If I ran the World Health Organization

An essay about health care access for the bottom billion

I am on-ground in Burundi, a small East African country and the poorest in the world by GDP per capita. I’m developing a quality improvement programme for a rural health clinic, 70km outside the capital, Bujumbura.

To build the programme I am using the WHO Quality Toolkit, the Joint Commission International Primary Care Standards and the Tanzanian STAR Rating Assessment. I’ll leave the project details for another time. What’s more important is the objective: apply the policies and knowledge we already have, to a place that desperately needs it. If the knowledge is there, all we’re missing is the action, right?

Just like my previous work in maternal mortality, I am tormented by the preventable deaths, available knowledge and the root cause of the problem: inaccessibility (important note: a really complicated set of factors lead to inaccessibility).

So that’s this project. To take the word of policy experts in Geneva, global medical doctors and implement the guides of reputable NGOs.

Now I’m deep into thousands of pages of WHO guidelines for primary healthcare. The well-formatted PDFs make it seem easy and solvable. Here’s the thing though: no healthcare worker in a LMIC has time to read the WHO’s 73 page guide to hand-hygiene.

Obvious statement? Apparently not because there are hundreds of these verbose ‘implementation guides’ and ‘toolkits.’

I’ve learned that the WHO has many assets like robust data collection, brand and national-level policies. However, their work just does not translate well on-ground in difficult and constrained settings.

Clinique Medicale Ubuntu in Mugamba, Bururi, Burundi: the focus context for my project.

Policies are nice, but without implementation, they are merely a collection of dead trees. It’s much easier to envision the ideal state. Instead, I want to engineer the theory into reality.

Right now I’m one girl, at one clinic, in one country, trying something new. One day I want to scale up. I want to compensate for bureaucracy. I want to create sustainable improvement systems.

So… I had a thought experiment:

If I ran the WHO (or had a big enough budget to change global health) …

My Top 3 Priorities would be:

1. To create an *intelligent* and custom search engine / resource database that pairs with great data collection and artificial intelligence
2. Organise existing guidelines and interventions into priority frameworks and algorithms for constrained environments
3. Language translation and promotional resources (posters, standard operating procedures, action plans)

I would create a bottom-up, intelligent search engine

• I would modularise all documents. No PDFs more than 10 pages. People can build custom guidelines from the bottom-up, rather than searching for the 3 pages they need in an 80 page document.
• I would create a search engine that can go through the modularised documents and build them into a collection.

The status quo (top down: find what you can in this bureaucratically long document!!!) vs what should be (bottom-up: health worker you are amazing here are the most curated, relevant, resources. Please I don’t want to waste your time you are so valuable)

• ^ many documents right now repeat frameworks, case studies and insights. This modularisation would reduce repetition of the same concepts. Within each collection (all the modules that relate to a specific topic for a specific concept), there would be no redundancy.
• Within the search I would also want to collect information about the health setting to customise the results and recommendations. Things like: bed capacity, water and electricity accessibility, refrigeration, geography (and then I would automatically consider food security, natural disasters, disease burden, etc). It would be an intelligent and personalised search engine. Again, the KPI is saving the healthcare workers time.
• The search engine would also ask clarifying questions to further customise the results.

Take a look. Here’s the status quo when searching for infection prevention control (IPC) resources for a facility:

The second document is 44 pages long and its whole purpose is to reference 106 more documents, many of which are also 44+ pages long. Reading these documents is like finding a needle in a haystack.

And this is what I’d build:

A way to navigate the tools and leverage personalised data from health-care settings. The implementation guides would not only consider constraints, but the constrains that are specific to the health setting.

I would make structural changes to documentation:

• Append the acknowledgements. They move to the back. As much as the writers deserve credit, people are dying from diarrhoea, malaria and childbirth; we need to protect the time of the workers changing these realities.
• Enforce executive summaries, not introductions. Introductions are a bunch of context. Executive summaries are the essence of what, where, why and how we should use the intervention or guideline. The default would be no introduction. If people want them, they can opt-in.
• I would create a plug in where people can hover over abbreviations instead of going back to the abbreviation page.
• Interactivity. Things like this page.
• There would be an enforceable ratio for our output. 1 policy report: 3 action-driven guidelines (for national, facility and community levels)
• I would focus on translating core materials (frameworks, infographics, executive summaries) in major (colonial) languages (Spanish, French, Portuguese) and local languages (e.g. Khmer for Cambodia, Kirundi for Burundi etc). Not entire documents. Not the acknowledgements. Not the extra rationale pages. The essential pages. Because the people doing the work who don’t speak English do not have time to read the excess.

