting, the team would discuss any obstacles encountered and collectively agree on strategies for overcoming them.

Over the year I spent in Kigali, progress on all these fronts was halting. Unit heads were often slow to seize their newfound autonomy. They usually felt more comfortable gaining Blaise’s assent before finalizing decisions, even where the decision was of only modest importance. The performance management system was not easy to implement in a context where many people claimed excuses for any shortfall, pointing to electricity outages, unreliable implementation partners and so forth.
Even as we focused on long-term management issues, I spent over half my time helping Blaise react to unforeseen crises. For example, the central health procurement agency notified us one day that it had ordered HIV test kits for the next wave of program expansion, but had neglected to order needles for drawing blood. So I drove 10 hours north to Uganda and bought 20,000 needles, enough to fill the gap for one month until a new shipment arrived in Kigali.

I often wondered whether our strategy of attempting to change management culture was the right one. Effecting change was both slow and expensive. Indeed, the amount of money used to cover my salary and expenses, though modest by Western standards, would have financed ten Rwandan salaries or funded treatment for 500 HIV-positive people for one year. Ultimately, though, I became convinced that the kind of work we are doing in Rwanda needs to be expanded, because any small improvement in management has powerful multiplier effects. The rate of staff turnover within the management unit has decreased significantly because people are more satisfied with their jobs. Even more importantly, the gradual changes we made within the management team contributed significantly to the proj-ect’s success in achieving almost all of its first-year objectives. In turn, that success attracted widespread attention from donors and the promise of increased funding. With a long-term investment plan in place, current and future financing will be channeled to logically ordered improvements. Though combating the epidemic of bad management is no easier than turning the tide against HIV/AIDS, it is a fight equally worth fighting.

Dai Ellis ’93

 

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