Some critical thinkers about complexity in development assistance

Thanks to Matt Dettman for pointing me to a new link,  now referenced in our resource page.

The idea of development happening in complex adaptive systems is so new, that the bloggers of 'Aid on the Edge of Chaos' are highlighting a speech on global resilience from 1970!

I'm going to keep an eye on this blog and see what other nuggets can be gleaned.

Cheers

Eric

Projects don't "do" Sustainability. Do they?

Trying to advance sustainability in the planning, design, implementation and evaluation of health programs--community health programs, or health system strengthening interventions--is our meat and potato at CEDARS. Some regular conversation topics keep coming back. One of the most critical and reasonable one comes up when someone says: "I like these ideas; it makes sense, and it does or would make sense to our local partners. But really, that's not how we work. We have 30 to 60 days to write a proposal, then staff up and kickoff a project and get deliverables. When exactly would you introduce those ideas?"

I've had these discussions so many times, so let me try to summarize the three lines of rationale these will gravitate toward:

• [1] It is actually possible to bring the steps of the Sustainability Framework (SF) process into the life of a project, and it doesn't have to be done as a ritual, design-along-the-dotted line kind of a thing.

The Lessons Learned report documents this with some level of detail, and options are presented again in the Long View Manual. And we're always interested in discussing practical options. 

• [2] The SF doesn't suggest a set of steps because we somehow missed how projects were planned for, designed, awarded, and implemented. 

There's a large body of evidence that the traditional way we end up running our projects has an inherent bias AGAINST sustainability (this may provide a useful, albeit long, reminder).

The proposed steps of the SF are trying to re-introduce in project designs some elements, which are naturally neglected and which have shown to have a major contribution to sustainability in multiple settings. We really did not invent anything, but having observed and learned from practitioners' best practices in the field, the SF is offered as a set of tools to attempt to intentionally force within our non-sustainable projects, some elements, which have a much better-than-average chance of improving the sustainability of health achievements in the communities where our projects place their heavy boots (rather Firestone or Dunlop 4x4 tires) on the ground.

• [3] The main issue is really again a - wait for it - system issue, but hear me out - I'm talking about a different 'system.'

Through the SF we often speak of the "local system" -- these actors / stakeholders who hold the future in their hands, on whose social capital, trust, cohesion, and then capacity, skills and performance, positive outcomes will rest long after we're gone. But, we are all are part of a global development system. Some call it an industry. This term denigrates the value of what a lot of people are doing day-to-day, but it reflects a basic truth: we operate in a system of agencies, funding streams, implementing mechanisms, country offices and project structures, private and government sponsors, marketing strategies, bids, projects, pursuit of "results", writing of promises in glamorous proposals, funding of some of these proposals as objectively as possible based on evidence, though sometimes not totally immune to fads, evaluations--the good, the bad and the ugly--and more lessons learned, and re-learned, and re-learned.

If I turn to those of us on the implementation side of thing (whether direct, partnership-capacity building, or just your friendly neighborhood beltway bandit Technical Assistance provider), of course we are on the receiving end of donor funds. This creates imperatives for survival (institutional, jobs, livelihoods). And this creates a necessity to be "responsive" (you cannot have great implementation of a project you did not win!). But we also influence and bring some learning to the overall system, even to our donors. If I look at USG language on sustainability, for example, I was struck last year by how the language had changed from old RFPs, concept notes and strategies, to how the Global Health Initiative writes about sustainability.

Years of experience, activism (think Global Fund), Paris Declaration, and maybe evaluation-research seem to have influenced how the language of sustainability is written up. Donors have their own systemic constraints, but over the long run, we are all eager to learn about what works and how.