I would upgrade the website and resource centres:

• I would create a way to monitor broken links and changed policies. Right now, there are so many dead-ends.
• I would create a WHO for Game Changers webpage. The most relevant, curated actionable materials. Specifically: health promotion posters, action plans, TLDRs of interventions, contacts by regions and continuous education.
• Do you know how impossible it is to find infographics in french about literally anything to do with healthcare? But, when I search on the quality toolkit for community engagement interventions… search results with 766 pages of documentation come up. They have similar messages: integrate the community, educate them in their local language, ensure to invest in health promotion. But the resources to do that? That’s on page 767 and it’s not done yet.
• We will put our resources through adaptable prioritisation matrices. For example, the 80/20 rule, Eisenhower matrix and the MoSCoW method. For, for malaria, you’ll be able to sort recommendations into their 80/20 pattern, urgency vs important, and the must, should, could and would-dos.
• I would invest in more courses, in more languages. Things like the essential newborn care (ENC) course. OPENWHO is one of the best and most useful things the WHO has for changing things on-ground.
• A dedicated page for example standard operating procedures (SOPs). I have seen the recommendation for SOPs referenced hundreds of times in the WHO documents. However, there is only 1 sample resource and that’s only to create SOPs for emergency care.

I would invest in new talent and teams:

• Technology and UX teams: on a mission to build navigable, accessible and user-friendly search tools to access the wealth of knowledge. Eventually we would also roll out technologies for low-bandwidth areas, such that on-ground workers can interact with SMS or Whatsapp to gain WHO knowledge/expertise.
• 80/20 team: I would create a team whose whole purpose is to distill guidelines and research into the 80/20 rule. I.e., what are the 20% of the interventions that produce 80% of the health-outcomes we care about? This would become a search filter. There would also be an interactive 80/20 webpage (like this) where organisations can map where they are vs where they need to be to reach the 80/20 state.
• On-ground missions: every year, lead authors must spend 2 months in a low-resource setting in order to maintain their seniority. They cannot just write the guidelines from their heated London flat. They will create a section of their guidelines for constrained environments. No losing perspective.
• Implementation: in every country, there will be one or a few people dedicated to implementation. Their job will be to disseminate the WHO’s materials. People serving their annual on-ground missions can be part of this effort. Clinics and health posts should get a visit every 6 months.
• Seminars: something I’ve noticed among the staff at my clinic is their willingness to learn from experts. They want more seminars. They want more guests. If this was a trend across many clinics, I would implement a seminar program. Experts would go around the world sharing knowledge. We would use their visits as an opportunity for systematic data collection too. I would also put these experts through advanced language emersion so they can teach bilingually.
• Health Promotion: we would have a resource database dedicated to health promotion materials. Our top priorities would be aggregating and translating what exists, and secondary to that we can create more comprehensive materials. We would focus first on colonial languages (there are fewer) and then we would go all-in with local and mother-tongue languages.
• Translators: most would be locals from the respective country. I would learn from the world’s best language programs (like the CIA and/or the Mormon mission trip language learning) and create a way to train language translation and information dissemination while hiring local.
• Operational Efficiency: I would bring in expert product designers and psychologists to optimise the flow of the website. KPI: reduce the amount of time people spend looking for what they need.
• Two pizza meeting rule: I would take on Jeff Bezos’ two pizza meeting rule to maximise the efficiency of meetings. I.e., we should not need more than 2 pizzas to feed everyone in the meeting.
• Culture: I would implement 3 core elements to the culture. (1) Practice what you preach. (2) We work for the workers on ground (flip the hierarchy). (3) Saving lives is our north star.

I hope we write fewer documents but train more translators. I hope there are less meetings in hotels that nightly cost someone’s annual living, and more meetings with the clinics that are changing lives. I hope no one ever has to spend 4 hours searching for health promotion posters in french; I hope those hours are instead used to deliver antenatal care in homes, take a course on TB infections or campaign in the community.

The WHO does some seriously incredible and important work. But we have to remember that a textbook never saved a patient. A doctor did.

So, let’s work for those people.

Our team at Ubuntu Clinic

Thanks for giving this a read. I’m Isabella and I’m on a journey to unlock operational inefficiencies in making the world a better place 🔑. Follow along here on Medium, my newsletter or my social medias: @isabellagrandic.