Who owns quality?

Atul Gawande has a rock star-like status in academic medicine. A towering global figure in public health and medicine and an author extraordinaire, he has been championing what is now dubbed as “improvement science”. Improvement science is an integrated approach, across various health units, aiming to convert research and knowledge into actual practices to substantially improve the performance of these health units. In a recent lecture to a packed audience at a Global Health Conference, he argued that a key principle in creating and sustaining improvement is to know and measure how far the current performance is from the norm. “This is, of course, obvious,” remarked someone sitting not too far from me. As I reflected on Dr Gawande’s point, and that of the person sitting close to me, I wondered: how obvious is it? Let us take the case of Pakistan as an example where the health, education, governance and many other systems are in constant need of improvement. That part is easy and hopefully we all can agree on. The part which stumps and endangers us is not knowing what the norm should be, and measuring how far we have deviated.

Let us forget about politics for now and think about our education system. Can we even agree on what the norm should be for a healthy education system? Is there a universal norm? Should there be a Pakistani norm? If so, what is it? Unfortunately, as the standards decline, year by year, not only does the system degrade, so does our definition of the norm.

The second part of the improvement science argument deals with improvement and quality itself. This part is connected to the first where one needs to know what the norm is and makes an effort to get closer to that norm. This is equally essential and perhaps, even harder to achieve. Let us assume, for a minute, that we somehow agree on what the norm is, and also agree that we are far from the norm. The question now is not only how we get closer to the norm, but who takes us there? Is it the government’s responsibility? Is it simply a matter of policing and creating incentives and penalties? And do we believe that as the government rids itself of incompetence, we all will enter the promised land? Or is it something that is the responsibility of citizens, parents, teachers and even students? The question to ask in this, and in many other systems of public welfare in Pakistan is, who owns quality?



While there is no reason to absolve those entrusted with leadership, the ownership of quality is not the same thing as having a head of an organisation. Ownership of quality does not rest upon a single individual but is, instead, a feature of the system as a whole. At a given university, a vice-chancellor may be entrusted with growth, stability or the financial well-being of the institution, but the ownership of quality rests on many more stakeholders within the system. The lack of ownership, at any point, creates small fractures that eventually become gaping holes beyond repair.

Other systems, such as pharmaceuticals, are no different. The ownership of quality rests not only on those who make the commodities, but also on those who distribute them, make them available, store and sell them and even those who use the products. We can enumerate systems ad nauseam and will find, in each case, that the desire to improve is inextricably linked to the ownership of quality.

Perhaps, the biggest transition needed in improving our systems lies within us. It lies in changing our attitude from demanding quality to owning quality.

Published in The Express Tribune, March 31^st, 2015.

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