and think of yourself as the leader of a country.

And let's say one of your biggest priorities

is to provide your citizens with high-quality healthcare.

How would you go about it?

Build more hospitals?

Open more medical colleges?

Invest in clinical innovation?

But what if your country's health system was fundamentally broken?

Whether it's doctor absenteeism,

drug stock-outs or poor quality of care.

Where would you start then?

I'm a management consultant,

and for the last three years,

I've been working on a project

to improve the public heath system of Rajasthan,

a state in India.

And during the course of the project,

we actually discovered something profound.

More doctors, better facilities, clinical innovation --

they are all important.

But nothing changes without one key ingredient.

Motivation.

But motivation is a tricky thing.

If you've led a team, raised a child or tried to change a personal habit,

you know that motivation doesn't just appear.

Something has to change to make you care.

And if there's one thing that all of us humans care about,

it's an inherent desire to shine in front of society.

So that's exactly what we did.

We decided to focus on the citizen:

the people who the system was supposed to serve in the first place.

And today, I'd like to tell you

how Rajasthan has transformed its public health system dramatically

by using the citizen to trigger motivation.

Now, Rajasthan is one of India's largest states,

with a population of nearly 80 million.

That's larger than the United Kingdom.

But the similarities probably end there.

In 2016, when my team was called in

to start working with the public health system of Rajasthan,

we found it in a state of crisis.

For example, the neonatal mortality rate --

that's the number of newborns who die before their first month birthday --

was 10 times higher than that of the UK.

No wonder then that citizens were saying,

"Hey, I don't want to go to a public health facility."

In India, if you wanted to see a doctor in a public health facility,

you would go to a "PHC," or "primary health center."

And at least 40 patients are expected to go to a PHC every day.

But in Rajasthan, only one out of four PHCs

was seeing this minimum number of patients.

In other words, people had lost faith in the system.

When we delved deeper,

we realized that lack of accountability is at the core of it.

Picture this.

Sudha, a daily-wage earner,

realizes that her one-year-old daughter

is suffering from uncontrollable dysentery.

So she decides to take the day off.

That's a loss of about 350 rupees or five dollars.

And she picks up her daughter in her arms

and walks for five kilometers to the government PHC.

But the doctor isn't there.

So she takes the next day off, again,

and comes back to the PHC.

This time, the doctor is there,

but the pharmacist tells her

that the free drugs that she's entitled to have run out,

because they forgot to reorder them on time.

So now, she rushes to the private medical center,

and as she's rushing there,

looking at her daughter's condition worsening with every passing hour,

she can't help but wonder

if she should have gone to the private medical center

in the first place

and payed the 350 rupees for the consultation and drugs.

No one is held accountable for this incredible failure of the system.

Costing time, money and heartache to Sudha.

And this is something that just had to be fixed.

Now, as all good consultants,

we decided that data-driven reviews

had to be the answer to improve accountability.

So we created these fancy performance dashboards

to help make the review meetings of the health department

much more effective.

But nothing changed.

Discussion after discussion,

meeting after meeting,

nothing changed.

And that's when it struck me.

You see, public systems

have always been governed through internal mechanisms,

like review meetings.

And over time,

their accountability to the citizen has been diluted.

So why not bring the citizen back into the equation,

perhaps by using the citizen promises?

Couldn't that trigger motivation?

We started with what I like to call the coffee shop strategy.

You've probably seen one of these signs in a coffee shop,

which says,

"If you don't get your receipt, the coffee is free."

Now, the cashier has no option

but to give you a receipt each time.

So we took this strategy and applied it to Rajasthan.

We worked with the government

on a program to revive 300 PHCs across the state,

and we got them to paint very clear citizen promises along the wall.

"We assure you that you will have a doctor each time."

"We assure you that you will get your free drugs each time."

"We assure you

that you will get your free diagnostics each time."

And finally, we worked with elected representatives

to launch these revived PHCs,

who shared the citizen promises with the community

with a lot of fanfare.

Now, the promise was out there in the open.

Failure would be embarrassing.

The system had to start delivering.

And deliver it did.

Doctor availability went up,

medicines came on hand,

and as a result,

patient visits went up by 20 percent in less than a year.

The public health system was getting back into business.

But there was still a long distance to go.

Change isn't that easy.

An exasperated doctor once told me,

"I really want to transform the maternal health in my community,

but I just don't have enough nurses."

Now, resources like nurses

are actually controlled by administrative officers

who the doctors report to.

And while the doctors were now motivated,

the administrative officers simply weren't motivated enough

to help the doctors.

This is where the head of the public health department,

Ms. Veenu Gupta, came up with a brilliant idea.

A monthly ranking of all districts.

And this ranking would assess the performance of every district

on each major disease

and each major procedure.

But here's the best part.

We made the ranking go public.

We put the ranking on the website,

we put the ranking on social media,

and before you knew it, the media got involved,

with newspaper articles on which districts were doing well

and which ones weren't.

And we didn't just want the rankings

to impact the best- and the worst-performing districts.

We wanted the rankings to motivate every district.

So we took inspiration from soccer leagues,

and created a three-tiered ranking system,

whereby every quarter,

if a district's performance were to decline,

you could get relegated to the lower tier.

But if the district's performance were to improve,

you could get promoted to the premiere league.

The rankings were a big success.

It generated tremendous excitement,

and districts began vying with each other to be known as exemplars.

It's actually very simple, if you think about it.

If the performance data is only being reviewed by your manager

in internal settings,

it simply isn't motivating enough.

But if that data is out there,

in the open, for the community to see,

that's a very different picture.

That just unlocks a competitive spirit

which is inherent in each and every one of us.

So now, when you put these two together,

the coffee shop strategy and public competition,

you now had a public health system

which was significantly more motivated to improve citizen health.