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I wrote in my February posting that the constraint to widespread use of New Rices for Africa was mainly one of overcoming the structural issues of access to seed, fertilizer and small-scale irrigation since farmers were very willing to adopt their use. In this post, I would like to explore these concepts around “getting to scale” a bit further using an example reported by Atul Gawande in the January 24, 2011 edition of the New Yorker. In the article, titled Hot Spotters, Dr. Gawande started with the question - Can we lower medical costs by giving the neediest patients better care? He wrote about the efforts of Dr. Jeffrey Brenner. Dr. Brenner is dedicated to developing a system of intensive outpatient care for complex high-need patients in Camden, NJ. He started his work by identifying and caring for one individual. If 1% of the 75,000 people living in Camden are considered “the neediest”, then Dr. Brenner’s system would have  to include about 750 individuals. In contrast to achieving widespread use of New Rices for Africa, Dr. Brenner faced issues of both identifying and activating individuals and of developing the structures to support a system to care for them.  

Dr. Gawande wrote of the skepticism Dr. Brenner faced in the community as his work unfolded. One woman, when hearing of the added attention she would receive from a social worker, asked “is she going to be all up in my business.” He enlisted the backing of a pastor with the Camden Bible Tabernacle and local community members to share stories about the large amount of money spent locally on health care. The message was that these dollars could be saved with the support planned by Dr. Brenner and better spent elsewhere in the community. Dr. Brenner also listened to the day-to-day issues people faced such as doctors who wouldn’t give appointments to individuals on Medicaid or some not knowing a clinic’s twenty-four hour call number. He worked within the community to overcome these issues. Once individuals began to make the decision to be part of Dr. Brenner’s program, he had to develop the structures needed to care for them. Sufficient staff, beyond volunteers, such as nurse practitioners to make home visits and social workers to serve as health coaches was needed. Information technology to gather referrals and track patients as the system grew had to be developed and sustainable sources of funding beyond small grants had to be found. Dr. Gawande wrote that Dr. Brenner’s Camden Coalition measured the impact on their first thirty-six patients. The results were impressive so Dr. Brenner continues his efforts to activate individuals in the community and to build structures to support their care as he works towards reaching the 750 neediest in Camden.  

Many health care organizations and community coalitions believe they can lower medical costs by giving the neediest patients better care. To realize this, they will need to take a testing and learning mindset and use good methods for influencing individuals to adopt changes and for building effective systems at scale. In this regard, there is a lot to learn from Jeffrey Brenner.

I recently came across a 2007 article I had saved from the New York Times. In the article titled, Africa, Prosperity from Seed Falls Short, Celia Dugger wrote about the merits of the New Rices for Africa, or Nericas. ”The seeds are a marvel producing bountiful, aromatic rice crops resistant to drought, pests and disease.” She continued however to describe a situation many improvers face “But a decade after their introduction, the seeds have spread to only a tiny fraction of the land here in West Africa where they could help millions of farming families escape poverty.” We often think reaching everyone who would benefit from an intervention or service is a matter of getting individuals to make the decision to adopt the change. Quite the contrary in West Africa, there “you have farmers who are very willing adopters of new technologies and want to raise yields.” To help diagnosis the problem, it is important to understand that to achieve improved performance at scale you need to consider methods for both spread and scale-up. Spread is focused on methods to increase the rate individuals adopt changes. Scale-up is focused on methods to identify and overcome the structural issues that arise as changes are adopted. When it comes to use of new rices, it is not a spread problem. “Villagers enviously spotted the new rices growing in a neighboring community’s field”. That was enough for them to make the adoption decision. The problem in West Africa is one of scale-up. Ms. Duggar wrote “getting access to seed, fertilizer and small-scale irrigation… is the holy grail of agriculture development” and so overcoming these structural issues is the constraint to wide use of new rices. Most improvers will need to spread and scale-up interventions to achieve their aims so, in future postings, more on the methods to do that and the connection to testing and implementation.