If our traditional project approaches and the way we deal with sustainability as an afterthought or through literary prowesses in our applications and evaluation reports have not been working (for the long-term of societies we serve), and just feed into an empty cycle (actually working quite well for the development system we're a part of), it has consequences on those we call beneficiaries. Shediac-Rizkallah, much referenced in the sustainability literature, really drove that point clearly: except for emergency situations, unsustainable approaches do cause harm in the long run. I think we tried to make that point--numbers attached!--in last year's Health Policy and Planning paper. Sustainability is not the only thing, and there are times when compromises need to be made. But by and large, as we get resources to deliver results, we need to strive to inform the system we are a part of, about what maximizes sustainable benefits for communities and societies. Being more intentional, explicit, rigorous (honest?) in our dealings with the S-word will influence how our global development machine will operate tomorrow. And in the meantime, we will be doing a better job on the ground, in the local system which we are disrupting.

So, projects might inherently not be designed to maximize sustainability; and it might take a little work to introduce more intentionally some fundamentals, which successful 'sustainable' projects have implicitly integrated. And yes, the broadening of the M&E lens, which this requires is an additional challenge.

In the current context of increased country ownership, the main question is going to be how seriously we want to take the sustainability question at the local and global levels. After that, let's just find the tools that get the job done.

Eric

Ontological Measurement

Great op-ed in the NYT today:

There are two kinds of measurement: ontic--meaning finding out how big or small a thing is using a scale, beginning point and unit; and ontological--more of an experience than an act, when we sense that things don't "measure up" to what they could be. The argument is that anything complex cannot be described through ontic measures, though we may think we have perfected them. We are tempted to seek all meaning through ontic measuring, perhaps because we have not made similar gains in developing ontological measurement methods.

This has implications for how we approach measuring progress toward sustainability, especially as we describe it as relationships in a complex system. Are scales and indices appropriate to describe something like "community capacity"? Can it be measured empirically? Is such an exercise worthwhile? Or should we pursue an ontological method?

Systems, Systems, Systems

This was quite cute and slick - so we're all thinking about systems. (Mothers and families being the first agents of the "system" though, right?).

Interesting page from the World Bank and nice video clip.

Index of Governance as an Example of Quantification of an "Intangible"

You cannot deal with sustainability without a thorough look at the "environment". I uploaded a link to an attempt to do just that and create metrics--an index for governance. It's methodologically interesting, and the response from a country perspective (Rwanda) on the creation of these metrics is a good illustration of both the value and perils of trying to quantify complex issues such as governance and (for us) sustainability. But the critical thinking provoked by the creation of metrics seems, in itself, to be worthwhile.

DISCUSS! Quantifying Vulnerability to Climate Change: Implications for Adaptation Assistance

This is an article that Matt Dettman has brought to our attention. Read and DISCUSS! in the comments section.

Quantifying Vulnerability to Climate Change - Wheeler

Early Indicator of a Turning Tide?

The Center for Global Development shares a video of Liberia’s President Ellen Johnson Sirleaf. In her speech, President Sirleaf announces the intention to lead her country to be free of foreign assistance within a decade.

That may be a tall order, a long journey (pick your metaphor), fraught with challenges and unwanted effects. But I see this as a first furtive sign on the horizon that big changes are going to come. I remember the head of a bilateral agency in one of the poorest countries on us telling me: "we will align when they make us."

The transition to country ownership--whatever this means (hopefully not again government domination over civil society)-- is unlikely to be smooth and linear, when we have created self-replicating systems and institutions. There might be some turbulence before more functional inter-workings are found. But no matter what, it will start by countries and their governments raising a voice and taking charge.

Not sure it will always be pretty, but I think it's necessary.

Eric

Can Health Systems Adapt to Global Demographic Changes?

