U.S. healthcare executives and managers planning to get involved in international ventures had best keep one thought in mind: There's no place like home.
"The most important thing for Americans to understand is, especially in healthcare, our unique system grew up in a very American environment, an environment that is not replicated anywhere else with the exception of white South Africa."
So believes Susan Cheney, a veteran of tours in Cameroon, the Central African Republic, Chad, India, Pakistan, Russia and Thailand, variously on the payroll of the World Bank, the U.S. Agency for International Development and private projects.
"When Americans go overseas and try to apply what they know, it's not (very) relevant, if at all," she says. "Of all the sectors, healthcare is as much cultural and economic and political as it is the technical delivery of healthcare."
Belief systems about medicine and care of the sick can play out correspondingly on the structure of healthcare delivery and finance. In every country they arise out of unspoken social norms and historical accident every bit as much as they do in the United States.
It's true, of course, that healthcare delivery systems around the world are wrestling with similar conflicts of cost and quality and choice and modernization. But Americans with foreign experience agree it's wrong to assume U.S. ideas about resolving these issues can simply be taken off the shelf and applied in a foreign setting.
The American who wants to be effective in an international setting must take heed that it's not just systemic contrasts in the workplace that matter, it's the entire style of interaction with local nationals and representatives of the host country. Personal relations, family life, language, food, even the sense of time-the successful candidate for a foreign posting must be adaptive on all counts.
Dan Mueller, an American who ran a hospital in Saudi Arabia from 1991 to 1994, learned more than he ever expected about rice. His hospital in Dammam employed 850 people, all of them guest workers from Bangladesh, India, Nigeria, the Philippines, Sri Lanka and other locales. It was the responsibility of Atlanta, Georgia-based Charter Medical Corp., the hospital contractor, to house, transport and feed all staff.
"They require different kinds of living environments, and feeding," says Mueller, now at BJC Health System in St. Louis, Missouri. "They don't eat the same kind of rice. That's culturally not acceptable. You can make a real bad mistake all at once" if you don't pay attention to these conditions.
Also, don't forget to leave time for prayer several times a day, and make sure all the units are covered when you do.
Mueller's stint in Saudi Arabia was a nonstop seminar on cultural diversity in the workplace. Communication was a constant challenge; correspondence had to be translated from English into Arabic, Tagalog and Hindi.
People from all those countries arrive on scene with wildly varying problem-solving styles and skills. "In the Mideast and South Pacific, consensus-making is extremely important," Mueller says. American-style top-down hierarchical decisionmaking doesn't get you anywhere. Issues and problems had to be discussed and resolved within the group. That can be time-consuming, but stronger buy-in from employees can save time in the long run.
"The task you want to accomplish, plan it well," Mueller says. "But adjust your time line. Don't be impatient. Relationship-building helped me. The execution, as a result, can be faster than I could execute over here."
Brian Stern, managing director of SHW Group in Cleveland, Ohio, an executive recruitment firm, recommends that Americans leave behind the authoritarian business style and feel out how the local nationals expect to be led. "Lead by example," he says. "You have to have control without being controlling."
And be flexible, Stern adds. "What it takes to be successful as you move abroad depends on a lot more than your technical expertise," he says. "You might understand healthcare intellectually and financially, but how quickly you can learn and how flexibly you can adapt is paramount."
What foreign countries want out of the U.S. is the technology, the quality and process improvement. "They certainly aren't looking for our administration and paper jams and legal system that go along with it," Stern says.
The U.S. Caesarean-section rate, for example, is higher than it should be partly because doctors delivering babies fear malpractice suits if anything should go wrong. Doctors practicing in countries without our legal apparatus don't live under that threat, and their C-section rates are lower without adverse effects, Stern said.
Virtually anyone you talk to about working abroad underlines the critical importance of building bridges to the locals. The standard American let's-get-down-to-business approach translates as rude and coarse in many parts of the globe.
Maria Currier, a partner in the Miami, Florida, law firm Steel Hector & Davis, has just moved to Caracas, Venezuela, to develop managed-care products in Argentina, Brazil, Chile and Colombia.
"It's been quite an adjustment. It's a little bit more laid-back. Response times are slower than we're used to," Currier notes. "It's part of their culture. There is a different sense of time. The urgency is not the same that we're accustomed to."
But doing business in Latin America is more formal than in the U.S., at least initially. It takes longer to develop the relationship that can lead to a deal. One of Currier's U.S. clients in Brazil had to work for a year before the Brazilians were comfortable enough to start talking about the actual details of the business arrangement.
