> Posted by Alex Counts, President & CEO, Grameen Foundation
It has been a few weeks since I have posted on this blog, but I have continued to study and to work inside Fonkoze all along. Now I feel like I finally have a juicy topic to write about and time to do so.
In response to my post on outcomes and impact (as opposed to inputs) in poverty reduction programs, Meredith Kimbell, a top-notch management consultant in the Washington, DC area whom I have known for years, mentioned the book Better by a physician named Atul Gawande, and in particular a chapter towards the end titled “The Bell Curve.” I read the entire book, which is basically about how the practice of medicine has been and can be improved (with lessons for other disciplines). I found that the book had some important lessons for the effort to end poverty through holistic approaches to microfinance such as those employed by Fonkoze.
The first third of the book is made up of some powerful examples of how medicine has improved, from the mundane (ensuring hospital staff wash their hands more frequently) to the dramatic (the story behind the massive improvements in battlefield medicine through trial and error-based innovation and rigorous quality control). The main lesson I took away from this section was that significant improvement in performance can be realized simply by more rigorously applying known best practices. Certainly this has applications to microfinance and poverty-fighting generally.
The book got me thinking about what would happen if every organization providing services to the poor (a) catalogued the five most powerful lessons they had learned for achieving positive outcomes, (b) put in place a high-level team hell-bent on ensuring they were integrated into everyday practice from top to bottom, and (c) made sure that staff were measured and rewarded on their success in doing so. Probably we could have a major impact without any new innovations or resource commitments to poverty alleviation.
The middle third of the book deals with topical issues in the medical profession – the fairness of the compensation doctors receive, malpractice insurance and lawsuits, and the ethics of physicians being involved in administering the death penalty. Interesting perhaps, but not so relevant to this project.
The last third of the book is most interesting. The two themes that stood out were:
- The power of measuring results and enabling benchmarking of effectiveness in spurring improved outcomes.
- A key distinguishing factor between good and great: in the latter case, the practitioner is both extremely rigorous, pushes his partners (in this case, patients) and “does not hesitate to improvise.”
Fonkoze, and many microfinance organizations committed to the being double-bottom line institutions, are committed to rigorous measurement and also openly sharing their results with the outside world. I also see in Fonkoze’s Chemen Lavi Miyo (“Pathway to a Better Life”) program for the ultra-poor success in delivering exceptionally high quality services to the most vulnerable through an asset-transfer and case-management approach adapted from BRAC. (I also hear echoes of Paul Farmer’s values, and how they have been embedded in Partners in Health — an organization I have blogged about previously in how it relates to Fonkoze.) But let me go back to the book.
On the power of measurement, Gawande describes the development of the Apgar score (named after Dr. Virginia Apgar, one of the few female physicians practicing in the 1930s). The score is a simple tool to assess on a scale of 1 to 10 the well-being of a newborn child at two moments in time — one minute and five minutes after birth. The development of the score – which has many parallels with the Progress out of Poverty Index that is incorporated into Fonkoze’s social performance tool – allowed hospitals to compare survival rates of children in similar circumstances.
The simplicity and clarity of the Apgar score revealed wide variations in results among hospitals, which led to feverish and productive efforts to study what worked and also to develop better approaches, and then to apply emerging best practices. This invariably led to the improvement of survival rates for newborns with comparable Apgar scores. Prior to the development of the scoring tool, hospitals with lower survival rates were able to blame the health of the mother and newborn as the main factors, rather than their own performance.
To read the rest of this post, visit Alex Counts’ blog.
Image Credit: The Checklist Manifesto
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