Last week I had the privilege of attending the Global Health Council’s 38^th Annual Conference in Washington, D.C. The conference focused on global demographic changes, which naturally result in a shift in the burden of disease as populations grow older. The key acronym of the week was “NCD,” or non-communicable diseases. As someone who has spent most of his professional life exploring ways to scale up proven interventions to fight infectious diseases in children (some of which are known as “NTDs,” or neglected tropical diseases), my first reaction was that the focus on NCDs would polarize the conference participants – NCDs vs. NTDs. One of my primary concerns was related to the scarce resources for global health and the concern that a focus on NCDs would divert resources – both human and financial – away from infectious diseases. In addition, I assumed that resources for NCDs would go to those who were living longer and more financially secure, which would overlook the poorest and most marginalized populations.
Recognizing the tension between the NCDs and NTDs, one of the conference co-chairs, Dr. Felicia Knaul (Director of the Harvard Global Equity Initiative), redefined the “NCD” acronym to represent the changing burden of disease by referring to “new challenge diseases.” Instead of focusing on the difference between communicable and non-communicable diseases, Dr. Knaul and the other co-chairs urged us to consider common obstacles and solutions that we all face. In particular, one problem that everyone encounters, regardless of the disease, is equitable access to healthcare. Those who are most marginalized have limited access to life-saving treatment and often die from preventable causes. This is true for both communicable and non-communicable diseases. For example, a child who is suffering from acute lymphoblastic leukemia has the same right to healthcare as a child who is suffering from acute diarrhea. Although the type of treatment may be very different, we should not evaluate a child’s right to quality healthcare based on the type illness. There is a need to strengthen health systems to provide quality, affordable, accessible healthcare that benefits all people who are suffering from all types of diseases. However, this will not happen by chance. Equity must be intentional. This is especially true when there are limited resources to address these new challenge diseases without neglecting the existing diseases that cause thousands of preventable deaths every day. We live in a world where the burden of disease is constantly changing and health systems are expected to adapt to these changes. In order to move towards a comprehensive, adaptable approach to health systems strengthening, we need to consider all health system components, processes, and relationships simultaneously and not as disaggregated parts. Although the solutions will be complex, they cannot be ignored.
How does this all apply to sustainable human development? As we consider the sustainability of health systems strengthening interventions, we must consider the fact that health systems, and the populations they serve, are not static. As populations change -- demographically, epidemiologically, and economically -- health systems must be positioned to adapt to the changing health needs of the population in a way that is equitable. This includes the health services provided at the facility-level as well as the household-level. Therefore, adaptive responses by the health facility must be matched by an equivalent response by the community so that treatment and prevention are accessible to all. This will certainly look different as countries go through demographic and epidemiological transitions at different points in time.
--Will

Link to Uganda New Food Price Crisis

As we've seen in a number of pieces of work, and most recently for us in 2007-2008 in the Middle East, food security--notably food prices have a direct negative impact on the poor even the middle class of a society. But the indirect effects accrue exponentially to the poorest: first they lack the "buffers" of economic resiliency which others can use, but then government responses tend to be self-protective and aimed at helping the urban middle class first. Nothing is lost, nothing is created: those responses tend to cost money and the money then comes short when it's time to maintain, for example, the health service infrastructure to remove and poor areas. Donor money also runs out...

This explains why there is so much current focus on food security, and why we feel it has to be an area of emphasis if we look at sustaining health outcome and human development.

Here's an updated blog from Bethany Duffield on Will's own blog page -- focused on today's situation in Uganda. A good read.

Wandering Thoughts on Sustainability, Conflict, and Social Capital

Last week, I had the opportunity to participate in a workshop at the Cyprus Institute on "Advancing Research and Science in Conflict Areas." This was organized by IPSO (the Israeli Palestinian Science Organization), Al Quds University (Palestine), Sapir College (Israel), the Cyprus Institute and our colleagues of RTI.

The three days were dedicated to developing a joint-research agenda on four main themes:

• Health, essentially psycho-social health—the area of my involvement as you may have guessed; but also 
• Water; Science Education; and Water History. 

We got exposed to the current situation in Cyprus, with presentations by Cypriot researchers involved on the two sides of the separation line (the "Green Line") between the Greek Cypriot (Republic of Cyprus) and the Turkish Cypriot (occupied by Turkey) zones. We got quite a taste for what researchers, as members of civil society, can do to advance intelligent dialog among people that have been alienated by conflict, notably through presenters from the Home for Cooperation / Association for Education and Research, a research association housed on the no-man's land / Green Line of Nicosia.

