Note: I moved last August to Save the Children in Washington DC, where I now work as Sr Health Systems Strengthening Advisor. I look forward to continued engagement with my friends and former colleagues at ICF/CEDARS.
It’s a little known secret that I own a network of low
altitude satellites which monitor every workshop and conference on sustainable
development in the world. Like every day.
I took a random representative sample of all 784 workshops
and meetings on development that were held last Tuesday and did a textual
content analysis. The following exchange was recorded verbatim 1,458 times,
which corresponds to 1.86 times per meeting with a 95% C.I. from 1.26 to 2.18:
- “Thank you to the panel for presenting an interesting approach, but I don’t think this can be applied with a cookie cutter in every [country | province | district | commune | village],” said one participant from ‘the field’. To which a first panelist replied:
- “Obviously, we are not proposing this as a blueprint. There is no blueprint to this complex issue.” A second panelist interjected:
- “I totally agree, there is no blueprint. Our approach needs to be adapted to the context.”
STOP!!!!!!!!!
My satellite monitoring is equipped with internal logic
contradiction sensors, and these sensors were systematically triggered by this
last statement.
Funny story actually about these sensors--when I had first
installed the logic analysis program, I struggled a bit. I was getting error messages
like “logic routines not applicable to development work,” and “analytics must
be supported by either evidence or shallow catchphrases supporting comfortable
intellectual habits.” I had to upgrade the software to accept logic again. I’ll spare you the details of programming, but
it involved encoding into bits Aristotle, Descartes, and Einstein’s thought
experiments. Hard work, but I’ve digressed.
The root of the internal logic contradiction is the simple
fact that it’s only blueprints that you need to adapt to context. So, if you’re
going to adapt to context, don’t tell me that there’s no blueprint. Say: “we
intend to adapt the blueprint for the context.” And that leaves unsolved the
question of what to do, when there’s actually no blueprint. But let’s take it a
step at a time.
The beauty of
blueprints
‘Blueprint’ is actually a metaphor in development—not a real
thing. Martin Reynolds of the Open University in the UK regularly points out
that we should not “mistake the map for the territory.” So, let’s start with
what a real blueprint is actually for.
A blueprint is a document which details the way to build
something, and shows how to arrange different sub-systems (drywall, electrical,
water pipes, ventilation, etc.) of a structure. It’s great to have a blueprint,
because someone has thought through and tested configurations of these
sub-systems and made sure that they all work together to provide integrity and
functionality to the structure. It spares you from [new metaphor coming]
reinventing the wheel each time, and taking advantage of evidence-based best
practices. Consider my neighborhood, a lot of houses were built on the same
pattern in 1940. Only small variations due to topography existed when the
houses were built, but people have been building additions, knocking down walls
and modifying them ever since, so every house is now a little bit different
from the next one.
I want to finish my basement and need to figure out how to
do it. Lucky for me, my neighbor did her basement and let me look at how she
did it. I’m happy with what she did and I’m going to use it as a blueprint for
my own basement. Since our two houses are not exactly identical (our basement
stairs were put in different places for one), I will have to adapt her blueprint to the specific context
of my house.
So, blueprint: great. Adapting to context: of course. It’s
not either or. It’s the latter because of the former. If there was no
blueprint, I would not be adapting my neighbor’s approach, I would have to
imagine something different for my basement.
And the same applies to global health. Consider just a
couple of examples:
IMCI (the integrated management of childhood illness) was a
blueprint. One could argue that because people always ignored the health
systems strengthening element of IMCI, basically because the blueprint was not
respected, IMCI was considered as a failure. I know this is a long debate. Another
example? iCCM (integrated community case management), infection prevention and
control, prevention of post-partum hemorrhage in health facilities and with
misoprostol in communities, the childhood immunization schedule—all countries
adapt those strategies or intervention packages, but there is an unmistakable
blueprint. Even some more complex non clinical interventions have blueprints, sometimes
tacit or enshrined in legal documents and policies. You want to run an NGO
(non-governmental organization) to deliver a public good? Well, there’s a
dominant blueprint that you need to have executive leadership, held accountable
to some sort of a board, and a financial accountability and oversight
structure. After that it gets messier, but those parts seem to be based on a
blueprint that is accepted for the robustness and risk mitigation they provide
to the organizations. And—again--it always has to be adapted to context.
So, before I tear some of this down, let’s recap the major
points so far:
- Blueprints are useful and they can help us be efficient and avoid re-inventing things that have been tested and validated through empiricism and accumulated human experience and wisdom.
- All blueprints need to be adapted to context. It would be utterly ignorant not to adapt to context, the worst kind of hubris. Even the science of management has long accepted contextual management as a requirement. I don’t think that I need to get into an inventory of the ‘white elephants’ of international development at that point. (Do we love our metaphors or what?)
