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Is this the ‘Next Big One’?

Posted in Agriculture, Biology, Communications, Evolution, Healthcare, Innovation, Institutions, Knowledge and learning, Leadership, Networks, Organisations, Public Policy, Research, Resilience, Strategy, Technology on April 23, 2013 | Leave a Comment »

As concern grows about H7N9 in China, this post explores the importance of managing such pandemic risks through collaboration, innovation and systemic thinking

In the month of World Health Day (April 8th), the latest outbreak of bird flu in Asia provided a sobering sense of the challenges the international community still faces. To date, H7N9 has killed 21 people, infected 104, shut down poultry markets across Asia, and has led to Chinese shares tumbling.

The WHO originally announced that the likelihood of this latest pathogen is transmittable between people is low, and that the world should not ‘get into a flap’ – as one observer memorably put it. The potential of bird flu to be the source of the “Next Big One” means however that we cannot be complacent. In terms of global catastrophic risks, it is hard to think of one more serious than the 1918 avian influenza epidemic which killed 50-100 million people worldwide – 3-5% of the global population. This was so devastating in part because the virus had acquired mutations that allowed it to cross from birds to humans, and then to ‘go pandemic’. Based on analysis of the mutations in H7N9, scientists fear that this latest variant may have the same potential.

But there is still a lot we don’t know about H7N9. Where has it come from, why, and how? What is its relationship to earlier variants? How might it mutate? What impact might it have in the future? What does it mean for our ongoing, historically loaded, battle with avian flu?

To answer such questions, we need to draw on a variety of disciplines: epidemiology, molecular biology, virology, all of which fit nicely with the current models of public health. The problem is that many of these models set us, humans, apart from nature. Diseases, the standard narrative goes, encroach on our territory and we need to fend them off. The reality is in fact the exact opposite.

It is now widely acknowledged that many – the majority, in fact – diseases are born in the intersection between society, environment and economy. More than 2/3 of all human infectious diseases are zoonotic in origin, meaning that they somehow crossed species boundaries. The terminology likely to be adopted in future Hollywood blockbusters on the topic is simple but evocative: ‘spillover’. Primates, birds, bats, pigs, rats, mice, dogs, insects – any creature we co-exist with can act as sources or carriers of pathogenic lifeforms.

Spillover is driven by a pattern of activity which is becoming all too familiar. Deforestation: 4% increase can lead to 50% increase in malaria rates. Hunting has led to HIV-AIDS, Ebola, all crossing the species boundary. And, to bring it back to bird flu, livestock. Around 70% of the rural poor and 10% of the urban poor are dependent on livestock. Livestock conditions are increasingly creating tremendous opportunities for pathogens to cross from wild birds to caged birds, and onto humans. And the demand for animal-based protein is expected to grow 50% by 2020, much of it in the developing world. This problem is not going to go away any time soon.

Leapfrogging on the success of the human race, trade and transport linkages provide a morbid global transmission network. The rate at which new diseases are emerging and spreading is nothing short of shocking.  Zoonotic diseases have increased in the past 40 years, with at least 43 identified outbreaks since 2004. ILRI estimates that 1.7 million people die each year thanks to spillover diseases. By way of comparison, the highly respected CRED crunch on disaster epidemiology found that the 2001-2010 average annual deaths from natural disasters was 107k  per year.

Ecological and evolutionary principles are vital in understanding these complex system effects on a more solid scientific basis. Experts at the University of Florida made the point in pithy fashion a couple of weeks ago, “If we don’t understand the reservoir and the ecology of the virus, it’s hard to design interventions to protect humans.” But such understanding is – with a few exceptions – still under-utilised in public health.

Of course, every disease is different, every context is unique. But the process by which spillover happens is similar. We can point to ecologies under stress. Life forms under duress. As an excellent briefing by colleagues in the Consortium on Disease Dynamics (CDD) puts it, “The health of people and animals are… interconnected and inextricably linked to the environments both inhabit. Given the complex pathways that lead to spillovers, it is important that prevention and control measures are undertaken with a strategic approach and an understanding of the many interdependencies.”

What does this challenge add up to for the global risk management community? The work by the CDD gives some very useful pointers.

First, multi-disciplinary approaches are vital. The WEF Global Risks report has for some years now been calling for better disciplinary collaboration in order to think about emerging risks. With avian influenza there is a clear need for better collaboration between public health specialists, disease ecologists and evolutionary biologists. Some important work is already happening, under the auspices of entities such as the global One Health initiative, organisations like the EcoHealth Alliance, and initiatives like the USAID-funded Predict, and this work needs to move firmly to the centre of the debate.

Second, anticipation and warning systems – new investments in surveillance are urgently needed to establish and maintain necessary systems at multiple levels – community, national, regional and global. We need multi-stakeholder information platforms, bringing together government, civil society and the private sector in new kinds of networks, in order to establish ‘systemic  surveillance approaches’. This needs to move beyond a focus on specific disease to looking at the whole system, looking at the intersection between disease drivers, disease incidence, and socio-economic factors.

