A farewell to MSH

The journey is finally coming to an end. And as the saying goes, it is not the destination but the journey that counts. Actually, there is no destination. I have not arrived, just turned a corner.

When I started working at MSH it was Thanksgiving week in 1986. My new boss had just left for a month and had written down some instructions on what I should be working on. I was hired as a research associate. I don’t think I had a job description. I was joining a team that had started a 5 year project just a year earlier. It was like a startup.  We were building a road towards better management of family planning projects, laying the bricks in front of us. There was lots of energy in the old mansion of Brandegee – a mini Versailles, built by a wealthy merchant with aspirations. We were surrounded, at least downstairs, by curtains from the Imperial palace in Japan, a life-size John Singer Sargent painting of the merchant’s wife, Flamish tapestries and a vast collection of leather bound books that were very, very old.  Upstairs our deputy project director sat in an office that was originally a bathroom, marble-clad. The toilet and bathtub covered with planks.

MSH was already a teenager by the time I joined. I had an informational interview at the mansion two years earlier with one of its many experts – a gentleman who asked me what my expertise was. If I wasn’t intimidated by the setting, I surely was intimidated by him. I am sure I stuttered, turned red in the face and said I could do anything and I was a quick learner. But he dismissed me by saying that MSH needed experts, not generalists. When MSH won the large global FPMT project that changed. Women started to invade what was essentially a male club. After FPMT MSH was never the same again. MSH partnered with Pathfinder in the FPMT project. I had been working as a consultant for Pathfinder and had led the writing of one of the first books that considered the user’s perspective in family planning service delivery. The quality of care movement had just been born, with Judith Bruce who had written the first authoritative book on the subject. Pathfinder proposed me for a position that was sufficiently vague and open that narrow expertise was not required and probably not desirable. My attitude of being a quick learner, speaking French, and having lived in West Africa clinched the deal.

It was a heady time. Of all the people who were there then Ken Heise is the only one left now at MSH. He was the Zaire man, as the DRC was called then, and ex Peace Corps volunteer who had a vast network of friends from that time. All our sister organizations at that time had ex PC volunteers from Zaire – he was known in this new world I entered. I was not. I also was not sure what I wanted to do and what I was good at. I was a psychologist who had lived in Lebanon and Senegal, spoke French, had an American husband and two young children, lived about an hour’s ride north of Brandegee and was looking for a purpose.

That purpose I found when I learned about MSH’s MT (management training) program that was run in collaboration with the Experiment in International Living. We delivered multiple programs for various management disciplines which were essentially the WHO’s health systems pillars: financial management, pharmaceutical management, information management, human resources management and the management of service delivery programs for Child Survival and Maternal and Child Health. With some twenty participants who had come from all corners of the world, each course lasted 6 weeks full of intense learning about management in a highly experiential way. Relationships were forged then that lasted. More than a decade later I was embraced and taken to someone’s home for a meal in Guinea – he had participated in a course and it had changed his life. I was awed by this part of MSH and wanted more of it.

We also had a formidable team, consisting of worker bees like Ken, Ann Buxbaum, and myself, supported by an impressive cast of advisors, faculty members from INCAE in Costa Rica, from AIM in Manila, from one of the management institutes in India and of course from our own backyard, Harvard.

We had organized the task based on levels: we would develop experiential curricula, lots of case studies (influenced by Harvard and the Harvard wannabees) that would target senior level people, mid level managers and young leaders. Since I did not have a job description and my boss was travelling most of the time, I started to read, a habit I developed then and never abandoned. There was not much written about managing family planning programs – the research and literature was either about managing in the (US) private sector, or about the clinical/technical aspects of family planning. We developed case studies and made a deal with Kumarian Press. We published a lot. And then we started teaching what we were learning. And that is when I truly found my purpose. My first trip was to Nigeria, a place few people wanted to travel to. I joined a team of people who became my mentors, already highly accomplished thinkers and doers. One of them introduced me to the reading list for students in Organizational Behavior at the Yale School of Management.  Suffice to say I read them all. I now know many of those books are still considered the classics.

Although I started my traveling as the person who hands out the per diem, the gopher, I was able to sit in the sessions and even do a session, on delegation. We used the book of case studies written by David Korten – the only existing grounded book on the management of family planning programs. I prepared about 8 hours for a 2 hour session, practicing in front of the mirror in my hotel room, and then in front of my mentors.

I soon became a Nigeria expert; that was easy in those days: make a few trips to a country most people didn’t want to travel to and you are an expert. So easy, and so arrogant!

Over the years I realized that it was not so much the teaching that I liked but working with the stories of the people in the room and engage with them, dissect their experiences and help them find things that they could do differently, with less agony or pain and more effect. The dormant psychologist in me finally awoke.

In those heady first few years we were one of just a few doing management training focused specifically on the delivery of programs (FP, child survival, etc). There were of course the universities but their teaching wasn’t practical – a label MSH had already earned and which kept differentiating us from the pack. The other actors in the Global Health space then were CEDPA, which also delivered such programs (and was a partner with us on FPMT), but geared specifically to women. CEDPA had carefully managed and nurtured its alumnae network, something I believe was a tactical omission on our side. We neglected the power of relationships – women of whom many would rise to the top, over the years and who could open doors where others could not. Our own Fatimata Kane in Mali was among them. Fast forward and we know that CEDPA was gobbled up by AED which was then was gobbled up by FHI, becoming FHI360. But CEDPA, in my view, left a giant fingerprint in every country where family planning is now normal.

