Sheila Leatherman is a Research Professor at the School of Public Health, University of North Carolina at Chapel Hill, and Visiting Professor of the London School of Economics in England. She conducts research and policy analysis internationally focusing on quality of care, health systems reform, methodologies for evaluating the performance of health care systems, and integrating microfinance and health access interventions in developing countries. Since 1997 she has worked in the UK as an independent evaluator of the impact on quality of care in the National Health Service (NHS), and in 2007 she was awarded the honor of Commander of the British Empire by Queen Elizabeth for her work in the NHS over the past decade. Her health care management experience in the US includes roles in state and federal health agencies, as chief executive of an HMO, and as a senior executive of United Health Group. She is an elected member of the US National Academy of Science Institute of Medicine and an Honorary Fellow of the UK Royal College of Physicians.

 

Ms. Leatherman is co-author of a series of chartbooks in the US produced by The Commonwealth Fund on the topics of quality of health care, child and adolescent health, the Medicare population, and health care quality in Canada (2010). Her current work in India, West Africa, Bolivia, and the Philippines includes serving as research advisor to two demonstration projects that seek to integrate microfinance and health access interventions, with the goal of identifying a global strategy for poverty reduction and health protection.

 

 

A: I’ve been working in health care for three decades. My first ten years were in the Veterans Administration (VA); that’s where I started my career in quality, in the late 1970s, as part of the VA transformation from the black sheep of health care to a paragon. After that, I was chief executive of an HMO. From there, I went to United Health Group, where I founded a health services research and policy institute. We did population-based work, similar to IHI’s Triple Aim work, to improve the performance and cost effectiveness of HMOs and hospitals around the country.

 

I became a full-time academic 11 years ago. In the late 1990s, I deliberately chose not to work in the US; the US health care system had so many flaws, and I did not see a will to reform. I had been invited to the UK initially for a short project; but I ended up staying on for 12 years, conducting an independent evaluation of the impact of the Labour government’s reform on the NHS over the past decade.

 

Over the past four years I’ve switched my primary area of research from wealthy countries to exploring the potential of integrating microfinance with health access programs to reduce poverty and improve health in poor settings. What started as a personal interest or avocation in microcredit for women in developing countries has developed into a research and policy analysis portfolio, working with microfinance institutions around the world. Our focus is working with local organizations and communities of women on education, training village workers, creating loans for medical care, and developing regional provider networks.

 

 

A: I think the promise is huge. Don Berwick [IHI former President and CEO] is sometimes frustrated with the standard of evidence that IHI is asked to come up with, as health care improvement is necessary and happening in real time. I find the same thing in the work I’m doing with microfinance. [Microfinance is the provision of small loans (microcredit) to poor persons to help them grow very small businesses.] Microfinance is going to happen; it needs to happen because it makes a difference in real people’s lives. I’m trying to figure out what is the level of realistic evaluation that can be done to help these small microfinance institutions that are in remote parts of the world to make better decisions about what kind of health care they’re going to be able to provide and sustain. It’s not randomized controlled trials — sometimes there are no controls at all — but you still need a model of evaluation. Quality of care is a hard science compared to microfinance!

 

 

A: It’s really hard. The most promising research we’re able to do right now is pre- and post-measurement. For example, if we educate women about water and sanitation, or diet, or HIV risk, or safe birthing techniques, there’s very good evidence that says women learn fast; they change behavior and it makes a difference to the health of families. And in some areas we’re beginning to get measured health outcomes. When women are taught about nutrition, we can do and have done anthropometric measures, like height for age and weight for age, and those children do better.

 

I’m a pretty data-driven person and I don’t believe in silver bullets, but if there is one, this is it: integrating the economic and the health interventions in one program that reaches women in their communities.

 

 

A: It’s always been around health and health care; it’s always been around improvement. The most interesting thing for me is, the older I get, the more experienced I am, the more sophisticated my work looks, all of that leads me back to the basics: so much emphasis is put on innovation, but to me one of the most innovative things is to do the basics right. That’s true whether it’s improving safety in tertiary hospitals through handwashing, or using microfinance to improve health by getting some source of income for a family to be able to have shelter and food, send the children to school, and get a little bit of health care when it matters.

 

 

A: Overall, I’m mainly motivated by where I can be most helpful; I don’t have an agenda. I’d like to work in population-based work, the Triple Aim work; in the Developing Countries area [Ghana, Malawi, and South Africa]; and thirdly, what I’ve always liked is figuring out what evidence is available, and how to put it together in a coherent fashion to inform policy and practice — especially national, state, or regional-level reform.

 

Most of my work, and what I’m most proud of, is functioning at the nexus of good enough science to hold my head up high in any academic setting, yet always using a realistic type of evaluation grounded in the real world of trying to do the work, and make the work better and better while we’re learning. That’s what IHI has done really well.

 

 

A: I stayed in the UK for 12 years, and I have been able to influence the government because I was able to find and put together data in a way that made sense. My colleague Doug McCarthy and I started this in the US with the chartbooks and I continued in England with another colleague, Kim Sutherland. We would figure out where in each country the data existed. Where we couldn’t find actual data we would go into registries, into clinical literature, into state health departments; we just relentlessly sort of trolled through the country. We did this in the US, the UK, Australia, and we’re now finishing up in Canada. In each country, it turned out to be a unique amalgamation of data pulled from lots of different places, and we basically organized it into a coherent framework and started telling the story through data.

 

 

A: It organizes data into domains, so that there’s a framework. Then for every bit of data, it says, “What is the meaning of this?” — whether it’s avoidable mortality, or death within 30 days of acute myocardial infarction — and tells it in a language that everyone can understand. And it’s all on one page. And the next thing you know, the chartbook data ends up being used for PowerPoint widely, picked up in Congressional testimony, and used by the media.

 

 

A: There are so many people who are real admirers of IHI, but they just need a little bit more to feel comfortable. IHI is working so broadly now, in so many different countries, on so many different clinical conditions, even non-conditions, that for really conscientious, smart people in the field, myself included, the question in our mind is, “They couldn’t be good at all of it, across the board. So what is it that they’re really good at?”

 

The answer is going to be a bunch of things, but not all the things. But as of now, that answer is not completely clear. It would be great to learn that, and to make it transparent to people.

 

 

A: Hopefully the US will pass legislation that increases access. Unfortunately, the legislation will be too narrow and limited in its scope initially, but the good thing is it will make clearer what the problems are, in terms of inequities in the US, inefficiencies, cost escalation that isn’t able to be supported. And that will create a whole new set of potential partners; the ones that may be most salient are the states. The national reforms are likely to put a lot of the responsibility for implementation and the financial burden back on states, so states will really have to up their game in terms of understanding how to improve the environment for health care within their borders. And IHI can be very helpful to states around this.

 

Some of that work is happening within the Triple Aim; and IHI’s experiences internationally also become highly relevant to states. This focus on what I call “geopolitical entities” will become more and more important to IHI in the future. It’s a different level of intervention. Instead of the focus being on the front lines and service improvement, it’s much more about taking into account things like community-level goal setting for population health, catalyzing regional networks, payment reform, regulation, even certificates of need which may come back into existence.