演講MP3+雙語(yǔ)文稿:如果你是國(guó)家元首，你將如何建立公共健康系統(tǒng)？

聽(tīng)力課堂TED音頻欄目主要包括TED演講的音頻MP3及中英雙語(yǔ)文稿，供各位英語(yǔ)愛(ài)好者學(xué)習(xí)使用。本文主要內(nèi)容為演講MP3+雙語(yǔ)文稿:如果你是國(guó)家元首，你將如何建立公共健康系統(tǒng)？，希望你會(huì)喜歡！

【演講者及介紹】Abhishek Gopalka

公共部門策略師阿布舍克?戈帕爾卡（Abhishek Gopalka）, BCG的阿布舍克?戈帕爾卡（Abhishek Gopalka）建議各國(guó)政府采取創(chuàng)新方法，為公民提供更好的服務(wù)

【演講主題】發(fā)自內(nèi)心的動(dòng)力是如何修復(fù)公共系統(tǒng)的

【中英文字幕】

翻譯者 Shengmin Huang 校對(duì)者 Yolanda Zhang

00:13

Take a minute and think of yourself as the leader of a country. And let's say one of your biggest priorities is to provide your citizens with high-quality healthcare. How would you go about it? Build more hospitals? Open more medical colleges? Invest in clinical innovation? But what if your country's health system was fundamentally broken? Whether it's bsenteeism, drug stock-outs or poor quality of care. Where would you start then?

花上一分鐘， 把自己想象成一國(guó)領(lǐng)袖。 假如你最首要的任務(wù) 是為貴國(guó)公民提供 高質(zhì)量的醫(yī)療保健。 你會(huì)如何著手？ 建立更多醫(yī)院？ 開(kāi)辦更多醫(yī)學(xué)院？ 投資醫(yī)療創(chuàng)新？ 但如果貴國(guó)的健康系統(tǒng) 已經(jīng)爛到根子里了， 醫(yī)生玩忽職守， 藥物供不應(yīng)求， 亦或是護(hù)理質(zhì)量堪憂。 你將從何下手？

00:48

I'm a management consultant, and for the last three years, I've been working on a project to improve the public heath system of Rajasthan, a state in India. And during the course of the project, we actually discovered something profound. More doctors, better facilities, clinical innovation -- they are all important. But nothing changes without one key ingredient. Motivation. But motivation is a tricky thing. If you've led a team, raised a child or tried to change a personal habit, you know that motivation doesn't just appear. Something has to change to make you care. And if there's one thing that all of us humans care about, it's an inherent desire to shine in front of society. So that's exactly what we did.

我是一名管理咨詢師， 在過(guò)去三年里， 我一直致力于一項(xiàng) 改善印度拉賈斯坦邦 公共健康系統(tǒng)的項(xiàng)目。 而在項(xiàng)目進(jìn)行過(guò)程中， 我們確實(shí)發(fā)現(xiàn)了一些深刻的問(wèn)題。 更多醫(yī)生、更好的設(shè)施、 醫(yī)療創(chuàng)新—— 這些都重要。 但這些東西都缺少了一項(xiàng) 能發(fā)揮作用的關(guān)鍵要素。 發(fā)自內(nèi)心的動(dòng)力。 但動(dòng)力是個(gè)棘手的玩意兒。 如果你帶過(guò)團(tuán)隊(duì)、養(yǎng)過(guò)孩子 或是試圖改變個(gè)人習(xí)慣， 你就會(huì)明白 動(dòng)力不會(huì)憑空出現(xiàn)。 有些事情得改變了 你才會(huì)去在意。 要說(shuō)有什么事 我們?nèi)祟惗荚谝猓?就是對(duì)自己能被社會(huì)矚目 發(fā)自內(nèi)心的渴望。 于是我們借此入手。

01:50

We decided to focus on the citizen: the people who the system was supposed to serve in the first place. And today, I'd like to tell you how Rajasthan has transformed its public health system dramatically by using the citizen to trigger motivation. Now, Rajasthan is one of India's largest states, with a population of nearly 80 million. That's larger than the United Kingdom. But the similarities probably end there. In 2016, when my team was called in to start working with the public health system of Rajasthan, we found it in a state of crisis.

