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.