演讲MP3+双语文稿:如果你是国家元首，你将如何建立公共健康系统？

听力课堂TED音频栏目主要包括TED演讲的音频MP3及中英双语文稿，供各位英语爱好者学习使用。本文主要内容为演讲MP3+双语文稿:如果你是国家元首，你将如何建立公共健康系统？，希望你会喜欢！

【演讲者及介绍】Abhishek Gopalka

公共部门策略师阿布舍克•戈帕尔卡（Abhishek Gopalka）, BCG的阿布舍克•戈帕尔卡（Abhishek Gopalka）建议各国政府采取创新方法，为公民提供更好的服务

【演讲主题】发自内心的动力是如何修复公共系统的

【中英文字幕】

翻译者 Shengmin Huang 校对者 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?

花上一分钟， 把自己想象成一国领袖。 假如你最首要的任务 是为贵国公民提供 高质量的医疗保健。 你会如何着手？ 建立更多医院？ 开办更多医学院？ 投资医疗创新？ 但如果贵国的健康系统 已经烂到根子里了， 医生玩忽职守， 药物供不应求， 亦或是护理质量堪忧。 你将从何下手？

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.

我是一名管理咨询师， 在过去三年里， 我一直致力于一项 改善印度拉贾斯坦邦 公共健康系统的项目。 而在项目进行过程中， 我们确实发现了一些深刻的问题。 更多医生、更好的设施、 医疗创新—— 这些都重要。 但这些东西都缺少了一项 能发挥作用的关键要素。 发自内心的动力。 但动力是个棘手的玩意儿。 如果你带过团队、养过孩子 或是试图改变个人习惯， 你就会明白 动力不会凭空出现。 有些事情得改变了 你才会去在意。 要说有什么事 我们全人类都在意， 就是对自己能被社会瞩目 发自内心的渴望。 于是我们借此入手。

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.

我们决定聚焦于本国公民—— 那些本就应该由 机关系统服务的人。 而今天，我将告诉你们 拉贾斯坦公共健康系统 的急剧转型， 其动力是如何由公民激发的。 拉贾斯坦是当今印度 最大的邦州之一， 有着近八千万的人口。 比英国全国还多。 但可比之处仅此而已。 当我的团队在2016年受邀 到拉贾斯坦开始参与 公共健康系统工作时， 我们发现它已 处于危机状态了。

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.

就拿记录了未满一个月就夭折 的新生儿死亡率来说， 该数字高出英国新生儿 死亡率十倍之多。 难怪本国公民会说： “嘿，我可不想去公立医疗场所。” 在印度，你如果要到 公立医疗场所看病， 你就得去“PHC”， 也就是“初级保健中心”。 一所初级保健中心应有能力 每天接待至少40名来访病人。 而拉贾斯坦的初级保健中心 每四所里只有一所 能达到这个病人接待量的下限。 换句话说，人们对该系统 已然不抱希望。 当我们更深入地进行研究时， 我们意识到问责机制的缺失 正是问题的核心。

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， 苏达，一名日薪工作者， 发现她一岁大的女儿 闹了痢疾令她束手无策。 于是她决定请一天假。 这将损失大约350卢比， 也就是5美元的日薪。 而当她怀抱着她的女儿 徒步五千米来到 政府的初级保健中心， 却发现医生不在。 所以第二天她也得请假， 再次来到初级保健中心。 这一次，医生在是在， 但药剂师告诉她， 由于他们忘了及时订药， 她有权免费领取的 药物已经用完了。 于是现在，她赶忙跑向 私立医疗中心， 而在她快马加鞭的同时， 还要眼看着女儿的病情 随着时间流逝而恶化。 她不禁会想， 自己是否在一开始就该直接去 私立医疗中心， 并支付350卢比的 门诊与医药费。 这无人负责的 耸人的系统失职 害苏达损失了时间、金钱， 还令她备受煎熬。 要查补的正是此类漏缺。

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.

作为合格的咨询师， 我们认为必须以 由数据导向的审查 来应对问责机制的改善问题。 所以我们创建了这些 花哨的绩效展示牌 去帮助健康部门能更高效地 展开审查会议。 可无济于事。 一次又一次的讨论、 一场又一场的会议， 全都无济于事。

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.

这才给了我当头棒喝。 要知道，一直以来 各项公共系统都是 由这些审查会议之类的 内部机制来监管。 而长此以往， 外界公民对他们问责的 作用就被淡化了。 如果能通过公民承诺， 让公民们再次起到作用， 又有何不可呢？ 这样不就可以激发人们的动力了吗？ 我们的启动方案 被我称为“咖啡店策略”。 你们应该在咖啡店里 见过这样的指示牌， 上面写着： “如果您没收到收据， 咖啡就算您免费。” 这样一来，收银员就不得不 在每次结账时都要给你开收据。

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.

