Intended for healthcare professionals

Education And Debate

Lessons from developing nations on improving health care

BMJ 2004; 328 doi: (Published 06 May 2004) Cite this as: BMJ 2004;328:1124

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  1. Donald M Berwick, president (
  1. 1Institute for Healthcare Improvement, 375 Longwood Avenue, Boston, MA 02215, USA
  • Accepted 17 April 2004

Evaluation of projects to improve health care in resource poor countries can provide ideas and inspiration to the often stalled efforts in healthcare organisations of wealthy nations

Improvement is, I believe, an inborn human endeavour. My belief arises mostly from watching children. You cannot find a healthy child who does not try to jump higher or run faster. It takes no outside incentive. Children smile when they succeed; they smile to themselves. And so, it is my premise that almost all human organisations contain in their workforce an internal demand to improve their work. It saddens me how few organisations seem to know that, and fewer still act on it. Improvement is not forcing something; it is releasing something.

Nevertheless, improving organisations is not easy. The barriers are many, and those barriers can produce a sense of helplessness and futility. Failing to improve, we feel unfortunate and wish that someone, somewhere, would give us that extra missing resource that we imagine would make change possible. “We want to make care better,” goes the complaint, “but they won't let us.”

It might help us in the wealthy world to pause for a moment and reflect not on what we lack but on our good fortune. And the best way to do that is to look at those with less in their hands. In the past few years, I have been fortunate to do some work in resource poor countries, which have 90% of the people but only 10% of the world's wealth. My work in these settings has convinced me not only that it is possible to improve health care in resource poor settings but also that improvement may even be more feasible than it is in wealthy ones. Two remarkable projects in progress in the developing world show the tremendous …

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