我們決定聚焦于本國(guó)公民—— 那些本就應(yīng)該由 機(jī)關(guān)系統(tǒng)服務(wù)的人。 而今天，我將告訴你們 拉賈斯坦公共健康系統(tǒng) 的急劇轉(zhuǎn)型， 其動(dòng)力是如何由公民激發(fā)的。 拉賈斯坦是當(dāng)今印度 最大的邦州之一， 有著近八千萬(wàn)的人口。 比英國(guó)全國(guó)還多。 但可比之處僅此而已。 當(dāng)我的團(tuán)隊(duì)在2016年受邀 到拉賈斯坦開(kāi)始參與 公共健康系統(tǒng)工作時(shí)， 我們發(fā)現(xiàn)它已 處于危機(jī)狀態(tài)了。

02:39

For example, the neonatal mortality rate -- that's the number of newborns who die before their first month birthday -- was 10 times higher than that of the UK. No wonder then that citizens were saying, "Hey, I don't want to go to a public health facility." In India, if you wanted to see a doctor in a public health facility, you would go to a "PHC," or "primary health center." And at least 40 patients are expected to go to a PHC every day. But in Rajasthan, only one out of four PHCs was seeing this minimum number of patients. In other words, people had lost faith in the system. When we delved deeper, we realized that lack of accountability is at the core of it.

就拿記錄了未滿一個(gè)月就夭折 的新生兒死亡率來(lái)說(shuō)， 該數(shù)字高出英國(guó)新生兒 死亡率十倍之多。 難怪本國(guó)公民會(huì)說(shuō)： “嘿，我可不想去公立醫(yī)療場(chǎng)所?！?在印度，你如果要到 公立醫(yī)療場(chǎng)所看病， 你就得去“PHC”， 也就是“初級(jí)保健中心”。 一所初級(jí)保健中心應(yīng)有能力 每天接待至少40名來(lái)訪病人。 而拉賈斯坦的初級(jí)保健中心 每四所里只有一所 能達(dá)到這個(gè)病人接待量的下限。 換句話說(shuō)，人們對(duì)該系統(tǒng) 已然不抱希望。 當(dāng)我們更深入地進(jìn)行研究時(shí)， 我們意識(shí)到問(wèn)責(zé)機(jī)制的缺失 正是問(wèn)題的核心。

03:35

Picture this. Sudha, a daily-wage earner, realizes that her one-year-old daughter is suffering from uncontrollable dysentery. So she decides to take the day off. That's a loss of about 350 rupees or five dollars. And she picks up her daughter in her arms and walks for five kilometers to the government PHC. But the doctor isn't there. So she takes the next day off, again, and comes back to the PHC. This time, the doctor is there, but the pharmacist tells her that the free drugs that she's entitled to have run out, because they forgot to reorder them on time. So now, she rushes to the private medical center, and as she's rushing there, looking at her daughter's condition worsening with every passing hour, she can't help but wonder if she should have gone to the private medical center in the first place and payed the 350 rupees for the consultation and drugs. No one is held accountable for this incredible failure of the system. Costing time, money and heartache to Sudha. And this is something that just had to be fixed.

想象一下， 蘇達(dá)，一名日薪工作者， 發(fā)現(xiàn)她一歲大的女兒 鬧了痢疾令她束手無(wú)策。 于是她決定請(qǐng)一天假。 這將損失大約350盧比， 也就是5美元的日薪。 而當(dāng)她懷抱著她的女兒 徒步五千米來(lái)到 政府的初級(jí)保健中心， 卻發(fā)現(xiàn)醫(yī)生不在。 所以第二天她也得請(qǐng)假， 再次來(lái)到初級(jí)保健中心。 這一次，醫(yī)生在是在， 但藥劑師告訴她， 由于他們忘了及時(shí)訂藥， 她有權(quán)免費(fèi)領(lǐng)取的 藥物已經(jīng)用完了。 于是現(xiàn)在，她趕忙跑向 私立醫(yī)療中心， 而在她快馬加鞭的同時(shí)， 還要眼看著女兒的病情 隨著時(shí)間流逝而惡化。 她不禁會(huì)想， 自己是否在一開(kāi)始就該直接去 私立醫(yī)療中心， 并支付350盧比的 門診與醫(yī)藥費(fèi)。 這無(wú)人負(fù)責(zé)的 聳人的系統(tǒng)失職 害蘇達(dá)損失了時(shí)間、金錢， 還令她備受煎熬。 要查補(bǔ)的正是此類漏缺。

04:59

Now, as all good consultants, we decided that data-driven reviews had to be the answer to improve accountability. So we created these fancy performance dashboards to help make the review meetings of the health department much more effective. But nothing changed. Discussion after discussion, meeting after meeting, nothing changed.

