The no-blueprint blueprint to development

Eric Sarriot 

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.

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

A review of "Systems science and systems thinking for public health: a systematic review of the field"

By Eric Sarriot

A recent publication in BMJ titled Systems science and systems thinking for public health: a systematic review of the field by Gemma Carey et al. describes findings from a systematic review of current literature on systems science research in public health, with a focus on specific “hard” and “soft” systems thinking tools currently in use. A review of the literature sub-selected for analysis in this paper revealed the absence of some pertinent articles that may have enriched the discussion, but as the authors acknowledge, quoting Williams and Hummelbrunner, “holism is ‘somewhat of an ideal. In reality all situations, all inquiries are bounded in some way.”

An interesting application of systems thinking can be found in David Peters and Ligia Paina’s paper on the Develop-Distort model. The Develop-Distort model paper does not reference the great thinkers of Soft Systems or Systems Dynamics, which could be why it did not qualify to be part of this systematic review, yet it is also of great interest. With this model, and other emerging ones, the question then becomes whether new tools and methods, that abide by key principles, should and could fit into the constantly evolving field of systems thinking. Of course, this question in and of itself, does pose some bias.

The review by Carey et al. continues by ascribing sub-selected literature with four types of systems thinking categories:

• Position pieces: the literature in this category mostly advocates for greater uses for systems thinking in public health;
• Papers with an analytic lens: most articles here maintain the caveat that once analysis using a systems thinking approach is complete, many researchers revert back to previously used analytic tools, likely due to a lack of practice and training in systems methodologies;
• Bench-marking of best practices: where systems thinking is used to evaluate public health practice – with some articles evaluating the best practice based on whether it abides by systems thinking principles, rather than whether the application of systems thinking advanced thinking and performance; and
• Systems modelling: modelling of real-life or dynamic processes using systems thinking.

While the discussion is fairly long, it makes several good points, including that systems thinking is not a panacea and should not be approached as such, that there is a need for greater verifiability of models, and last but not least, that there is a need to improve skills of public health researchers in systems methods and thinking. The authors then move to discussion on the value of soft system methodologies emphasizing how metaphors can be used as a useful heuristic. The authors describe this evolution in thinking as a challenge to how health policy makers define “evidence,” and conclude with a note that systems thinking in health will improve if and as we learn to ask the right questions of systems science, and play down some of the accompanying rhetoric.

Social accountability - review of existing literature and learning

Social accountability is an essential element to improving health outcomes and facilitating health sector reform. The following links provide two important summaries of some literature on the topic. 

The Role of Social Accountability in Improving Health Outcomes: Overview and Analysis of Selected International NGO Experiences to Advance the Field

CORE Group

Source: http://www.coregroup.org/storage/documents/
Resources/Tools/Social_Accountability_Final_online.pdf

 This review discusses three social accountability models used in various sectors at community, district, and national levels, to increase accountability and improve health outcomes. The approaches reviewed, analyzed, and described are: (1) Citizen Voice and Action, implemented by World Vision; (2) Partnership Defined Quality, implemented by Save the Children; (3) and the Community Score Card, implemented by CARE.

Voice and Accountability in the Health Sector
Health & Education Advice & Resource Team (HEART)

This resource by HEART is a nice and concise review of key peer publications of voice and accountability in the health sector, assessing specific initiatives in the health sector, using Bangladesh as a country example, and providing available models for increasing social accountability.

EGPAF's Experience with Transitioning HIV Care and Treatment Programs to Local Partners, By Stephanie Cálves of EGPAF

For eight years, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has supported HIV prevention, care, and treatment services to women, children, and families through the Centers for Disease Control and Prevention (CDC)-funded initiative Project HEART in Côte d’Ivoire, Mozambique, South Africa, Tanzania, and Zambia. Through its groundbreaking, lifesaving work in these five countries, Project HEART has enabled 1 million people to lead healthier lives. In addition to scaling up access to care and treatment services, two additional focuses of Project HEART were strengthening government health systems and the empowerment of local partners to provide quality health services. As part of this effort, in 2008, EGPAF began a process to transition Project HEART’s programmatic work to local, independent partners, including local NGOs and host country government agencies.

Through Project HEART, EGPAF has helped launch and strengthen three new independent NGOs in Côte d’Ivoire, Mozambique, and Tanzania:

• Fondation Ariel Glaser pour la Lutte Contre le SIDA Pediatrique – Côte d’Ivoire
• Fundação Ariel Glaser contra o SIDA Pediátrico – Mozambique
• Ariel Glaser Pediatric AIDS Healthcare Initiative – Tanzania

In the organizational development process, local staff and stakeholders identified a need for a long-term partnership between EGPAF and the new NGOs in order to promote accountability to international standards; provide access to technical resources and shared management systems; facilitate capacity building; and provide brand credibility to enhance organizational viability. To address these challenges, EGPAF and the new NGOs have developed a model for long-term affiliation, which has resulted in the emergence of a network of organizations that has a shared investment in supporting HIV programming in each country.

