Interactive exercise companion to The Formula for Better Health teaching resources by Dr. Tom Frieden. This tool is designed to be used alongside the original teaching materials — visit formulateaching.theformulaforbetterhealth.net for the full instructor resources.
The Formula for Better Health
Chapter 4 · Believe in a Healthy Future · Interactive Exercise
SEE
BELIEVE
CREATE
From pilot to scale — India, early 1990s
500,000 TB deaths a year. A proven treatment exists. What do you do?
"Pilot projects are the graveyard of innovation — not because they produce bad evidence, but because they produce evidence under conditions that do not predict performance at scale."
— Chapter 4, The Formula for Better Health
SEEBELIEVECREATE
What this exercise is for
Chapter 4 argues that the central obstacle between seeing a problem and acting on it is the illusion of inevitability — the assumption that current suffering cannot be prevented. Three practices shatter that illusion: celebrating past progress, making phased progress, and cultivating optimism as a deliberate strategy. This exercise works through all three, using India's tuberculosis programme as the case.
You will make four decisions about how to design Phase 1, assess whether your design actually produced what Phase 2 needs, make a scaling decision and navigate its consequences, and confront the challenge of maintaining belief in the goal while arguing for a careful pace.
Graduate framing
As you work through each step, notice what is driving your intuition — evidence, political logic, operational constraint, or institutional habit. The chapter's synthesis is: Believe = evidence + optimism. Evidence without optimism produces paralysis. Optimism without evidence produces Soper. This exercise asks you to hold both, and to identify where each element is present or absent in your decisions.
The situation — India, early 1990s
India faces the world's largest tuberculosis burden: an estimated 500,000 deaths per year from a treatable disease. DOTS (directly observed treatment, short-course) achieves high cure rates where it has been implemented. The question is not what to do. The question is how to take a proven intervention from the handful of places where it has been tested to the hundreds of districts across the country that need it. You advise the programme director. Phase 1 is about to begin.
500KTB deaths/year in India
Hundredsof districts nationwide
Highcure rates possible with DOTS
5districts selected for Phase 1
How it works: Five steps. Design Phase 1 → check readiness for Phase 2 → make the scaling decision → confront the optimism question → see your outcome and debrief. Allow 20–25 minutes.
Learning objectives
1
Distinguish a phase from a pilot structurally — and explain why the difference is not rhetorical. A phase presumes Phase 2; a pilot does not.
2
Apply Styblo's three Phase 1 criteria, identify which failure mode each prevents, and assess whether a given Phase 1 design actually produced what Phase 2 requires.
3
Analyse the speed tension — and articulate the conditions under which immediate scale-up would be justified and what concretely fails first when it is not.
Analyse the political economy of scaling decisions, and apply the chapter's distinction between cultivated optimism and misplaced optimism to the challenge of arguing for measured expansion without losing team belief in the goal.
Step 1 of 5 — Design your Phase 1
Four decisions
How would you set up the first phase of India's national TB programme?
Graduate framing
For each decision, identify the failure mode you are most trying to avoid — not just the outcome you want. A programme designed to avoid the wrong failure is as dangerous as one making the wrong choice. The conventional pilot "selects the best site to maximise success rates and produce the most impressive results" — Styblo's Phase 1 is designed to answer a completely different question.
Select one option per decision. Each reflects a real and defensible position — there are no obviously wrong answers until you see what each produces.
1
Which districts should Phase 1 operate in?
You have resources to run Phase 1 in five districts — India's Phase 1 did run in five, including Vaishali in Bihar. How should they be selected?
2
How many districts should Phase 1 cover?
More sites broaden the evidence and test transferability; fewer allow deeper supervision and more concentrated learning.
3
How will programme leadership stay connected to what is actually happening?
Supervision takes time and resources. You need to decide how intensive to make it — and whether its purpose is oversight or joint learning.
4
What is Phase 1 primarily designed to produce?
Phase 1 takes political capital and time. Each option below prioritises a different output. What does your Phase 1 treat as the primary goal?
Please make a selection for each of the four decisions above.
Step 2 of 5 — Phase 2 readiness check
Before you scale
What did your Phase 1 actually produce?