作為合格的咨詢師， 我們認(rèn)為必須以 由數(shù)據(jù)導(dǎo)向的審查 來(lái)應(yīng)對(duì)問(wèn)責(zé)機(jī)制的改善問(wèn)題。 所以我們創(chuàng)建了這些 花哨的績(jī)效展示牌 去幫助健康部門能更高效地 展開(kāi)審查會(huì)議。 可無(wú)濟(jì)于事。 一次又一次的討論、 一場(chǎng)又一場(chǎng)的會(huì)議， 全都無(wú)濟(jì)于事。

05:29

And that's when it struck me. You see, public systems have always been governed through internal mechanisms, like review meetings. And over time, their accountability to the citizen has been diluted. So why not bring the citizen back into the equation, perhaps by using the citizen promises? Couldn't that trigger motivation? We started with what I like to call the coffee shop strategy. You've probably seen one of these signs in a coffee shop, which says, "If you don't get your receipt, the coffee is free." Now, the cashier has no option but to give you a receipt each time.

這才給了我當(dāng)頭棒喝。 要知道，一直以來(lái) 各項(xiàng)公共系統(tǒng)都是 由這些審查會(huì)議之類的 內(nèi)部機(jī)制來(lái)監(jiān)管。 而長(zhǎng)此以往， 外界公民對(duì)他們問(wèn)責(zé)的 作用就被淡化了。 如果能通過(guò)公民承諾， 讓公民們?cè)俅纹鸬阶饔茫?又有何不可呢？ 這樣不就可以激發(fā)人們的動(dòng)力了嗎？ 我們的啟動(dòng)方案 被我稱為“咖啡店策略”。 你們應(yīng)該在咖啡店里 見(jiàn)過(guò)這樣的指示牌， 上面寫著： “如果您沒(méi)收到收據(jù)， 咖啡就算您免費(fèi)?！?這樣一來(lái)，收銀員就不得不 在每次結(jié)賬時(shí)都要給你開(kāi)收據(jù)。

06:18

So we took this strategy and applied it to Rajasthan. We worked with the government on a program to revive 300 PHCs across the state, and we got them to paint very clear citizen promises along the wall. "We assure you that you will have a doctor each time." "We assure you that you will get your free drugs each time." "We assure you that you will get your free diagnostics each time." And finally, we worked with elected representatives to launch these revived PHCs, who shared the citizen promises with the community with a lot of fanfare. Now, the promise was out there in the open. Failure would be embarrassing. The system had to start delivering. And deliver it did. vailability went up, medicines came on hand, and as a result, patient visits went up by 20 percent in less than a year. The public health system was getting back into business.

因此我們將此策略 應(yīng)用在了拉賈斯坦。 我們與政府合作了一項(xiàng) 在全州范圍內(nèi)恢復(fù)300家 初級(jí)保健中心的計(jì)劃， 還讓他們將每一條公民承諾 都清清楚楚地印在了墻上。 “我們向您保證 您每次都能看上醫(yī)生?！?“我們向您保證您每次都能 領(lǐng)取到您的免費(fèi)藥物。” “我們向您保證 您每次都能接受免費(fèi)診斷?！?最后，我們還與民選代表合作， 幫這些恢復(fù)的 初級(jí)保健中心重新開(kāi)業(yè)， 讓它們大張旗鼓地 將這些公民承諾 推廣至社區(qū)。 現(xiàn)在，這些承諾已世人皆知。 食言就意味著蒙羞。 機(jī)關(guān)系統(tǒng)必須開(kāi)始出力。 他們也確實(shí)出力了。 醫(yī)生出勤率有所上升， 藥物一應(yīng)俱全， 而結(jié)果就是 不到一年，病人來(lái)訪率 就提升了兩成。 公共健康系統(tǒng)正在重回正軌。

07:36

But there was still a long distance to go. Change isn't that easy. An exasperated doctor once told me, "I really want to transform the maternal health in my community, but I just don't have enough nurses." Now, resources like nurses are actually controlled by administrative officers who the doctors report to. And while the doctors were now motivated, the administrative officers simply weren't motivated enough to help the doctors.