From the U.S. frame of reference, how can that be economical? "There are always some very high upfront costs," Currier says. "You may not always reap the benefit of the capital you've invested for a few years."
However, she counters, if you take a look at how mature and competitive some of the managed-care markets in the U.S. are, you come to the conclusion that some of the best opportunities around lie south of the Caribbean, where countries are starting to privatize their obsolete and dysfunctional public healthcare systems.
At the same time, be sure to check out local firms carefully. "There are some outfits you don't want to do business with," Currier warns. "Some local entrepreneur types give you information about what they can do, what they have done, which may not necessarily be true."
Latin American business practices can be maddening even to Americans who have spent their whole careers there. Paul Bydalek, president of Atlantic Rating, an agency that rates credit of hospitals and other businesses, says from his office in Sao Paolo, Brazil, that the problem of not speaking the language pales beside the fundamental fact that in Brazil nothing is ever in black and white.
"Everything is negotiable. There are no hard deadlines and tough standards," Bydalek says. The idea of standards "will always be discussed," but they'll "slide a bit, which must be infuriating to people who have extremely high standards and tough deadlines. That's my own frustration after 30 years."
Bydalek sees a two-tier system in Brazil: a very expensive, technologically sophisticated and U.S.-trained elite of private doctors, serving the top economic caste, and a socialized system of public clinics operated by the government that's frightfully inadequate.
"You can find first-class care in Brazil as good as anywhere in the U.S.," he says. But the real problem is a lack of managerial depth, even in that top tier. The equipment might be state-of-the-art, but the nonphysician management is untrained and unsophisticated.
"Once you get beyond this doctor, who has been U.S.-trained, then you get to a local professional who may not speak English, who may not know how to use that equipment properly, who may not know safeguards for use or maintenance," he says.
After some research for a U.S. hospital that wanted to enter Brazil, Bydalek discovered "the professional administrator doesn't exist down here. You typically have just physicians who are part-time administrators, or you have full-time administrators who don't know much about medicine."
Staffing locally is troublesome, he says. "The department director doesn't exist in the same way. Even the job of chief nurse, those kinds of professions don't exist in Brazil."
Brazilians recognize this as a bottleneck; that's why people of means have serious procedures done in Miami.
U.S.-style parochialism can rear its head even within the multinational firm. "We probably have more of a problem in the U.S. thinking globally than we do in our international affiliates," says Sharon Campbell, export operations manager for Europe at Baxter International in Deerfield, Illinois.
Most of Baxter's sales are logged outside the U.S. Every now and then, a product is in short supply. Baxter can't manufacture enough of it to meet worldwide demand.
When that happens, it's hard for U.S. distribution managers to avoid supplying the domestic market first, then leaving the leftovers for the international market.
"It's not a process, it's not a system," Campbell says. "It's an individual (who) makes a decision, and the priority in the individual's mind is the United States."
Breaking out of the domestic U.S. mind-set is hard for most people planning international ventures, Cheney says. She now spends her days in Oakland, California, teaching physicians and managers at Kaiser Permanente International "how to adapt what we know." In the case of Kaiser, a managed-care company, that's mostly a matter of applying what's known about payment incentives to specific circumstances of the 20-odd countries in which KPI operates.
You have to empty your mind of the U.S. context if you're going to be effective abroad, Cheney emphasizes. If you don't, the results can be disastrous.
About 10 years ago she was called in to consult on a big project in Indonesia. A state-run company wanted to trim the costs of its in-house healthcare delivery system. The U.S. Agency for International Development persuaded officials to convert to a health maintenance organization, and they contracted with a U.S. managed-care company to learn how to do it.
"This consulting company brought over these two people who were extremely bright and talented," Cheney remembers. "They just had a very, very difficult time, even coming up with a plan how to transition this plan to an HMO.
"Because they were so out of context, they couldn't grasp how to problem-solve with them," she says. "They felt the first step was to convert this system into a third-party administrator and gather utilization information." But they had neglected to find out if there were any paper records in the employer's primary-care clinics.
"The rest of the world does not have healthcare claims that capture utilization information, upon which our U.S. care system is really based," Cheney says. Utilization information comes from claim forms, which were invented in the U.S. by insurance companies to process payments.
"It's possible to deliver care without a million paper claims," she says. The physicians on salary at this huge company were doing a great job in prevention, infant mortality and other things. "We, on the other hand, were focusing on minutia: how many lab tests and doctors visits, which was less relevant to these people," Cheney says. "It illustrates how you can get into a real problem if you can't adapt to the unique circumstances of the country you're in."