Insiders Scoop: Achieving Health Equity – Dr. Kedar Mate



Name: Kedar Mate

Specialty/Interests: Physician Executive | Health System Design | Health Equity

Education: Brown University (BA) | Harvard Medical School (MD)

Current Position: President & Chief Executive Officer at the Institute of Healthcare Improvement | Faculty of Weill Cornell Medical College

About Dr. Mate:

Kedar Mate, MD, is President and Chief Executive Officer at the Institute for Healthcare Improvement (IHI), President of the IHI Lucian Leape Institute, and a member of the faculty at Weill Cornell Medical College. His scholarly work has focused on health system design, health care quality, strategies for achieving large-scale change, and approaches to improving value. Previously Dr. Mate worked at Partners In Health, the World Health Organization, Brigham and Women’s Hospital, and served as IHI’s Chief Innovation and Education Officer. He has published numerous peer-reviewed articles, book chapters, and white papers and has received multiple honors, including serving as a Soros Fellow, Fulbright Specialist, Zetema Panelist, and an Aspen Institute Health Innovators Fellow. Dr. Mate graduated from Brown University with a degree in American History and from Harvard Medical School with a medical degree. You can follow him on Twitter at @KedarMate


1 | What experiences solidified your dual interest in medicine and policy?

Early on, I was uncertain if I wanted to make medicine my profession. Instead, I was certain only about one thing: I wanted to position myself to try and remediate the injustices that I saw in the way the world worked.

For context, my father is a physician and my mother is a microbiologist, and given their work, I found myself exposed to medicine from different angles at a very early age. And admittedly, it may have been this very exposure that left me uncertain if I wanted to pursue this profession in the first place.

Growing up, I would travel to and from India, which gave me ample opportunity to glean insight into the burdens that different populations are forced to bear. Quite honestly, it is hard when you’re in India not to experience poverty in some form. It happens to be right there in your face. You can’t avoid nor should you try. But it was pretty stark to see the difference between what life was like for me and what life was like for other people.

I came to realize that even amongst people who are at the same economic level in their respective societies, life could be substantially different from one country to the next. Personally, my family was positioned in the middle to upper-middle class, but our standard of living was very different from what it was for people who were at the same economic level in India.

These insights forced a younger version of myself to probe, ask questions, and dig as to why the world was the way it was. And it became apparent that these differences were rooted in the systems that were built. To some degree, the systems in place perpetuate this kind of injustice – economic injustice – which culminates in avoidable suffering.

This perspective complemented my exposure to my parents’ work. Again, medicine was in the water around me and I was routinely exposed to the field, which ultimately influenced my interests. I went to Brown University to continue grappling with these questions surrounding injustice by studying American History. Some might wonder about history as a path to a career in medicine and public health, but for me understanding the root causes of disease had everything to do with our histories.

After graduating from college, I started to work for an organization called Partners in Health (PIH) from 1999 to 2001, which many in medicine recognize as the foremost social justice organization. As a relatively young man right out of college, my time with PIH was very influential and ignited my interest in medicine and policy.

It happens to approach social justice questions through the lens of healthcare, and it has a very interesting ecosystem through which it imparts global change. I saw doctors, anthropologists, economists, political scientists, and diverse disciplines come together with a shared focus on improving the health of impoverished communities in countries like Haiti and Peru. Despite the nonmedical backgrounds that some of these individuals had, the team brought rich perspectives that beautifully and effectively converged to redress social injustice through healthcare and medicine.

After working with PIH, I decided to pursue the medical path thinking that at some point, I’d shift my focus towards policy. Formerly, I figured that I would pursue a master’s in public policy or something of the sort down the road, but my primary interest at the time was medicine.

While I was at Harvard Medical School, I took a leave of absence and I went to work for the World Health Organization (WHO). So instead of formerly pursuing a master’s in public policy, I went to work for a policy organization and garnered real-life educational experience in policy.

My experience was incredibly formative. We were trying to operationalize a massive treatment expansion of HIV care. I was a part of a team that was running an initiative entitled “3×5,” which was established with the goal of treating three million people with HIV infection by 2005.