Third, new approaches – especially in the realm of complex adaptive systems – have a lot of relevance for how we think about such outbreaks in the future. Methods such as systems thinking, network analysis, agent-based simulations, and dynamical systems theories can help develop a more precise and accurate understanding of the complex dynamics of disease. Together with the rise in ‘big data’ approaches, there is scope to develop new models and theories of how pandemics unfold which are more appropriate to our ‘hyperconnected world’. We need to be careful however to ground this science in local, community understanding – to support affected communities to become the frontline of defence: adaptive managers of emerging risks.

Fourth, we need changed funding models – funding prevention, not just response, and linking pandemic risks to high-risk development activities, and ensuring that we don’t forget history too quickly. There needs to be attention even when the threats may not be imminent. The private sector, with interests in business continuity, can be key actors here. Done right, such investments can engender what might be seen as positive spillovers. As the CDD work suggests, investments in prevention of avian influenza can provide the basis for such work on other potential pandemics.

In closing, if we want to take a wide-angle lens on the problem of disease outbreaks like HN79, to understand why these diseases are occurring at an increasing rate, we could do worse than taking a lead from Nathan Wolfe. A globally renowned virologist, a couple of weeks ago Wolfe wrote a tub-thumping piece on the WEF blog about the continued risks of unregulated hunting, especially bushmeat, which gave birth to human immunodeficiency virus (HIV). His basic argument was by ignoring the implications of our food production systems, we are running an unacceptably high risk of terrifying global scourges in the future.

Clearly, we all need to start pay much more attention to the intersection of economy, society and the environment if we are serious about proofing ourselves against the Next Big One.

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Reflections on bias and complexity

Posted in Accountability, Evaluation, Healthcare, Knowledge and learning, Reports and Studies, Research on May 29, 2012 | 6 Comments »

Earlier this month, Nature published a piece by Daniel Sarewitz on emerging challenges faced in science and research, which has some useful lessons for the aid system.
The greatest threat to science is not  due to the usual suspects of “inadequate funding, misconduct, political interference”, etc, etc. Instead, according to Daniel Sarewitz, the problem is more fundamental and relates to a widespread bias towards over-simplified models and positive results.

Bias is an inescapable element of research, especially in fields… that strive to isolate cause–effect relations in complex systems in which relevant variables and phenomena can never be fully identified or characterized…”

The field Sarewitz is writing here about is biomedicine, but he could easily be describing development or humanitarian work. The fundamental problem, as he sees it, is that biases are not random but systemic: “if biases were random, then multiple studies ought to converge on truth [but] evidence is mounting that biases are not random.”

This claim is not new, of course. As the piece argues, systematic positive bias was identfied in clinical trials funded by the pharmaceutical industry back in the mid-1990s. More recently, reviews of so-called ‘landmark’ studies in fields such as cancer research has shown that positive results could only be replicated in a minority of cases.

However, these previous assessments tended to assume that the problem was not with science per se, but rather with those forces that sought to co-op it: industry, government, special interests, and so on. Reduce the influence of these interests, the argument went, and you would eradicate such biases.

But it is now emerging that there are some serious underlying problems within science itself. The cases are wide-ranging across biomedicine: “evidence of systematic positive bias [is] turning up in research ranging from basic to clinical, and on subjects ranging from genetic disease markers to testing of traditional Chinese medical practices.”

The two major faultlines, according to Sarewitz, are the methodological narrowness of the approaches employed to generate evidence, and the culture and incentives of scientists and science funders.

The first one is pertinent for readers of this blog. Researchers seek to reduce bias “through tightly controlled experimental investigations. In doing so, however, they are also moving farther away from the real-world complexity in which scientific results must be applied to solve problems.” Ironically, “the canonical tenets of ‘scientific excellence’” are threatening to undermine the whole enterprise. One rather shocking (for me, at least) example relates to the latest developments in research on mice, where a lot of resources and funds have been poured into the cloning of genetically identical animals, in order to enable fully controlled, replicable experiments and rigorous hypothesis-testing. Any sense of moral repugnance aside, perhaps the worst thing about this endeavour is that the findings of the research subsequently undertaken have turned out to be useless when applied in the real world.

Sarewitz also writes about the lack of incentives to ‘report negative results, replicate experiments or recognize inconsistencies, ambiguities and uncertainties’. There are also challenges around the various cultural and attitudinal positions taken toward science among funders, scientists, the media and the public at large. Sound familiar?

