Health Affairs

Over the past decade, it has become popular to invoke the term “strategy” in global health.  For many NGOs operating in developing world contexts, strategy is synonymous with “vision.”  For others, strategy is the set of operating activities that meet a defined goal.  And for others, still, strategy represents the ex-post principles invoked to justify an organization’s actions.  In short, the term remains variably used and ill-defined.

But what is “strategy” really?  And how can a disciplined focus on it enhance the work of global health organizations?  At the risk of further confusing the term, I offer a definition enumerated for use by for-profit firms:

Strategy is the unique set of activities and operating structures that an organization puts in place to deliver value to its customers.

I offer clarification and refinement to three components of this definition to help demonstrate how a rigorous focus on strategy can improve the effectiveness of global health organizations.

“Unique Set of Activities”

The first part of the definition of “strategy” that warrants elaboration is the term “unique set of activities.”  A “unique set of activities” implies making choices about what an organization does and does not do.

In global health, these choices represent a special challenge.  When an organization has to broadly source funds, it is exquisitely vulnerable to mission creep.   In runs the risk of being perpetually hostage to the funding priorities of donors.

I do not write this native to the temptations of funding.  For over a decade, I have been involved with an NGO that focuses itself on providing women’s and children’s health services in rural villages in South Asia.  A major US donor recently offered the NGO financial support to launch renal dialysis centers.  Did the NGO turn away the funding because it was outside of its core priorities?   No, it did not.   Instead, it proceeded to develop the centers, and hundreds if not thousands of people have since benefited.

But the decision to expand into dialysis services did not come without a cost.  The NGO was no longer so clearly associated with women and children’s health.  While management had previously been vigorously focused on those domains, it was now learning and operating in a new field in which it had minimal background or foundation—detracting, in important ways, from the organization’s core work.

The donation—while seemingly an unmitigated boon—had many hidden costs that made the decision to offer dialysis services more complex in retrospect.  “Strategy” in global health requires making tough choices about where to focus efforts and resources—and where not to, even turning down funding opportunities from time to time.

“Unique Set of Operating Structures”

The second part of the definition of “strategy” that warrants elaboration is “unique set of operating structures.”

As an example of one dimension of an organization’s operating structures, many global health organizations function as confederacies, distributing responsibility for execution to regional offices.  By emphasizing the voice of the front lines, the logic goes, the organization will be uniquely responsive to local problems.  This represents a deliberate choice that carries associated costs, i.e. not standardizing operations.

In one organization to which I have consulted, the operations looked and felt different in South America than they did in West Africa, prompting me to ask how these offices were related outside of their funding streams.  In the absence of standardization in operations across the regions, what was the role of the organization’s central leadership?

The right balance of central or distributed control will vary according to the organization and its aims, but there is a decision implicit in an operating model that shapes the nature of the contributions it will make.  And this decision may very well contradict or be in tension with other strategic aims.  Defining a coherent and “unique set of operating structures” is a critical, often overlooked, aspect of developing strategy for global health organizations.

“Value to Customers”

The final idea that warrants elaboration is delivering “value to customers.”  As others have written, value to customers implies a ratio of outcomes achieved to the cost required to achieve those outcomes.  How we define value is yet another important decision.

In global health, different notions of value may guide us towards different operational activities and structures.  In our India-based NGO, we have historically measured our “outcomes” in terms of quantity of services, i.e. number of babies delivered or vaccines administered.  Yet for service-oriented NGOs, should the relevant outcome measure incorporate overall access to services?  Quality of services?  Or some aggregate thereof?  The term “value” will take on different meanings depending on the answer.

There is an additional question implicit in the notion of value to customers, namely, who are the organization’s customers?  Are they Ministries of Health?  Funders?  Multilateral organizations?  Or the end users of the services?  The answer, of course, is likely to be all of the above.  Yet, the relative weight given to different customers leads to different definitions of success and different ends.

The failure to prioritize among constituencies is regrettably common.  No matter how noble the aspiration, judgment is required to drive towards a vision of value that is consistent with the organization’s overall mission.

Bringing Strategy to Action

Strategy, defined clearly, implies tradeoffs.  A first step towards building “strategy” in global health is in navigating through the various ideas implied by the term, and building a common understanding of its meaning.  Strategy requires that organizations puzzle through different sets of “conflicting virtues”—funders, activities, customers—and establish a priority order among them.  None of these decisions are without their challenges; deciding to clearly define and grapple with them, however, will be an important step towards greater organizational effectiveness and results.

This entry was posted on Monday, March 12th, 2012 at 11:32 am and is filed under All Categories, Global Health, Personal Experience. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.