Graduate framing
Three conditions must be met before expansion is justified: trained managers confirmed for every district that will receive the programme, drug supply and laboratory capacity confirmed at national scale, and supervisory coverage maintainable across the expanded programme. In practice, these conditions are rarely met simultaneously — which is why phasing is the default, not the exception.
Why this check matters
"The conditions under which immediate scale-up would be justified: when the programme has already produced trained managers for every district that will receive it, when drug supply and laboratory capacity are confirmed at national scale, and when supervisory coverage can be maintained across the expanded programme. In practice, these conditions are rarely met simultaneously — which is why phasing is the default, not the exception."
Step 3 of 5 — The scaling decision
The minister's question
Phase 1 results are strong. How fast do you scale nationally?
Graduate framing
The minister's urgency is not unreasonable — every year of delay has a cost measured in preventable deaths. The phasing argument must engage that reality directly, not avoid it. As you choose your pace, keep in mind your Phase 2 readiness assessment from the previous step: the right pace is the pace your Phase 1 actually prepared the programme for.
Moving too fast — scaling to all districts before Phase 1 has produced transferable knowledge — thins management capacity, overwhelms supply systems, and loses the quality control that made Phase 1 results meaningful. Moving too slowly loses political momentum and institutional support. The costs of scaling too fast are also preventable deaths. A programme scaled beyond management capacity will have poor treatment success rates. Patients who fail treatment are more likely to develop drug-resistant TB — harder and more expensive to treat.
How fast do you expand?
Select the option that best reflects what you would recommend to the minister.
What is driving this recommendation?
Please select a scaling speed before continuing.
Step 4 of 5 — Cultivated optimism
Believe = evidence + optimism
How do you argue for careful expansion without losing belief in the goal?
Graduate framing
The chapter's synthesis is precise: "Evidence without optimism produces paralysis. Optimism without evidence produces Soper." This is not a philosophical observation — it is a programme management problem. The TB India case sits in Chapter 4's Believe section specifically because phased expansion requires sustained belief that the goal is achievable, held through the political difficulty of arguing against the minister's urgency.
The chapter's central argument
Chapter 4 argues that the illusion of inevitability — the assumption that current suffering cannot be prevented — is the central obstacle between seeing a problem and acting on it. Three practices shatter it: celebrating past progress, making phased progress, and cultivating optimism as a deliberate strategy. Phased expansion is not just an operational framework. It is how a programme sustains the belief that scale is achievable while doing the careful work that makes scale real.
Evidence
+
Optimism
=
Belief
Cultivated optimism — Foege
Foege called himself the "Resident Con Man" — he knew the goal of smallpox eradication was achievable because the evidence supported it, and he protected his team from the moments when evidence seemed to contradict it. Cultivated optimism: "we can do this because we have done comparable things and we understand the differences." Grounded in evidence. Deliberately sustained.
Misplaced optimism — Soper
Soper's confidence was earned — he eliminated Anopheles gambiae from Brazil and Egypt. But he applied it too broadly, assuming his model would transfer to settings with different vectors, different constraints, different politics. Misplaced optimism: "we can do this because we have done things that looked like this." The difference is not enthusiasm — it is whether evidence has been tested against the current context.
The minister is waiting. How do you make the case for measured expansion?
You have argued for a pace the programme can sustain without losing the quality Phase 1 achieved. The minister pushes back: "Every year of delay is preventable deaths." Select the response that best captures the argument you would make.
Please select a response before continuing.
Step 5 of 5 — Outcome & debrief
What happened
From Pilot to Scale — outcome & analysis
Decision by decision
How your choices map onto Styblo's framework
Each criterion is a failure-prevention mechanism, not a checklist item. The table below shows where your choices aligned with the framework and where they missed — and the specific failure mode each gap produces.
What Phase 1 must produce — the three outputs
"A Phase 1 that produces only outcome data is a pilot with a different name."
Management capacity
Trained managers who can lead Phase 2 districts — not the Phase 1 team redeployed in new locations.
Transferable knowledge
Operational learning that could only come from real-world implementation — what reports do not contain.
Institutional commitment
A pre-committed Phase 2 timeline built into the programme structure — making Phase 2 the default, not a new political decision.
Interactive exercise design, scenario architecture, and tool format by Dr. Louisa Sun, National University Health System.
Licensed under CC BY-NC-SA 4.0.