Over a year and a half, I gathered extensive experience in policy and translation. I was able to work with governments and institutions and thoroughly understand how policy is brought to life.

Ultimately, my time with Partners in Health and the World Health Organization fed my perspective and became hugely influential parts of my background. In the end, these experiences fueled my interest in both medicine and policy, and fundamentally, it was exposure that led me to make the decisions that I did.


2 | What were some of your most formative experiences from your time with Partners in Health and the World Health Organization?

At the time, we were working on Tuberculosis care and I spent a lot of time in Lima, Peru, where I supported community health workers in delivering treatments. My job was to help these health workers to assist their patients to take their medicines and get better.

My time with these workers was greatly formative because I was able to immerse myself in community-level efforts, visit peoples’ homes, and observe patients and their treatments. I saw firsthand how patients could take second or third-line anti-tuberculosis agents, heal, and return to their livelihoods. And ultimately, my time in community health work shaped my medical interests and solidified my interest in medicine.

On the policy side, I also had an experience that was particularly memorable. At the WHO, we were setting up a mechanism to procure second and third-line anti-tuberculosis medications and distribute them amongst countries that needed them.

These countries were trying to navigate their way through a market failure in second and third-line medications. Because certain countries had relatively few cases of drug-resistant tuberculosis, their capacity to buy TB meds was very much compromised because they didn’t have the volume to negotiate a reduced price. An incentive for a manufacturer to produce those meds was relatively limited because the countries didn’t have the purchasing volume. Nobody was buying these drugs because they were priced so high.

So we found ourselves with very poor countries trying to buy very expensive medications for a very small number of patients – and these patients were effectively falling through this policy crack.

To resolve this, we aggregated the demand of all of these countries that had relatively small numbers of TB patients and added them all up, creating a much larger, collective demand for these medications, which allowed the manufacturers to lower the prices. This enabled more of the countries to buy these medicines, which allowed these patients to get treated. The policy mechanism we leveraged was known as the Green Light Committee.

It’s not a very creative name, but we created this Green Light Committee at the WHO to pool that procurement and essentially farm out medications to countries that had technical programs and could consistently deliver them amongst patients.


3 | What does your current role entail today and what have you been working on since the pandemic?

Currently, I am the President and Chief Executive Officer at the Institute of Healthcare Improvement. The institute is a Boston-based organization that has been around for 30 years. We collaborate with health systems and gird them to deliver evidence-based practice reliably and consistently and solve the persistent systems-level challenges that clinicians are tasked with each day.

As a trainee, a medical student, or as a resident, you’ll see the daily challenges that healthcare systems face in the context of delivering great patient care and evidence-based treatments with reliability and consistency.

IHI is in the business of trying to solve this fundamental problem and has built a reputation as an innovator, convener, leader, and trustworthy partner in this domain. Having been around for 30 years, we are situated in 40+ countries and have forged hundreds of relationships with strategic partners and health systems across the world, which positions us to impart change at a systemic level.

Over the course of the pandemic, we did several things.

First and foremost, as time unfolded, we were constantly expanding our knowledge and capabilities to combat COVID-19 and were focused on transmitting this growing understanding across healthcare systems and nursing homes. We then worked with these groups to translate this understanding into tangible guidelines that would enable care to be delivered effectively and safely for all patients.

We began supporting national partners in several countries. In the early days, we collaborated with these partners to identify sources of Personal Protective Equipment (PPE) and to develop and standardize clinical practice guidelines around COVID-19 care.

We were then invited to partner with the Agency for Healthcare Research and Quality (AHRQ) to help nursing homes.

As you might recall, in the early days of the pandemic, the first few cases of COVID-19 were traced to nursing homes. Unfortunately, nursing home infections were getting out of control and culminating in tremendous death and despair amongst residents and caretakers.

Given this challenge, we were invited to partner with an organization called Project Echo to reach all US-based nursing homes and supply them with COVID-19 knowledge and skills, and to optimize their operations for safety and effective delivery. We served to help resolve clinical problems as well as operational problems: we tailored their visitation policies, found a means of separating infected residents from non-infected residents, helped vaccinate the nursing home population, and administered treatments.