然而前路漫漫， 改變并非一蹴而就。 曾有一位惱怒的醫(yī)生告訴我， “我是真心希望改變 我們社區(qū)的婦產(chǎn)保健， 但苦于護(hù)士人手不足?！?目前，像護(hù)士這類資源 實(shí)際由行政官員掌握， 醫(yī)生也得向他們匯報(bào)。 現(xiàn)在醫(yī)生們是有動(dòng)力了， 這些行政官員 卻沒(méi)有足夠的動(dòng)力 去幫助醫(yī)生。

08:09

This is where the head of the public health department, Ms. Veenu Gupta, came up with a brilliant idea. A monthly ranking of all districts. And this ranking would assess the performance of every district on each major disease and each major procedure. But here's the best part. We made the ranking go public. We put the ranking on the website, we put the ranking on social media, and before you knew it, the media got involved, with newspaper articles on which districts were doing well and which ones weren't. And we didn't just want the rankings to impact the best- and the worst-performing districts. We wanted the rankings to motivate every district. So we took inspiration from soccer leagues, and created a three-tiered ranking system, whereby every quarter, if a district's performance were to decline, you could get relegated to the lower tier. But if the district's performance were to improve, you could get promoted to the premiere league.

對(duì)此，公共健康部門負(fù)責(zé)人 維努·笈多女士提出了一條妙計(jì)。 所有地區(qū)每月都要排名。 該排名會(huì)對(duì)各地區(qū) 在每項(xiàng)重大疾病 和每次重要執(zhí)行程序上的 績(jī)效做評(píng)估。 而最妙的是： 我們公開(kāi)了排名。 我們將排名放到了互聯(lián)網(wǎng)上， 放到了社交媒體上， 不等你反應(yīng)過(guò)來(lái)， 媒體就都參與進(jìn)來(lái)了， 通過(guò)報(bào)刊文章 點(diǎn)評(píng)著各地區(qū)表現(xiàn)孰好孰壞。 我們不只是希望這些排名 能影響表現(xiàn)最好 與最次的地區(qū)， 我們希望它能激起 所有地區(qū)的動(dòng)力。 于是我們從足球聯(lián)賽中獲取靈感， 創(chuàng)建了一套有著三級(jí)排名 的排名系統(tǒng)， 每個(gè)季度， 如果某個(gè)地區(qū)的績(jī)效下降了， 那就將其排名降低。 而如果一個(gè)地區(qū)的績(jī)效上升了， 就將其提升至最高檔。

09:19

The rankings were a big success. It generated tremendous excitement, and districts began vying with each other to be known as exemplars. It's actually very simple, if you think about it. If the performance data is only being reviewed by your manager in internal settings, it simply isn't motivating enough. But if that data is out there, in the open, for the community to see, that's a very different picture. That just unlocks a competitive spirit which is inherent in each and every one of us. So now, when you put these two together, the coffee shop strategy and public competition, you now had a public health system which was significantly more motivated to improve citizen health. And now that you had a more motivated health system, it was actually a system that was now much more ready for support. Because now, there is a pull for the support, whether it's resources, data or skill building.

這套排名系統(tǒng)大獲成功。 人心大振， 各地區(qū)開(kāi)始相互競(jìng)爭(zhēng)， 爭(zhēng)當(dāng)?shù)浞丁?仔細(xì)想想，也不出奇。 如果只是由你的上級(jí) 在內(nèi)部環(huán)境里 審核績(jī)效數(shù)據(jù)， 動(dòng)力自然是不夠的。 但如果數(shù)據(jù)公開(kāi)了、 對(duì)外了、全社區(qū)都能看到了， 事情就會(huì)大不一樣。 這樣一來(lái)釋放了潛藏在 我們所有人體內(nèi)的競(jìng)爭(zhēng)精神。 于是乎，當(dāng)你們將 咖啡店策略與公開(kāi)競(jìng)爭(zhēng)合二為一， 就有了一個(gè)對(duì)于提升公民健康 今非昔比、動(dòng)力十足的 公共健康系統(tǒng)。 既然現(xiàn)在的公共健康系統(tǒng) 背后充滿動(dòng)力了， 它就比過(guò)去更需要獲得支持。 因?yàn)楝F(xiàn)在，無(wú)論是系統(tǒng)的 資源、數(shù)據(jù)、還是技術(shù)積累， 相應(yīng)的支持都要跟上來(lái)。

10:30

Let me share an example. I was once at a district meeting in the district of Ajmer. This is one of the districts that had been rising rapidly in the rankings. And there were a group of passionate doctors who were discussing ideas on how to better support their teams. One of the doctors had up-skilled health workers to tackle the problem of nurse shortages. Another doctor was using WhatsApp in creative ways to share information and ideas with his frontline workers. For example, where are the children who are missing from immunization? And how do you convince the mothers to actually bring their children for immunization? And because their teams were now significantly motivated, they were simply lapping up the support, because they wanted to perform better and better. Broken systems certainly need more resources and tools. But they won't drive much impact if you don't first address the motivation challenge. Once the motivation tide begins to shift, that's when you get the real returns off resources and tools.