It should – such issues are not a problem for biomedicine alone:

[they are] likely to be prevalent in any field that seeks to predict the behaviour of complex systems — economics, ecology, environmental science, epidemiology and so on. The cracks will be there, they are just harder to spot because it is harder to test research results through direct technological applications… and straightforward indicators of desired outcomes…

Sarewitz closes with one potential solution, which may also be of relevance for work in development and humanitarian fields:

Scientists rightly extol the capacity of research to self-correct. But the lesson coming from biomedicine is that this self-correction depends… on the close ties between science and its application that allow society to push back against biased and useless results.

So what can we in the aid sector do about such bias, if indeed it is present in our work?

The first idea is the one that Sarewitz suggests: “societal push back”. Sadly, despite the rhetoric and growing practice of participation, the scope for Southern stakeholders – especially aid recipients – to ‘push back’ against useless results in development and humanitarian research is still severely limited. This doesn’t mean we should stop the effort, however, and perhaps new technologies and feedback processes can help us here.

The second strategy might be to address issues of the incentives and cultures which perpetuate such biases. But we seem to be far too concerned with developing country actor incentives and motivations to look at those in our own organisations. As one participant at a recent ODI event put it: “why do we always say that developing country leaders have mixed motives at best whereas the motives of donors [and other aid actors] are always considered impeccable?” We should find a way to ensure that these aid “physicians” first heal themselves.

The final course of action is to try to expand and adapt the concepts and models used in our work. This effort (of which this blog is one small part) is still very much a work-in-progress, but the growing interest  among researchers and practitioners should give us some small cause for hope. After all, the key to paradigm shifts in science – and in other fields – is not just logical argument and experimental proof. In the words of Thomas Kuhn:

as in political revolutions, so in paradigm choice—there is no standard higher than the assent of the relevant community.”

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The Complexity of Scaling Up

Posted in Accountability, Evaluation, Evolution, Healthcare, Innovation, Leadership, Malaria, Public Policy, Reports and Studies, Strategy on October 3, 2011 | 4 Comments »

Despite increased prominence and funding of global health initiatives, attempts to scale up health services in developing countries are failing, with serious implications for achieving the Millennium Development Goals. A new paper argues that a key first step is to get a more realistic understanding of health systems, using the lens of complex adaptive systems.

Much ongoing work in development and humanitarian aid is based on the idea  of ‘scaling up’ effective solutions. Healthcare is one of the areas where this idea has played a central role – from WHO’s Health for All in the 1960s to UNICEF’s child healthcare programmes, from rolling out HIV-AIDS, malaria and TB treatments to the package of interventions delivered to achieve the Millennium Development Goal on health.

However, despite the fact there are many cost-effective solutions to health problems faced in developing countries, many agencies are still frustrated in their attempts to deliver them at scale. This may be because of a widepread failure to understand the nature of health systems.

Melissa Leach, director of the superb STEPS Centre, has described health systems as:

complex systems made up of networks of many heterogeneous components that interact non-linearly. While pathways of change can be shaped by governance and are influenced by path dependencies, they are not entirely controllable or predictable; there will always be uncertainties and unintended consequences and new ‘emergent’ interactions and behaviours.’

If we accept this eminently sensible description, then it is little wonder that scaling up efforts continue to be frustrated. The paper by Ligia Paina and David H Peters, published in Health Policy and Planning in August, argues that there is a drastic need for a shift in thinking:

…from the current models around scaling up health services, which revolve around linear, predictable processes, to models that embrace uncertainty, non-linear processes, the uniqueness of local context and emergent characteristics.”

Their argument is supported by the fact that existing assumptions about the nature and hoped-for successes of scaling up have led to a lot of disappointments. Moreover, these efforts ‘offer little insight on how to scale up effective interventions in the future.’

The paper explores 5 concepts of complexity science, illustrated below.


All of these ideas carry relevant lessons for the design, planning, implementation and evaluation of health policy and programmes. As the authors conclude:

The implications include paying more attention to local context, incentives and institutions, as well as anticipating certain types of unintended consequences that can undermine scaling up efforts, and developing and implementing programmes that engage key actors through transparent use of data for ongoing problem-solving and adaptation.”

The authors close with a proposal that future efforts to scale up should adapt and apply complex systems models and methodologies which have been used in other fields but which remain underused in public health. These include network scinece approaches, modelling techniques, and tools to better understand systems dynamics.

The potential benefits are clearly stated:

This can help policy makers, planners, implementers and researchers to explore different and innovative approaches for reaching populations in need with effective, equitable and efficient health services.”

These ideas are already being applied in practice, The authors are involved in a capacity strengthening programme on complexity and health systems in China. Separately, the WHO has published a guide to using systems analysis in health systems strengthening, which builds on a number of the concept described above.

These are all fascinating developments, and suggest that health may be a key area where the ideas from complexity science can prove of tangible value for development and humanitarian work.

Interested readers can hear an podcast about the article here, with David Peters talking about his ideas and experiences (and me saying a few words about the history of complexity science and the relevance for health efforts.) David has also blogged about it here.

