Products and processes

About a decade ago, I heard Atul Gawande at a global health conference. Dr Gawande, who now directs the bureau of global health at USAID, was a Professor at Harvard Medical School at the time. I was familiar with his writings and his books, some of which I had particularly enjoyed. On that afternoon, however, Dr Gawande talked about something else. He talked about the “checklist” study that he had been leading globally for quite some time. The idea was simple — to have a basic checklist for medical care providers to make sure stupid mistakes were avoided before surgeries. Among the first questions — as Dr Gawande described in his typical wit — was: “is this the right patient?” There were other questions as well, about things trivial and not so trivial, on that checklist. Sitting way back in the packed room, I was mesmerised. Other talks were all about cool gadgets and new technologies. This was exactly the opposite. It was about a topic that was simple, plain and seemingly ordinary. Yet, the impact of this mundane checklist was extraordinary. When Dr Gawande showed the results, I was stunned. The simple surgery checklist decreased death and morbidity by as much as 35% in several hospitals around the world. At the core of this trial was a simple, yet profound notion. Yes, we need new products to improve lives, but first we need to get the basics right for these new products to do what they are supposed to do. Without the basic processes in place, the structures built on shiny new products were just an illusion. His ideas were articulated in a brilliant book The Checklist Manifesto: How to Get Things Right.

The fixation on “innovation” is all too common these days. Progress is measured by the presence of innovative products, not basic processes that are the foundations of an ecosystem where innovation can provide meaningful outcomes. The necessity of basic process in innovation became obvious to me as I spent more time in global health. There was often no shortage of gadgets or cool technologies, yet they continued to underperform time and again. While healthcare is a particularly prominent example, the issue is pervasive in nearly all sectors.

The fixation on products in Pakistan is not hard to miss. Ministers in governments — across the political spectrum — often talk about how they are bringing new products to the market, whether they are financial tools or new technologies in other areas. Yet the underlying process to keep these products functional remains in a permanent state of disarray. Shiny new technologies arrive in hospitals with fanfare, yet remain under-utilised or in a state of disrepair because no one has thought about creating a cadre of technicians who are qualified to repair the new toys. Online payment systems sound great, but opening a bank account in the country is not for the faint-hearted. Freelancing is exciting these days but internet access or online services continue to be sacrificed at the altar of politics. Focusing on processes also means creating systems that are resilient and robust and are not that easy to turn on and off at the whim of a person.

This takes me to where we are right now. We can have products like forms 45 and 47 in all kinds of shapes and sizes, but in the absence of a robust basic process that links this information in a transparent and reliable manner, these products are not going to be of any use. We can have another half a dozen forms and documents, but the end result would remain the same if we do not invest in processes that ensure reliability and trust. Creating another election monitoring cell with big screens or introducing a new “fool proof” result transmission system would be just as bad as the previous one. We forget that the cool tools are exciting because someone did the boring stuff of developing reliable and resilient process first. No one, unfortunately, seems to be interested in doing that boring stuff.

Published in The Express Tribune, February 20^th, 2024.

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