Professor Anita McGahan visits Class

by admin on March 3, 2009

Last Monday, we were lucky to have Professor Anita McGahan visit our class. Prior to her visit, two students, Susan and Hadiza, provided the following introduction:

“We are pleased to have Anita M. McGahan speak to our class this coming Monday. Professor Gahan has widespread experience in Global Health and has written several articles on the subject. Her current work is on the process of scaling up organizational models in the pharmaceutical, medical devices, and health-delivery sectors of emerging economies. In addition she has bold, innovative ways of looking at sustainability, economics, and social justice in health. She will lead a discussion on on building organizational capabilities in resource-limited settings, a topic relevant to all of our projects in Africa.

Professor McGahan is currently the Rotman Chair in Management at the Rotman School of Management at the University of Toronto, visiting Professor of Social Medicine at the Harvard Medical School, a Senior Associate at the Institute for Strategy and Competitiveness at Harvard University, the Senior Economist at the Massachusetts General Hospital Division for Global Health and Human Rights.  Her previous work experience also includes several years at McKinsey & Company and at Morgan Stanley & Company.”

Professor McGahan led a wonderful discussion that touched on many of the issues of the course. Afterwards, another student, Dapo, provided the following reflection:

“We were privileged to have Professor Anita McGahan as a guest faculty in the GLAB-Global Health Delivery class on February 24, 2009.

Relative to her huge career accomplishments, she is slightly built, rather sprightly and energetic, with a voice that demands your attention. Her fast-paced speech, sprinkled with the occasional “ Aye”, made me want to belt out the Canadian National anthem, “ O’ Canada…..” in celebration of the valiant attempts they have made to make healthcare accessible to the citizenry. Don’t pack your bags just yet though, healthcare for all is a work in progress…

Prof. McGahan jumped right in and engaged the class by asking about motivations for taking the class- responses ranged from interest in healthcare, to learning managerial challenges in resource-constrained settings, to passion for and curiosity about Africa. Likewise, the class got her warmed-up with questions arising from their experiences working in Africa in the previous month- issues raised ranged from the shortage of human resources, to operational efficiency and the dreaded “sustainability” question. The issue of sustainability not only linked the other questions together, but it is also an issue of great interest to Prof. McGahan.

She has written extensively about sustainability in global health, and argues that the current conceptualization of sustainability from the funder perspective is short-sighted and parochial. In her view, improved health itself is reinforcing and sustainable, when one takes a long term systems perspective. Paradoxically, she argues that while a specific program may not be sustainable using current metrics used by funders, the program health outcomes may in fact be sustainable using other measures. She posits that complex and varied reporting obligations are onerous and impose a significant administrative “sustainability burden” on fledgling organizations. While I appreciate her perspective, a counter-argument would be that programs or organizations need to themselves be sustainable in order to reach the promised land of desired health outcomes.

The aphorism that structure and incentives induce behavior holds true here- vertical healthcare programs, by design, have a parochial perspective and are loathe to measure success by horizontal outcomes. Perhaps an analogy from the U.S. healthcare system would be useful here- consider for a moment, that a pharmaceutical company makes a favorable cost-savings argument to a pharmacy benefits management company (PBM) based on decreased hospitalization. The likely response will be something along the lines of, well, that’s great, but for someone else, since I don’t pay for hospitalization.

This kind of “silo” thinking is pervasive in healthcare delivery in various settings; resource-constrained or otherwise. As an aside, I would argue that all healthcare systems are resource-constrained to varying degrees. The vertical-horizontal dichotomy is a losing proposition and there is clearly an opportunity for a third way – the diagonal approach or as some have described, a “public health polypill”. Here, I find the concept of integrative thinking espoused by Roger Martin, one of Prof. McGahan’s colleagues at Rotman quite useful. http://www.rotman.utoronto.ca/integrativethinking/definition.htm

In much of her work on sustainability in global health, McGahan makes a case that sustained funding commitments should be the focus and if persistent enough, positive health outcomes will follow. Put another way, it’s not about inefficient resource utilization, but rather insufficient sustained funding. This is a difficult pill for funders to swallow, even those with deep pockets. Is effective resource utilization at odds with increased levels of funding? I guess it’s the old chicken or egg debate.

Is health care different enough from other sectors, such that externalities (especially in global health) preclude rigorous measurement of organizational performance? If one extends the argument out, there would not be room for pay-for-performance metrics. Is global health too-big to fail? How do we know we have attained this utopian health state that Prof. MCGahan envisions, at which time sustained funding for global health can start asking tough questions? In my view, organizational and program performance and sustainability cannot be decoupled from program health outcomes.”

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