October 31, 2012 by Alex Counts
This post by Alex Counts was originally published on his blog, where he describes the process of writing a book on Haitian microfinance pioneer Fonkoze. 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.
An Important Book with Implications for Poverty Alleviation Globally
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. The second main message about “good vs. great” comes from the history of the treatment of cystic fibrosis, and has a performance measurement element to it. The author bridges the subjects with these words: “Finding a meaningful way to measure performance, as Virginia Apgar showed was possible in child delivery, is a form of ingenuity in itself. What you actually do with that measure involves another type of ingenuity, however, and improvement ultimately depends on both kinds.”
Dr. Virginia Apgar (1909-1974), Courtesy of the National Library of Medicine
In the 1960s, a pediatrician named LeRoy Matthews was claiming to have off the charts results in treating cystic fibrosis (CF) patients, and as often happens in such cases, he “was driving people in his field crazy.” Doubtless, people who were achieving more traditional outcomes thought he was cooking the books. Then a doctor named Warren Warwick raised $10,000 “to collect reports on every patient treated at the thirty-one CF centers” in the country, in part to test Matthews claims. The research confirmed Matthew’s claims. Over time, his techniques were copied and the database on clients that was begun by Dr. Warwick was taken up by the Cystic Fibrosis Foundation, which maintains it to the present day. While Matthews methods were copied by many, leading to significant improvements, only a few were able to match his results. One of those was Warwick, the doctor who did the study that confirmed Matthews results. Gawande visited several CF clinics, including some that were trying mightily to improve their outcomes using the Matthews/Warwick techniques, and was impressed despite their middling performance. Then he visited Warwick’s clinic and was astounded by its total dedication to doing everything possible, including things that had not been proven effective yet but had satisfied them through their trial and error approach, to help patients. No stone was left unturned. There was no muddling through or “phoning it in” at all. Patients themselves were challenged to step up and take more responsibility for their own treatment through highly customized case management. As I read this section, I repeatedly thought of Gauthier Dieudonne and his team at Fonkoze and the intensive services they provide to CLM clients — services that have led to an astounding 96% success rate. There is one final interesting part of the CF story. The book begins the CF topic with a hospital that was achieving average scores in terms of patient outcomes. They knew this because of the data that was collected and published, but they could not find out which hospitals were the top performers because the outcomes were anonymized. After a major campaign to disclose which hospitals were doing the best, the Cystic Fibrosis Foundation did so – which enabled people to know that Dr. Warwick’s clinic was among the best. As a result it was intensively studied and visited in order to glean best practices and understand what separated “good” from “great.” Over time, the Foundation decided to publish all the outcome data, even for the worst performing hospitals. This “radical transparency” and focus on outcomes (and benchmarking) clearly has improved the health of patients suffering from cystic fibrosis. It is not difficult to imagine the same dynamic developing in microfinance and more broadly, in international poverty alleviation, if we have the courage to change our ways.