Ultimately, we helped 9,000 nursing homes, securing their environments from the threat of COVID-19.

We also host a dynamic Leadership Alliance – a group of 55 of the largest health systems across the US – to facilitate fruitful collaboration. Over the pandemic, we leveraged this alliance to trade knowledge and information about COVID-19.

This practice is representative of one of the biggest things that IHI does: we cultivate learning communities within health systems and across health systems.

Thus, a great deal of what we were doing was helping not just nursing homes, but hospitals and health systems to learn about what would make the most sense to do and to help approve and standardize best clinical practices.


4 | What are some of the greatest challenges facing the US healthcare system?

Looking at the present constellation of challenges that we have here in the US, there are two issues that immediately come to mind.

Fundamentally, I believe that to truly bring about a healthier society, we have to invest in social sectors, social care, and coordination between healthcare and social care.

To be clear, we have done a lot when it comes to our investment in healthcare delivery. However, there remains a lot that we can accomplish through healthcare investments that are better optimized to create health. There are a lot of lessons we can derive from examining systemic investments in Europe.

In particular, in the UK, they have combined budgets to ensure that healthcare and social care are integrated, and they’ve facilitated better communication between these two sectors far more successfully than we have. And across the OECD, you see that social care investment has increased and healthcare investment has leveled.

We have to think about this. I don’t know that we have to level our healthcare investment but we certainly have to increase our social care investment so that we can create safety-net systems that are capable of improving the health of our communities.

A great portion of what we see in the ER and hospitals are manifestations of a very fragmented social safety net and a relatively weak infrastructure to support social care. There is a need for investments in social care, investments in insurance and health, and investments to better meet the social needs of our patients and their families.

Secondly, we have to work on health equity. I have spoken and written on what we can do to achieve health equity, and I sincerely believe in the concept of targeted universalism.

Targeted universalism entails pursuing processes aimed at helping specific (targeted) populations to meet (universal) goals to benefit all.

We can break this concept down. Firstly, we all have universal goals – peace, and better health for our families are two such goals. These are not goals that are uniquely shared by one person. They are widely held goals. However, one’s capacity to achieve these goals and bring them to fruition is not constant across society. As you can imagine, we have different starting points for our ability to achieve these universal goals.

We all strive to raise prosperous children, but the reality is that we all have different histories and are positioned at different starting points to work towards this goal.

If we seek to achieve this universal goal – to raise a generation that is more successful and healthier than we are in this present generation – then it will require us to invest in a targeted fashion in families who have not been as fortunate to date.

This is what we need to do to create real equity in health. We have to make targeted and specific anti-racist net-discriminatory investments that will enable the next generation to live healthier lives than we presently live. And I think that is going to be a big game-changer for us.

To summarize, we need to increase our investments in social care and better integrate such social care into healthcare. Secondly, we need to work towards health equity and leverage the concept of targeted universalism to get there.


5 | Given the hurdles that the pandemic has exposed, what should healthcare leaders and policymakers be focused on?

While I can name countries doing a better job at social care and healthcare integration and social investment, I cannot name a country that is wildly way more successful at remediating health inequity. That is where we have to lead.

We have a history and legacy of slavery that is rooted in millennia of oppression here and elsewhere. But this is our chance to turn that narrative on its head and make a difference. As I’ve described, for us to turn this narrative around, we need to reinforce the systems in place so that we have more than a health care system. Instead, we need to develop a health-creating system.

I have five proposals I’ve written about: we need to shift digital health from invention to implementation; create environments that empower patients to co-produce their care; extend our duty to care to the safety of our workforce; ensure an authentic focus on equity and harness targeted universalism as the mechanism by which we bring such equity to fruition; and design for scale.

To proffer more on the third point, as we are seeing in this pandemic, there is enormous pressure on the system to create better health. This pressure has taken a toll on those in healing professions, and we have to find a way to help our workforce.

