In achieving the Millennium Development Goals (MDGs) we face a serious management crisis—our inability to configure the already available resources to deliver intended outputs and outcomes. The norms and benchmarks are well established, thanks to a variety of academic and advocacy organizations that have, thus far, primarily led the charge. It is now time that program implementers, who can realize these intentions on the ground, take the reins. From Engineer Henry to Mechanic Joe.
First, we must determine why things that have been done so far have not produced the desired results. Of course more resources need to be devoted, but are the precedents reassuring enough for us to march forward without some course correction? After all, we do not want to subscribe to Einstein’s definition of insanity—doing the same thing over and over again and expecting different results.
The main villain is our inability to deal with the scale of need. This is particularly so in environments of high poverty, weak infrastructure and scarce resources—emblematic of villages in the developing world. Ironically, these villages are home to 3/4 of the population in many of these countries. Unless their needs are addressed within the context of where they reside, achieving MDGs will remain a pie in the sky.
There are two avenues to deliver at scale for these populations: the public sector and the private sector. (The charitable sector on its own would not help much—3.3 million NGOs contribute less than 1% of health care in India. Of course, some African countries have a significant NGO sector, mainly faith based.) Since rural delivery is inherently more expensive, we need tax rupees and dollars to pay for them; the public sector inevitably takes the lead. If this works within its own channels, way to go—look at Vietnam, Cuba and Iran or, in India, Tamil Nadu and Himachal Pradesh states. But the public sector faces constraints —in many parts of India and across the world—in managing the here-and-now issues at service delivery points.
Although the public sector should remedy these shortcomings for the long term, in the short term, the public sector must leverage the other avenue: the private sector. Using private providers—engaged in an economic activity—to care for the poor is an oxymoron in its natural state. What special strategies do we need to engage with this sector so care can be delivered to the poor communities irrespective of the internal force that pulls the sector away from the poor? Don’t forget the wealth of resources—in which the country has already invested—sitting there. An eminent Indian economist estimates that the public subsidy to produce each of the 450,000 Indian doctors in the private sector is $40,000. There are less than 30,000 doctors in the public sector to deal with 850 million rural people in India. I rest my case.
We need to create a composite service delivery structure that is optimized by combining the resources available in the public and private sectors. This needs to be done by program implementers who understand the operational benefits and shortcomings of each of these sectors and harness their collective utility. For rural communities, for instance, the public sector is often where the formally qualified providers are available. There is a parallel private channel that normally consists of informal providers who have some rudimentary knowledge of therapeutics, traditional healers and local community workers. What these providers lack in medical and technical competence, they more than make up with their 24X7 presence and a phenomenal empathy for the community. And lest I forget, they have the ability to determine the credit worthiness of the family, essential for rural commerce given cyclical agrarian incomes. The latter can be turned into an effective way to target services to the bottom of the pyramid through insurance, vouchers and coupons.
As 2015 fast approaches we must take stock and examine why we are not on track to achieve the Millennium Development Goals. I believe the solution lies in program implementers leveraging public and private sector resources to help deliver products and services at the scale required to address this problem. While some developing nation governments have successfully attended to their rural populations the vast majority have fallen short. Calling all Mechanic Joes, the clock is ticking.