Many health system diagnostics focus on understanding why performance is low. There may be more value in focusing instead on understanding why performance in some parts of the system is high. Chip and Dan Heath in their book Switch refer to these as ‘bright spots’, places where there are already successful ideas in place.
As an example, variation between neighboring countries can help identify areas in which to look for proven, scalable solutions.
For instance, access to timely diagnosis for infants born with HIV is critical to initiating life saving treatment. In this heat map of access to diagnosis for infants in Africa, countries such as Liberia, Zambia, Rwanda and Lesotho stand out as having much greater access than their comparable neighbors. The countries can help provide a blueprint for interventions elsewhere.
At the same time, variation between neighboring areas within countries can help identify good practice.
In Punjab, Pakistan, routine immunization coverage varies significantly between the province’s 36 districts. While Punjab’s average routine immunization coverage in 2011 was 47%, district performance varied between 9% and 80%.
While some inter-district variation is due to economic and geographic factors, the difference between neighboring districts cannot be explained only by these extrinsic factors. In fact, it turns out that in Punjab, the main driver of variation between neighboring districts is the effectiveness of district management of the vaccination program. Recognizing this trend meant that successful management approaches could be identified from high performing districts and spread throughout the system.
Most governments are well aware of the challenges they face. Where they struggle is in defining and implementing practical solutions to overcome those challenges. Concentrating more on understanding what works, rather than what doesn’t, may hold the key to helping them improve.