The healing professions are the best – admittedly, I may be a bit biased – but ideologically, the concept of serving to support another person’s health and wellbeing is beautiful. After all, what can be more important than helping a fellow human live?

I can’t think of a more noble thing to do. But in my view, we have not protected our workforce.

Most glaringly, this was apparent in the face of the personal protective equipment (PPE) challenges we faced but has become apparent more recently and throughout. Mental health as a phenomenon has been a challenge for many of us, but I think the pandemic has provided an opportunity for us to renew our focus on our workforce and take better care not only of our patients but also the people that provide the care: the nurses, the doctors, the social workers, the online health professionals, everyone.

There have been moments over these last two years that illustrate the importance of realizing the interdependencies in medicine. Moments, where nobody on a ward can get lunch because the food service team is depleted by COVID-19, should not be overlooked. Nothing works when we are not healthy as a workforce – and this applies to everybody.

I don’t think we need to necessarily look at countries to figure out how to solve this. We can learn from different industries.

I think what manufacturing has done to protect its workforce is remarkable. I think what Paul O’ Neill used to do with Alcoa – stressing workforce safety as a cardinal principle to center all efforts around – is the gold standard. That is what we need to be thinking about moving forward.

How do we ensure that our workforce feels heard and protected? How do we make sure that our workers feel physically and psychologically safe?


6 | How might the dynamic between insurers, the government, providers, and hospitals change in the coming years?

I think the dynamic between these groups will shift with time. Over the last 10 years, public engagement in the health sector has grown, and just over the last year, we have spent 10% more on healthcare because of COVID-19 primarily. This isn’t a small thing: 10% of a very large number is itself a very large number.

Given this trend, I do see government investment in healthcare increasing. I hope government investment in health will include social care as I mentioned earlier so these investments are not purely going towards robotic surgery and advanced cancer care. Not that these things aren’t important – they are. But investments should also flow just as much towards redressing food insecurity, ensuring that everybody has a home, and equipping every child with a pre-kindergarten education. These variables largely determine health expenditures down the road. Not whether or not a hospital has the latest eye machine.

Again, I imagine government investment in healthcare increasing. That said, I don’t foresee an end to private insurance. I think that will always be present, but I believe that the role of private insurance will change over time as public insurance becomes a bigger part of what we do.

I also think that the definition of a provider is liable to change. Historically, we have largely seen providers as clinics and hospitals, but we are already seeing diversification in the providers of care.

We see expansion in retail – Walmart, CVS, and Walgreens to name a few – and we see home health growing very substantially. We also see nurses and doctors coming out to our houses and homes to do work like dispatch health. These examples are indicative that hospitals and clinics will morph over time from fundamental centers to receive health into something different.


7 | What should the US healthcare system eventually look like?

It’s been widely said that health begins in the home, and hospitals are for repairs.

Our engagement with the healthcare system should resemble our engagement with automobiles. To keep a car healthier, we regularly add oil, but every now and then, in the face of something unexpected, we have to take it to the shop. That is how we need to be thinking about healthcare.

Health shouldn’t wholly happen in hospitals and clinics. We have to systemically maintain good health on a regular basis.

Technology is going to change things as well – it will significantly enhance our ability to know how healthy we are and those who have access to that technology will be able to tailor their decision-making to optimize for health.

Again, this raises the concern of equity, which needs to be taken into account as technology shapes our capacity to maintain good health.


8 | What would you like to instill within all physicians-in-training?

I want to reinforce the choice that you made – the amazing decision to commit yourself to caring for people. Despite the challenges we’ve been facing, I want to instill within all members of the healthcare sector that they’ve made the right choice. There is no doubt about it.

Someday, when you have the opportunity to bring a baby into the world or tell someone that they are healthy again or even share some bad news – perhaps the course of one’s illness has taken a negative turn – you’ll realize that you’ve made an amazing choice and entered a very privileged space where people place their trust and faith within you for the most important thing they have: their life. It is indeed a privilege, so embrace this amazing choice you’ve made to pursue this road and serve those in need.


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