- So, please don’t ever brag again about adapting to context. And do me a favor; next workshop you attend, when the panelist says, “there is no blueprint. Our approach will be adapted to the context”, please rough him up a bit and just make him stop. It really messes with my satellite monitoring analytics, and I can’t have any of that.
When there’s actually no blueprint
Let’s go back to our panelist and participant from ‘the field.’ [Spoiler alert: I may caricature the differences in perspectives to stress my point.] The panelist actually has a blueprint, a plan, an idea, an intervention, which he believes is now tested and proven to be able to deliver a public good. Variation in contexts is a challenge--an adaptation and implementation challenge--to be able to deliver what he knows can work and to take it to scale. The statement “there is no blueprint”, we now know, only serves to control the unpleasant complexity and skepticism of the participant, but what the panelist really wants to apply is definitely a blueprint. Adapting to context is a bone he is throwing to these pesky field people who don’t know any better and would have us to boutique projects all the time.
Let’s go back to our panelist and participant from ‘the field.’ [Spoiler alert: I may caricature the differences in perspectives to stress my point.] The panelist actually has a blueprint, a plan, an idea, an intervention, which he believes is now tested and proven to be able to deliver a public good. Variation in contexts is a challenge--an adaptation and implementation challenge--to be able to deliver what he knows can work and to take it to scale. The statement “there is no blueprint”, we now know, only serves to control the unpleasant complexity and skepticism of the participant, but what the panelist really wants to apply is definitely a blueprint. Adapting to context is a bone he is throwing to these pesky field people who don’t know any better and would have us to boutique projects all the time.
The field participant, on the other end, is immersed in a
context. She is richly informed about the geography, history, politics, micro-social
and societal reality of that context. The level of complexity increases with
the level of attention paid to details, and our participant has seen over and
over again when approaches cooked outside of her context have failed on the cliffs
of that complexity. (This metaphor at no extra-charge.) What she really is hinting at is not that a
solution needs to be adapted to context, but that a solution needs to be
developed, created, imagined, and invented in the specific context where the
problem is identified.
Those two views are not solved by the adapting to context platitude; they represent very different
approaches to problem-solving. So, who’s right?
Well, no surprise here; the answer is… it depends.
As we have just seen, there’s a beauty and value to
blueprints. But there’s also a world where contextual design and innovation
dominate. And it is underappreciated in central / global spheres of decision
making of global health. As many things are, there is a continuum to navigate,
but the dominant model of our work is blueprint thinking. The necessary and
productive intellectual discussion about where blueprints fail us and when we
need a different type of thinking is too systematically squelched. This could
be due to power differentials between the center and the periphery of all our
systems, and to blind spots emerging from our different points of observations.[1]
There are a couple of models out there describing where
complex takes over complicated in the problem definition and solutioning space.
One of the most famous is David Snowden’s Cynefin model, which represents
problems from simple, to complicated, to complex, on to chaotic. When problems
are complicated, best practices can be identified and promoted through
protocols and, yes, adaptable blueprints. But when we enter the space of
complexity, emergence takes precedence over best practices. I once tried to map
out how complexity increases in the definition of global health problems, based
on work by Geyer and Rihani. It turned into this table, which might provide a
concrete illustration.
The more your problem is on the right side of the table, the
more useful will be a blueprint, if used with smart adaptation to context. But
as you move to the left, the value of the blueprint decreases. At some point,
adaptation is no longer the solution. Creation, invention, context-based design
become the requirements. This means that you start from the perspective of the context
actors, as opposed to that of the global experts.
Figure: increasing level of complexity in problem definition from right to left (Source: http://link.springer.com/article/10.1007/s11213-014-9329-9)
A clarification: I am not claiming that this is the way to
determine whether a blueprint is appropriate or not. But I suggest that more
often than not, problems on the left side of the table will not be amenable to
blueprints, even if they may incorporate sub-issues where a valid best practice
or blueprint is available.
In conclusion, let’s acknowledge that “there’s no blueprint;
we need to adapt to context” is an illogical statement, used sometimes with the
best intentions, but also too often as the expression of a central-planner bias
preventing an intellectual debate that we badly need. In the absence of a
blueprint for figuring out whether a blueprint can be used, maybe we can start
by listening to the question of the field participant with a little less
condescension and a little more intellectual curiosity.
So, make sure to bring that up at the next workshop. And
remember: my satellites are watching!
[1]
I’ve probably been led on this trail of thinking following a presentation that
I made in June 2016. The topic of it was about blind spots in global health,
specifically blind spots to self-organization. Definitely some overlaps. The
summary of the presentation is available here: http://www.witpress.com/elibrary/dne-volumes/11/4/1273