So - what does any of this have to do with sustainability?

Much, I'm afraid. And I won't go into all of it now. But I want to underline two main lessons, which actually hit me between the eyes on the first day of the workshop:

• [1] The ubiquitous importance of social capital to advance and sustain any social progress.

We speak a lot about social capital at CEDARS. It comes back again and again in the Sustainability Framework (Component 5), even if we usually use a less academic language a speak of 'Community Capacity.' We've mentioned before three types of social capital: bonding: bringing people together within a community (simplifying here)-- bridging: bringing communities together across a geographical or other divide-- and linking: linking community groups to authorities.

• During the workshop,stories made clear the erosion or destruction of 'bridging capital' through the Cypriot conflict; and of course the current situation in Israel-Palestine, where walls and check points keep communities almost totally apart except for "security" encounters.
• But the issue of 'linking capital' also came up, in conversations with people reporting progress in trying to work together on water management issues, or dealing with advocacy for peace initiatives, but identifying the next bottleneck of progress in reaching out to policy and decision makers.

So, end or mean, social capital and the processes that foster it are probably going to remain central to our--at least my interests for quite a while.

• [2] The progress achieved in Cyprus--while imperfect and with a long road ahead--illustrated to me another way in which complexity plays out between social, political, and development processes.

While our development efforts can create processes of social change, which can allow people to push for political and policy changes when needed; the acceleration of progress in Cyprus in very recent years also shows how political decisions are central in allowing more progressive, sustainable and scalable social and development processes to happen.

Situation of conflict or post-conflict just put a magnifying lens on these virtuous or negative spirals.

No simple take-home message, but the increased conviction that accepting to work on processes within complex systems is a necessity for all of us aiming to not just achieve results now, but be part of advancing sustainable human development, as researchers, implementers, policy agents, donors, partners, technical specialists, evaluators, and others.

--Eric

PAHO and the Lancet on Sustainability and Equity in Health in Brazil - the weight of people and politics

Health in Brazil - towards sustainability and equity in health 

May 9, 2011

The Lancet with PAHO are presenting a series of papers on the Brazilian health care approach. Here's the announcement text for this series, which can be accessed on Lancet's Website http://bit.ly/iAayVm

"……..Brazil has made significant improvements in maternal and child health, emergency care, and in reducing the burden of infectious diseases. But the news is not all good. The country continues to have a burden of injury mortality that is different from other countries due to the large number of murders, especially using firearms. Obesity levels are increasing and caesarean section rates are the highest in the world.

Brazil now has the opportunity to move closer towards its ultimate goal of universal, equitable, and sustainable health care as enshrined in the 1988 Constitution. To highlight this opportunity, The Lancet is publishing a Series of six papers that critically examine what the country's policies have achieved and where future challenges lie. As Cesar Victora and colleagues conclude in the final paper of the Series: "the challenge is ultimately political, requiring continuous engagement by Brazilian society as a whole to secure the right to health for all Brazilian people." 

Perhaps a good topic for a journal review with SHOUT colleagues.

Eric

Food Drives Global Politics

http://www.npr.org/2011/05/18/136394365/food-shortages-the-hidden-driver-of-global-politics

Fresh Air interviewed Lester Brown of the Earth Policy Institute in a segment about food as a driver of global politics. He wrote on this topic for the May/June issue of Foreign Policy.

A New Way to Engage in Dialogue about Sustainable Health and Human Development

Greetings all CEDARS Friends and SHOUT Members.

We've heard that the Forum Pages were not the most user friendly and did not allow rapid exchanges. We're going to try this format and this if it works better.

If you create a blog entry, please provide a label based on the broad categories of the CEDARS page. If more than one label applies, you can list as many as necessary and if you need a new label, then create a new one.

If you have not been given access to the blog, you can submit a question and will upload it within a day or two. Just email Ilona Varallyay or any one of us at Info@CedarsCenter.com.

And stay up to date on CEDARS by visiting us here.

Cheers All,

Eric