Keep it Simple

By Deborah O’Neil, Ariadne Labs

Global health leader Atul Gawande has forged a groundbreaking approach to healthcare innovation by focusing on simple systems solutions, such as checklists, for improving care. The Brigham and Women’s Hospital surgeon and Harvard professor founded Ariadne Labs in Boston to deliver on this vision. He recently answered a few questions on its work.

You’ve been involved in a global initiative to improve primary health care systems. What is the role of primary care in achieving SDG 3: Ensuring healthy lives and promote wellbeing for all at all ages?

It may seem strange to hear a surgeon advocating for primary health care. But achieving universal health care is simply not possible without strong primary care systems. SDG 3 focuses on ensuring healthy lives across the age span, and the single most important but most neglected system required for meeting people’s primary health needs is primary health care.

The Primary Health Care Performance Initiative was founded by the World Bank, WHO and the Bill and Melinda Gates Foundation to improve primary health care through better measurement and transparency. Ariadne Labs is lucky to be among those involved. We have zeroed in on assessing the four key functions primary care provides — the “4 C’s” — that are known to save lives and improve health: (1) a reliable point of first Contact for health needs; (2) Continuity of care; (3) Coordination with other services; and (4) Comprehensive-enough care to handle the vast majority of a community’s health needs.

Every country is on a journey from limited primary health care, often focused on maternal and child health, to a more complete array of services for all ages, including prevention, chronic disease management and mental health care. The specific weaknesses of primary systems for delivering these, however, are invisible to local, national and global leaders. Our first step in this initiative has therefore been to make data public, revealing how differently countries even at the same income level perform. Ultimately, identifying clear, scalable strategies for strengthening primary health care systems is going to be essential for countries to reach universal health care efficiently, cost-effectively and equitably.

You recently published research showing that national rates of C-section delivery up to 19% are associated with reducing maternal and neonatal mortality rates. What are the global implications?

The implications are more complex than simply saying 19% is the target. The research indicates that countries with 19% of births occurring by cesarean delivery have the systems in place for maximal lifesaving capacity for pregnant women. But above that level, countries appear to lack systems capable of avoiding what can be significant overtreatment with high rates of cesarean delivery that confer no mortality benefit despite significant risks of surgical complications.

It is a major challenge to build systems that assure access to the care while ensuring that C-sections are provided appropriately. In a given country, you can have rural areas with no access to emergency obstetric care and urban areas with disconcertingly high rates of surgical delivery. No interventions yet exist to avoid the harms of both over-treatment and under-treatment.

What will it take to achieve the SDG targets to reduce the global maternal and neonatal mortality ratios?

Over the last century, science has identified a whole menu of practices that reduce the mortal danger of childbirth. They include measures that can prevent asphyxiation of the many babies born with difficulty breathing, and that can markedly reduce major maternal risks such as hemorrhage and eclampsia. And they include simple measures, such as skin-to-skin newborn warming and basic hand hygiene, known to be profoundly lifesaving. Public health authorities around the world have successfully increased facility childbirth rates in recent years. Yet the reductions in mortality have been meager because of poor quality of care. You just cannot count on birth attendants delivering these practices, even when they’ve been trained. The reasons have less to do with lack of skill or knowledge than lack of systems and management for quality of care.

That’s why I think that achieving the SDG targets will require scalable approaches to improving the frontline quality of childbirth care. The highest risk of death occurs in the perinatal period, and the quality of care of each facility has been a black box that we are only starting to open.

Debate will emerge over how much resources to direct at improving the management of facility childbirth. In the BetterBirth trial with PSI-India, we are testing whether we can improve practices and survival by coaching birth attendants and their supervisors to use the WHO Safe Childbirth Checklist through frequent face-to-face visits to foster problem-solving skills and using data to inform quality improvement strategies.

As programs like ours generate evidence, the question will be whether face-to-face interventions scaled across the world are considered cost effective, or whether we can make do with less intensive approaches. We are often more excited about investments in technology than we are about investments that support quality, but my sense is that’s where the big payoff will be.

Want to hear HER STORY? Read “BetterBirth Coaching Inspires Improvements in Birth Attendant Practices.”


Photo Credit: Aubrey Calo, courtesy of


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