What Public Health Programs Lack
On: June 9, 2021

A Q&A with Family Health Project founder Joe Knowles on why and how public health programs should take a page from business 101 and learn to scale programs.

What can the business world offer public health to help it reach more families with strong interventions? Joe Knowles, Director of the Family Health Project, thinks it’s the concept of scale. “Going to scale” is an unfamiliar idea to many, but it’s critical to success in a world of tight budgets, scarce resources, and growing problems.

What can the business world offer public health to help it reach more families with strong interventions?

So what is scale and how can public health benefit from it? We talked with Joe, who has launched and run several businesses over his career before getting a master’s in public health at Harvard. He started the Family Health Project to perfect an antipoverty program for young mothers. FHP is modeled after Babies First Years, a test of a guaranteed monthly income on babies’ brain development and health.

Below is an edited conversation.

FHP: So let’s start at the beginning. What is scale?

Joe Knowles: The simplest way to think about scale is for a business to produce its product at a lower cost per unit as they grow. They can do that in part because of their growth but also because of certain economies of scale. It sounds simple enough and it makes a certain immediate sense, but it gets complicated.

The best example is found in publishing. It costs the New York Times millions of dollars to put out one paper. But the second one costs a nickel because it takes no more extra effort. Software is similar. It costs a lot to produce one disc of software but from then on you’re just copying it. Then it’s a cash machine.

FHP: So you can grow without scale but it’s better to grow and scale, right? 

JK: Right. It takes a lot of resources to sustain growth without scale.

FHP: Yet public health is not profit making. So why worry about scale? 

JK: In this case it’s not about making a profit. It’s about being self-sustaining. For that you need two things.

First, you need to keep your eye on the expensive elements and do things as cost-effectively as you can. Nurse home-visiting, for example, could maybe achieve scale if they didn’t use nurses but used a paraprofessional with the right set of skills. And you could use technology to help with scheduling and to figure out the optimal number of visits per month. Right now, the program’s nurses visits as much as is needed. That kind of variance simply can’t scale.

FHP: So successful scaling is kind of like Marie Kondo-izing—if you don’t use it, wear it, or need it, get rid of it and streamline your life. In public health it’s not about more (unnecessary) activity, but about limiting activity to the optimal degree?

JK: The business sensibility says that when you’re looking at your impact, you look at every piece to make sure it’s necessary. If not, you want to get rid of it. Take diagnostic codes, which are a step toward scaling.  But I’ve seen people ask for more codes for intake. They have a code for a broken hip but they want to add a code for a left-handed person with a broken hip. Suddenly you’re looking at a standard public health form with 75 things to fill in even though you’re only looking for 8. You have to ask, is that helping youor the patient?

FHP: What about mission creep? Is that a problem in scale? 

JK: You have to keep your eyes on the prize and not get pulled in all directions just because the funder or the state or the head agency wants you to chase another outcome that fits an immediate need. Scale the program you started with. Diversions muddy the mission and your impact gets reduced. Same with the customer–succeed with the customer you can succeed with. You might branch out later but if you have to deal with a serious problem outside your purview, you won’t be as effective.

FHP: So what about the Family Health Project—what are the elements that make it scalable? 

JK: The beauty of the Family Health Project is that it’s a very simple idea and as long as we keep it simple, it’s powerful. It’s simple because it’s giving out money and it’s elegant for the same reasons. It’s a snap-it-together program with three elements.

There’s a referral source—federally qualified health centers, which are spread across the country. They are neck deep in the constituency we want to serve. Otherwise, if we went to a hospital or social service agencies, they’d all be a little different–different assumptions, constituencies, etc. We’d spend all our time figuring out how to do that.

The second piece is the debit card company, which gets the money to the mothers. Transferring money should work the same way every time, whether it’s a debit card, PayPal, or cutting checks. Luckily, we are working with a card company that has done this before. They can do it for $15, $15,000., Or more.

The final piece is a standardized screening tool for the referrals, which generates operational data that we can use. By the way, we collect no data on participants in the program. The group doing the screening is also able to offer other supports to the families as well, a bonus.

FHP: What’s the biggest “yeah but”– what do the skeptics zero in on? 

JK: Here are a few, each of which I’ve seen in action….unfortunately:

The first is that they say, but we arescaling:  our budget is bigger, we have more people, we’re serving more clients – isn’t that scaling?

The second is that they argue that scaling is less important than responding to the needs of the people they help (whatever that requires), making sure the members of the team are happy and employed, that no one in their mission-driven “family” is ever at risk of getting left behind,

And third, they are obsessed with maintaining absolute “fidelity” to their approach, which is after all “our reason for being”. So they never want to change it

Another one, is “We will scale, just as soon as we have the time and the money.”

FHP: Ironic, right? Thanks Joe.

As you’ve said before, we fully admit that we are amateurs in this antipoverty realm, but at the same time, like in business, we can learn and adjust, test and retest until we get it right.