Back to the late 80s and early 90s: the world, it seemed, was awash with money for family planning. Population pressures, especially in Asia, had already surfaced as major drags to development over the last decades, though in many African countries family planning was eyed with suspicion, as a plot by their former colonial rulers to keep populations down. Family planning program managers had to tread lightly. Especially in Francophone Africa where family planning programs were delivered through state structures advocating for family planning was political suicide. As a result progress was slow and the activists often lonely.  The FPMT project created a network when networks weren’t as much in vogue as they are now, but our instincts were good: we had to connect them to each other and create processes and structures so they could learn from each other rather than teach them. The Francophone Regional Advisory Committee (FRAC) was created in 1986 at MSH in Boston. For the following 12 years we managed to bring people together in nearly each of the countries of the members with a fairly stable membership. Over the last 6 months I have met three women who were part of this network; we hadn’t seen each other in 25 years. Fatimata Kane of MSH/FCI/Mali was one of them. In Niger our FRAC founding member became minister and is now retired. In Mali, just a few weeks ago, I sat with another, also retired now. We talked about how the landscape has changed – family planning is no longer a dirty word and, although not at the levels where it should be, contraceptive prevalence has moved everywhere into the double digits.

And then there was AIDS, as it was referred to at first. The HI virus and resulting ‘slimming’ disease took the world by surprise. Early on we decided that family planning service providers should talk about AIDS and provide information and counseling (there wasn’t much else possible then). But the family planning program directors balked, as were the older nurses. Family planning was respectable, AIDS was not. They didn’t want any association.  But when years later PEPFAR started, with all its extra money, top up payments or attractive salaries, the family planning providers left in droves to work in the PEPFAR funded programs. I imagine one can pinpoint drops in performance of FP programs at that time.

And now the world is a different place in countless ways. Recruitment was easy way back, no need to check terrorist lists, no need to go through security checks at airports, Libya and Iraq still run by dictators (only Mugabe is still there). There was no internet – we had a telex machine that brought us messages from the field, long strips of punched paper curled up on the ground when one walked into the office in the morning. Our cable address was ‘MANSHEALTH.’ We had business cards that looked like lawyers’ business cards, Times New Roman type, no logo, no color. Voicemail was still in the future. We had phones that had small pieces of paper stuck to them with the names of our colleagues and the name of their significant other in brackets. We were amazed when we got our first COMPAQ computers, not individual ones, mind you. You had to go to the third floor library where one was installed. We used IBM selectric type writers. The new computers were not portable but, if needed, luggable, with amber letters dancing on a tiny screen, and floppies. To get anything done in the field took patience and perseverance and lots of time. I remember organizing a FRAC meeting in Guinea and getting a Peace Corps volunteer to travel 100 km to the nearest telephone so we could communicate about logistics.

I have worked an entire generation at MSH. Some of my young colleagues were born the year I started, or even later. They believe in MSH’s purpose. MSH’s creation story remains powerful, as some of us experienced when Ron came over this spring to address the JWLI fellows. He saw a need and he saw a problem that he ascribed not to lack of technical know-how but to the lack of management structures and, more importantly, leadership thinking. Over the years we have expanded management to include leadership and now governance, but the essence remains the same: if people responsible for services start to think and behave as managers who lead then the intended results will flow from there. How to operationalize this in a manner that differentiates us from our competition is the big challenge now.

And so I end this reflection on my journey at MSH with a sense of deep gratitude for what this journey has allowed me to do and become: I am clear on my purpose and will pursue it wherever I can: helping people to have productive conversations. I have been able to raise and educate our kids (one and 5 when I started, and now 32 and 37) – and yes, to all the new moms, it is possible to be a professional and a mother, but not without the agony of thinking you are not enough for anyone tugging at you, the sacrifices, the sleepless nights and tearful farewells.  They will appreciate later what it is you were trying to do, and admire you for it. There’s nothing like a good role model nearby.

I have a network of people I know and respect all over the world. I have gained innumerable deep life-long friendships with people near and far. I have been introduced to a young startup in Zambia that closes the loop for me: there are new versions of MSH in the making. There are young Rons out there. The opportunities for doing good abound, and so does the talent, like Ron’s all these years back, to do something about it. MSH can play the role of a wise elder, nurturing this talent and helping these young idealists to expand the work we are so deeply engaged in.

I want to end with something our erstwhile colleague Morsy (Mansour) wrote in the foreword to Managers Who Lead. Before we even developed the LDP, and in the experiments Jana Ntumba and I did in Guinea, we learned that leading is not about technical expertise – in fact expertise can get in the way and serve as a shield. It is also not about the numbers as the numbers can be fudged and require more controls which starts an endless cycle of more controls and more clever ways around them – people have an amazing capacity to spend their creative creative energy on the wrong things.

What we learned and now know to be true, is that what we are trying to bring about is a change of heart, as hearts cannot be fudged like results; hearts are sustainable as long as they keep beating.  Morsy expressed this so well: “what was missing was something inside [people’s] hearts, something that ignites the fire inside all who want to truly contribute or make a difference. What was missing was commitment. The question became: “How can we inspire this commitment in every health service team and team member?” This is the question that health managers around the world are asking. How can we take our limited resources and give the best of ourselves to ensure the quality we want our people to have? How can we not be stopped in the face of inadequate systems and limited resources? How can we motivate our staff to be creative in overcoming obstacles, when there are so many? I believe that when people are committed they can produce incredible results. Even if the systems are poor, with commitment they will find ways to continuously improve them.”

Morsy and Kahlil Gibran come from the same region and so it is not surprising to find that one echoes the other. Gibran reminds us that “Work is love made visible. The goal is not to live forever; the goal is to create something that will.” There you go, that’s the work. I hope these two quotes take you by the hand and lead you wherever you need to go.