Given the nature of the transition process, effective organizational change management was a key factor for success. The establishment of the new NGOs meant that new communication structures, coordination mechanisms, and supervisory roles for staff would be developed. Some of the staff responsible for implementing Project HEART for EGPAF would be starting to work for the new local organizations, thus requiring that human resources systems be harmonized and staff be capacitated to take on new levels of leadership within the new organizations. The transition also meant that new finance, administrative, human resources, and program management systems needed to be established. To ease the impact of these types of changes on staff, at both the global and country levels, EGPAF established working groups at both levels to lead the transition process and established regular forums for communication across the organization.

With the transition also came risks. These risks included the potential for interruption of the continuity of programs, mismanagement of funding, and reputational risks if the process did not proceed smoothly. To address these risks, the transition process included a strong monitoring component. An accreditation structure was established for the new organizations, which facilitates ongoing organizational strengthening, allows for early detection of problems, and facilitates capacity building to address weaknesses.

As the eight-year Project HEART initiative came to a close in February 2012, EGPAF is excited that these organizations are able to move forward independently through new projects funded by the U.S. Centers for Disease Control and Prevention (CDC). Through these projects, they will be able to continue to support HIV care and treatment programs, strengthen their organizational capacity, and expand their impact. In addition, EGPAF and these new local partners will continue to partner with host country governments to strengthen health systems at the national, provincial, and district levels to assume greater ownership, leadership, and management of HIV/AIDS programs. The success of these future efforts will require both EGPAF and its local partners to maintain strong partnerships with host country governments, innovative mechanisms for measuring capacity building activities, and a strong focus on strengthening operations, leadership, and management systems.

EGPAF has developed a number of important tools through the process of launching Affiliates and transitioning programs to these new organizations. We view these as important resources for other organizations also engaged in HIV/AIDS programming. EGPAF has brought these tools and resources together in the toolkit Sustainability Focused Organizational Development: Tools and Resources for Foundation Affiliates. This toolkit includes an overview of the EGPAF’s affiliation model and accreditation system, a checklist organizational start-up, and the EGPAF’s accreditation review tool. It also includes the Organizational Capacity and Viability Assessment Tool, which is a product of EGPAF’s collaboration with ICF International.

For more information on Project HEART or EGPAF, contact Stephanie Cálves at scalves@pedaids.org.

ICF/CEDARS completes work with EGPAF

Over the past three years, ICF/CEDARS has been supporting various different aspects of the Elizabeth Pediatric AIDS Foundation’s (EGPAF) transition monitoring efforts for their CDC-supported PEPFAR program, Project HEART (Help Expand Antiretroviral Therapy to children and families). This month marks the successful completion of both Project HEART and the technical support from CEDARS (the end-of-project report and more information on Project HEART can be found at: http://www.pedaids.org/ProjectHEART).

As part of the PEPFAR Track 1.0 treatment initiative, this eight-year project was launched in Côte d’Ivoire, South Africa, Tanzania, and Mozambique in an effort to scale up ART through existing organizations implementing PMTCT (prevention of mother-to-child transmission). A core goal of Project HEART was to transition care and treatment activities to local partners in a sustainable way.

EGPAF contracted ICF/CEDARS to provide technical assistance in 1) the development of a plan for this transition, 2) the design and development of tailor-made data collection tools to measure progress in this transition process: the Organizational Capacity and Viability Assessment Tool (OCVAT), the Site Capacity Profile (SCP) for facility level assessments, CBO Capacity Profile for local organizations providing ARV treatment support, and a service delivery site mapping inventory, 3) the design and development of a training curriculum for country programs on program design for sustainable health outcomes, based on the Taking the Longview Sustainability Planning Manual.

The fruits of this productive collaboration between EGPAF and ICF/CEDARS will be posted on the CEDARS website over the course of the next few weeks—keep any eye for them!

Watch this video about the impact of Project HEART:

Living Proof: A Father and Son Love Story from EGPAF on Vimeo.

Emergence of Sustainability in a Complex System

On January 26, CEDARS was featured at a Microlinks Breakfast Seminar, which turned out to be a great success, as well as a unique learning experience for everyone.

Eric Sarriot, joined by Sudhir Wanmali, Sharon Arscott-Mills, and Owen Calvert, presented a simple definition of "Complex Adaptive Systems", described how the concept of Sustainability fits into this definition, and provided real-world examples of its use.

Following the presentation, a thought-provoking Q&A session took place amongst both the panel and the audience. One question, in particular, asked how complex systems in food security could be incorporated into Pastoral Systems, and the bulk of the discussion focused on data collection challenges, the need for accurate indicators, and stakeholder organization in these types of systems.

Watch Eric's follow-up interview:



For more information, view the full presentation with audio or visit the Microlinks website.

Read a detailed summary of the event on ICT 4 Agriculture's Blog: Sustainability Lessons from HSS: Implications for FS and ICTs Projects.


Cheers,

The CEDARS Team

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

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