Making healthcare accountable

By John Zebrowski

As the new clinical care coordinator for the William J. Clinton Foundation's drive to halt the transmission of HIV/AIDS between mother and child, Sostena Romano is responsible for programs in 12 countries across Africa and Asia. For her, happy hour has become part of her management plan. "People work so hard that burnout is a real threat," she says. "So I insist we all stop for an hour or two each day to relax, to talk things over and figure out what we're going to do next. Sometimes the problems we're facing can seem so overwhelming that we need to take a step back so we can process what we're really facing."

Romano's career before joining the Clinton Foundation last summer had been on the clinical side of HIV/AIDS. For nearly 20 years she was the clinical coordinator for the pediatric AIDS program at Yale-New Haven Hospital. Advances in prevention and treatment essentially put her out of a job, so she joined the inaugural class of SOM's MBA for Executives: Leadership in Healthcare program, graduating last May. Her intention in joining the Clinton Foundation was to fuse her clinical background and business education in a way that makes healthcare delivery more efficient and effective. This aspiration was in keeping with the mandate of the foundation, which claims to be run more like a business than a traditional NGO.

Romano explains what it means to run an NGO like a business in terms of stakeholders and shareholders. For decades, the stake-holders in development projects have been the people on the ground receiving the aid; in essence, there were no shareholders. Donors gave money without strings and had little say on projects beyond approving what they saw in grant applications. "We function as a for-profit model, even though we're nonprofit," says Romano. "Our stakeholders are still the countries where we're working. But now we have shareholders, too. With our donors, it's no longer a blank check. They monitor and evaluate our programs — we encourage them to ask a lot of questions. Now the donors want to know what the plan is before you start implementing it. There's a real bottom line, which forces us to be more efficient and results-oriented."

When Romano first met with the head of the HIV/AIDS initiative, he told her that if most NGOs have a target of reaching 80% of a population but reach only 40%, they still consider it a success. "If you're running a real business model, that outcome is a failure," she says.

Romano's role at the foundation is analogous to that of an upper-level manager in an international conglomerate. She keeps tabs on the country teams from her home office outside New Haven, but takes frequent trips to visit them in the field, where she gathers information about events on the ground and provides guidance and motivation. Part of her job is to instill an entrepreneurial spirit in local workers. "I set the global framework, which lays out what we're trying to achieve, but leave the details of how each country team is going to do it up to those on the ground," she says. "I fly in when they need something, but also because there's a timeline and we're not working with an endless pot of money. This requires a certain amount of oversight. We're not just talking about delivering medicine. That's been done and it's not enough. We're trying to develop a healthcare system."

The goal of the initiative is to halt the transmission of HIV from mother to child in the targeted areas within three years. Effective treatments exist; the rate of transmission in most developed countries is nearly zero. But the lack of a healthcare system in the places where Romano and the country teams are working presents a problem. In the part of Tanzania where they're working, there is almost no infrastructure. The nearest hospital is at the top of a mountain, and can only be reached by unpaved, often impassable roads. Just getting the water to mothers so they can take the pills that prevent transmission of HIV to their babies is an epic task.

Most businesses would survey the situation on the ground and change course. "The reality of it can seem terrifying at first," Romano says. "But there's little we can do about it. We're going into places where when women go into labor, they start the four-hour walk to the hospital — when I went into labor I could barely make it to the car.

"In Tanzania, people travel five hours to get to the hospital. You've got an old woman, who's quite ill, and she's on a chair tied to a bicycle, and her sons are pulling the bike up the hill. Part of what I really like about this organization is that we know this is how things are, but we aren't deterred. We look at the problem and we say, 'We're going to do this.' It's that simple. To do any less would be to fail."