因此我们将此策略 应用在了拉贾斯坦。 我们与政府合作了一项 在全州范围内恢复300家 初级保健中心的计划， 还让他们将每一条公民承诺 都清清楚楚地印在了墙上。 “我们向您保证 您每次都能看上医生。” “我们向您保证您每次都能 领取到您的免费药物。” “我们向您保证 您每次都能接受免费诊断。” 最后，我们还与民选代表合作， 帮这些恢复的 初级保健中心重新开业， 让它们大张旗鼓地 将这些公民承诺 推广至社区。 现在，这些承诺已世人皆知。 食言就意味着蒙羞。 机关系统必须开始出力。 他们也确实出力了。 医生出勤率有所上升， 药物一应俱全， 而结果就是 不到一年，病人来访率 就提升了两成。 公共健康系统正在重回正轨。

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， 改变并非一蹴而就。 曾有一位恼怒的医生告诉我， “我是真心希望改变 我们社区的妇产保健， 但苦于护士人手不足。” 目前，像护士这类资源 实际由行政官员掌握， 医生也得向他们汇报。 现在医生们是有动力了， 这些行政官员 却没有足够的动力 去帮助医生。

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.

对此，公共健康部门负责人 维努·笈多女士提出了一条妙计。 所有地区每月都要排名。 该排名会对各地区 在每项重大疾病 和每次重要执行程序上的 绩效做评估。 而最妙的是： 我们公开了排名。 我们将排名放到了互联网上， 放到了社交媒体上， 不等你反应过来， 媒体就都参与进来了， 通过报刊文章 点评着各地区表现孰好孰坏。 我们不只是希望这些排名 能影响表现最好 与最次的地区， 我们希望它能激起 所有地区的动力。 于是我们从足球联赛中获取灵感， 创建了一套有着三级排名 的排名系统， 每个季度， 如果某个地区的绩效下降了， 那就将其排名降低。 而如果一个地区的绩效上升了， 就将其提升至最高档。

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.

这套排名系统大获成功。 人心大振， 各地区开始相互竞争， 争当典范。 仔细想想，也不出奇。 如果只是由你的上级 在内部环境里 审核绩效数据， 动力自然是不够的。 但如果数据公开了、 对外了、全社区都能看到了， 事情就会大不一样。 这样一来释放了潜藏在 我们所有人体内的竞争精神。 于是乎，当你们将 咖啡店策略与公开竞争合二为一， 就有了一个对于提升公民健康 今非昔比、动力十足的 公共健康系统。 既然现在的公共健康系统 背后充满动力了， 它就比过去更需要获得支持。 因为现在，无论是系统的 资源、数据、还是技术积累， 相应的支持都要跟上来。

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.

我来分享个例子。 有一次我在阿杰梅尔区 参加地区会议。 这正是其中一个排名 飞速上升的地区。 会议上有一伙热忱的医生 在为如何更好地支持 他们的团队出谋划策。 其中一位医生 让业务娴熟的护工 来填补护士的短缺。 另一位医生妙用 通讯软件WhatsApp 来分享一线医护人员 的消息与想法。 例如： “尚未接种疫苗的孩子们都在哪儿？” “又要如何说服那些母亲们 把自己的孩子带来接种疫苗？” 正因为他们的团队 现在动力十足， 他们对支持来者不拒， 以求绩效更上一层楼。 支离破碎的系统 固然需要更多资源与工具， 但如果不先把动力点燃， 那些东西只会收效甚微。 一旦动力的浪潮开始涌动， 你才能真正获得 来自资源与工具的回报。

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.

但有个关键问题 我还没回答： 拉贾斯坦的公共健康系统 绩效如何？ 2016年，在我们的工作启动时， 印度政府与世界银行 给出了一份公共健康指标。 在21个大邦之中 拉贾斯坦排名第20位。 但到了2018年， 次届排位公布时， 拉贾斯坦一跃而上连升四位， 是印度各大邦中 排名提升最大的邦。 举个例子，其中一项 降低程度最大的指标 就是新生儿死亡率。 每年增加了3000个被拯救的新生儿。 一般来说，公共健康系统转型 旷日累时，可达数十年之久， 但这套方法仅两年 就见效了。

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， 我们研究的方法 并不仅限于拉贾斯坦。 实际上，这套利用公民 激发动力的方法 也并非仅限于公共健康系统。 我由衷地相信任何国家， 任何公共系统， 如果缺乏活力， 都需要找回其动力。 为公民提高透明度 就是激发动力的不二法门。 在教育，卫生 乃至政治代表方面 我们都能用上。 公立学校可以根据学生的 入学人数进行公开评比。 城镇可以对比清洁度。 而政客们可以 就他们提升公民 生活质量的程度评分。

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.

世上支离破碎的系统还有很多。 我们要让它们重拾动力。 那里的公民望眼欲穿。 我们的行动刻不容缓。

14:02

Thank you very much.

非常感谢。

14:03

（Applause）

（掌声）