我來(lái)分享個(gè)例子。 有一次我在阿杰梅爾區(qū) 參加地區(qū)會(huì)議。 這正是其中一個(gè)排名 飛速上升的地區(qū)。 會(huì)議上有一伙熱忱的醫(yī)生 在為如何更好地支持 他們的團(tuán)隊(duì)出謀劃策。 其中一位醫(yī)生 讓業(yè)務(wù)嫻熟的護(hù)工 來(lái)填補(bǔ)護(hù)士的短缺。 另一位醫(yī)生妙用 通訊軟件WhatsApp 來(lái)分享一線醫(yī)護(hù)人員 的消息與想法。 例如： “尚未接種疫苗的孩子們都在哪兒？” “又要如何說(shuō)服那些母親們 把自己的孩子帶來(lái)接種疫苗？” 正因?yàn)樗麄兊膱F(tuán)隊(duì) 現(xiàn)在動(dòng)力十足， 他們對(duì)支持來(lái)者不拒， 以求績(jī)效更上一層樓。 支離破碎的系統(tǒng) 固然需要更多資源與工具， 但如果不先把動(dòng)力點(diǎn)燃， 那些東西只會(huì)收效甚微。 一旦動(dòng)力的浪潮開(kāi)始涌動(dòng)， 你才能真正獲得 來(lái)自資源與工具的回報(bào)。

11:50

But I still haven't answered a key question. What happened to the performance of Rajasthan's public health system? In 2016, when our work began, the government of India and the World Bank came out with a public health index. Rajasthan was ranked 20th out of 21 large states. But in 2018, when the next ranking came out, Rajasthan showed one of the highest improvements among all large states in India, leapfrogging four positions. For example, it showed one of the highest reductions in neonatal mortality, with 3,000 additional newborn lives being saved every year. Typically, public health transformations take a long time, even decades. But this approach had delivered results in two years.

但有個(gè)關(guān)鍵問(wèn)題 我還沒(méi)回答： 拉賈斯坦的公共健康系統(tǒng) 績(jī)效如何？ 2016年，在我們的工作啟動(dòng)時(shí)， 印度政府與世界銀行 給出了一份公共健康指標(biāo)。 在21個(gè)大邦之中 拉賈斯坦排名第20位。 但到了2018年， 次屆排位公布時(shí)， 拉賈斯坦一躍而上連升四位， 是印度各大邦中 排名提升最大的邦。 舉個(gè)例子，其中一項(xiàng) 降低程度最大的指標(biāo) 就是新生兒死亡率。 每年增加了3000個(gè)被拯救的新生兒。 一般來(lái)說(shuō)，公共健康系統(tǒng)轉(zhuǎn)型 曠日累時(shí)，可達(dá)數(shù)十年之久， 但這套方法僅兩年 就見(jiàn)效了。

12:50

But here's the best part. There is actually nothing Rajasthan-specific about what we learned. In fact, this approach of using the citizen to trigger motivation is not even limited to public health systems. I sincerely believe that if there is any public system, in any country, that is in inertia, then we need to bring back the motivation. And a great way to trigger the motivation is to increase transparency to the citizen. We can do this with education and sanitation and even political representation. Government schools can compete publicly on the basis of student enrollment. Cities and towns, on the basis of cleanliness. And politicians on the basis of a scorecard of how exactly they're improving citizen lives.

而最棒的是， 我們研究的方法 并不僅限于拉賈斯坦。 實(shí)際上，這套利用公民 激發(fā)動(dòng)力的方法 也并非僅限于公共健康系統(tǒng)。 我由衷地相信任何國(guó)家， 任何公共系統(tǒng)， 如果缺乏活力， 都需要找回其動(dòng)力。 為公民提高透明度 就是激發(fā)動(dòng)力的不二法門。 在教育，衛(wèi)生 乃至政治代表方面 我們都能用上。 公立學(xué)校可以根據(jù)學(xué)生的 入學(xué)人數(shù)進(jìn)行公開(kāi)評(píng)比。 城鎮(zhèn)可以對(duì)比清潔度。 而政客們可以 就他們提升公民 生活質(zhì)量的程度評(píng)分。

13:49

There are many broken systems out there in the world. We need to bring back their motivation. The citizen is waiting. We must act today.

世上支離破碎的系統(tǒng)還有很多。 我們要讓它們重拾動(dòng)力。 那里的公民望眼欲穿。 我們的行動(dòng)刻不容緩。

14:02

Thank you very much.

非常感謝。

14:03

（Applause）

（掌聲）