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Tuesday, November 30, 2010

The Way of the Future for Social Services

The purpose of this post is simple. I want to point out the ridiculousness in that we have embraced high quality, low-cost production for things like shoes and cat food, but not for important products in our lives like healthcare and education. Let's think about what industrialization has done to footwear. Three hundred years ago, you probably had to go to your local shoemaker. This shoemaker had to be trained as an apprentice by another expert shoemaker. The only people that made shoes were shoe experts, and because expertise was needed, shoemaking was in their hands. This expertise was rare and hard to come by, so not everyone had access to a shoemaker or one capable of making quality shoes. This shoemaker practiced shoemaking off on his own, requiring him to own all of the tools of the trade, and these capital costs were passed on to the consumer. But eventually shoemakers realized they could make shoes cheaper, and therefore could reach more people and sell to them. They did this with industrialization. They standardized the processes, shifted tasks to non-experts, and increased volume. This lowered costs, standardized quality, and changed our footwear possibilities forever. 

We went from this...

... to this

We now have thousands of footwear choices, at different prices, for different situations. Standardization at first meant less complexity, but by building these systems we now have more footwear options than an individual shoemaker would ever be able to provide. Important to note is that in addition to footwear production being industrialized, so is the sales relationship. Foot Locker doesn't produce sneakers, but they have non-experts that can size your foot, etc. And so industrialization has gone from footwear to finance to food. With industrialization, experts build the systems and the standardized processes to make things happen at scale. But this hasn't happened in medicine and education (and development broadly). These sectors have remained cottage industries. Because of government or non-profit provision, the economic incentive to move to these delivery models hasn't occurred. Because of various professional trade groups, these shifts have been resisted. And the effects are embarrassing. We practice medicine with practically the same delivery model that we had 50 years ago. We practice education with the same delivery model as a 100 years ago.

Yet over the last few decades and centuries, other industries have embraced these shifts. Take for instance the information systems of McDonald's vs. a hospital vs. a classroom. The McDonald's has computer-based ordering which has a workflow that guides low-expertise, task-shifted employees to run a restaurant. With this system, McDonald's can operate thousands of restaurants. The hospital likely has paper records that require experts to write notes readable to other experts. If they happen to be using an electronic system, the workflow still doesn't enable lesser trained non-experts to manage diabetes or follow vaccine schedules or prescribe antibiotics - the system is simply an electronic version of the same medical notes taken by paper records. And similarly in schools, how much has technology been used to enable teachers to manage self- and peer-based learning that is far more effective? Unfortunately, not so much. But these barriers to change don't mean that if industrialized versions are built that they won't be wildly successful.

I am happy to report that this is already where we are going. Many patient safety advocates in the US like Peter Pronovost and Atul Gawande (The Checklist) have similarly been pushing for standardization, although less so for the cost benefits and more so for the quality improvement benefits. Business strategy guru Michael Porter has built an entire literature on the healthcare delivery value chain, and he makes use of these successful examples in his case studies. In India, the Aravind Eye Hospital has built a system of eyecare services that serves a population the size of the United Kingdom, with the same quality outcomes and with over an order of magnitude less cost. And so it should go for social services. Experts make a service standardized.

Standardized means task shifting. Task shifting means scale. Scale means high volume. High volume allows unit costs to be lowered. High volume, standardized, low cost. Those concerned with social services having high quality, low cost, and equitable access should embrace these trends toward industrializing social services. Yes, there will be those that will resist these changes. Some will have reasonable complaints that industrialized services will have to deal with seriously. Many people that resist will simply have vested economic interests or old-fashioned beliefs about how medicine and education should be done. But ultimately, anyone, especially those working in developing countries, who is concerned with equity, social impact, and national financial security will be forced by these successful low-cost examples to see the way of the future.


  1. Hey Andrew- I like what you're alluding to with medicine (and other fields) as essentially a guild. At least in the US, I think the competitiveness of medical school admissions is ridiculous, given the desperate need for more health care workers in this country (especially in primary care). We all knew tons of bright pre-meds who gave up at some point during college who would have made fine physicians. Basically, the field of medicine keeps the number of slots low to keep salaries high. This argument is furthered by the fact that it's damn hard to get into medical school, yet you see very few people failing out once they're admitted.

    I wonder how this specific aspect applies to global health, because I would imagine there are greater constraints on poor countries' abilities to train physicians, nurses, and other health care professionals. And many of these people end up leaving their countries for better opportunities (aided by preferential immigration policies in the US and EU).

  2. I couldn't agree more, Adam. But it's important to consider that a transition to more doctors would be painful: many (all?) current doctors took on a heavy burden of loans and long academic training with the expectation of a certain level of pay and we would be taking that away.

    One way lower-cost care could help poor countries is to reduce the incentive for their physicians to leave for the US. The higher physician salaries are in America the more talent we will soak up from around the world.

  3. Google should run our education system.

  4. I agree that it should be a no-brainer to apply evidenced-based, scientific approaches which leverage the power of markets to increase access to health care and financial services.

    Yet, it seems to me that there are a lot of assumptions about health embedded in this post that need to addressed by future game-changers, such as yourself and the people who post on this blog, before they change up the game.

    For example, how are you defining health?
    What is your explicit goal, to be arrived at through all this standardization?
    Who will design more efficient and equitable systems, and who will implement them? This post mentions non-profit NGOs, profit-maximizing companies, and an academic, as experts with proven track-records. Who is in charge though, and who perhaps should be in charge in designing more equitable and efficent health care delivery?
    What do you see as the role of government in this system reform process?
    How would you address issues of agency and consent in democratic and nondemocratic contexts?
    How would a standardized biomedical system address issues of antibiotic resistence and the social determinants of disease (many of which, such as industrialization and globalization, seem in fact integral to your idealized, factory-like vision of health care delivery reform?)

    I don't know, I'll keep thinking about what you wrote. Perhaps the cases you mentioned are best considered independent of each other, not as part of some grand system or scheme. I mean, what works works, and we have the evidence to prove it.

    I know all these questions are bit much to ask for a short blog post, but thanks for the provocative thoughts.


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