Previous Aid on the Edge posts relevant to this topic include MDGS and theories of change, Scan HIV-AIDS Globally, Reinvent Locally and How do you solve a problem like malaria?.

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Results 2.0: Towards a portfolio-based approach

Posted in Accountability, Evaluation, Healthcare, Innovation, Institutions, Knowledge and learning, Leadership, Malaria, Meetings, Organisations, Public Policy, Strategy on June 30, 2011 | 9 Comments »

The international development sector has been in a tug of war around the ‘results agenda’ for the past few months. This post explores the tensions and suggests a way to bring the sides together by focusing on the relevance and appropriateness of different approaches.*

I: The Results Tug of War

Development results is one of many areas where discussion and debate seem increasingly polarised. On one side of the results tug of war are those calling for more and better results, more rigour in analysis and more discipline in reporting. The failure of development, they argue, is basically about the failure to focus on results. ‘Modern management techniques’, especially those that are embodied by ‘results-based management’ are seen as the answer.

On the other side are those who argue for a ‘push back’ against this approach. Such reductionist approaches are seen as only suitable for certain kinds of development interventions, and that at their worst, these approaches inhibit the creativity and innovation needed to achieve results in the first place. The danger here is that we throw out the results baby with the reductionist bathwater (see here for a previous Aid on the Edge post on this).

What is increasingly evident is that, in the diverse and dynamic aid landscape we face today, all agencies attempting to genuinely strengthen accountability and learning face a number of common challenges. This is a preliminary list, I am sure readers will be able to think of more.

  • Data availability, coverage and quality are perennial problems
  • Participation and ownership - as Robert Chambers might ask: ’whose results count?’
  • Incentives and disincentives to use information and results, especially when they run counter to individual and institutional interests
  • Bureaucratic inertia: all too often results-related work is placed on top of and increases the already considerable bureaucratic and administrative burden on aid agencies, rather than simplifying and reducing it
  • Risks and fear of failure: How can we manage and be transparent about the different kinds of risk failures inherent to development projects & programmes?
  • Many conflicting imperatives: learning vs accountability, policy vs operations, domestic vs international

The key point is that these apply equally to both sides of the results tug of war. As a result, a lot of effort is being wasted, with problems being dealt with in entrenched intellectual silos rather than in a collective manner.

So what to do to move beyond the ‘tug of war’? I would argue that a first step would to think about how to bring the different results approaches together to establish a more constructive dialogue. What is needed is a more flexible and differentiated approach to results, one which takes account of the diversity of the development and humanitarian portfolio.

II: A Draft ‘Portfolio of Results’ Framework

What might such a portfolio-based approach look like? There are a number of useful approaches from academia, civil society and business strategy that can help here. These include Brenda Zimmerman’s simple-complicated-complex distinction, the Cynefin framework of Cognitive Edge, work done by Alnoor Ebrahim at Harvard University, work done by Eliot Stern on relevance of different approaches to impact assessment and finally a recent model put forward by Patrick Moriarty of IRC.

All of these suggest in their different ways that appropriate strategic approaches (and by extension, results approaches) need to be based on:

(a) the nature of the intervention we are looking at, and

(b) the context in which it is being delivered.

Reading across these approaches we can suggest a preliminary framework which may prove useful in bringing together different results approaches in a productive and mutually beneficial way.

First, imagine an agencies projects and programmes being distributed across a spectrum of the ‘nature of interventions’, placing relatively simple interventions on one end, and more complex issues, at the other.

Then let’s add in a vertical axes on context. Again, think of a spectrum, this time from stable / identical to dynamic / diverse.

This gives us a 2 by 2 framework for analysing and mapping different development interventions - in effect, this is a draft ‘portfolio of results’ framework. Where an intervention is positioned on this framework has implications for the kinds of results orientation we can take, as shown below.

In the top left corner of simple interventions in identical stable settings, is the Plan and Control zone – here ‘traditional’ results-based management approach, conventional value for money analyses and randomised control trials work well.

The bottom right corner of complex interventions in diverse, dynamic settings is what I have termed Managing Turbulence – here the philosophy is less ‘Ready, Aim, Fire’ (as in the Plan and Contol zone) and more ‘Fire, Ready, Aim’. Here we need to learn from the work of professional crisis managers, the military and others working in dynamic and fluid contexts.

In between is what I have called Adaptive Management, where either because of the nature of the intervention or the nature of the context, multiple parallel experiments need to be undertaken, with real-time learning to check their relative effectiveness, scaling up those that work and scaling down those that don’t.

III: Applying a Portfolio of Results Approach: A health-focused illustration

By way of illustration, let’s look at three health interventions – vaccines, HIV-AIDs, and rebuilding national health systems. I would argue that they could be distributed on the matrix something like this.

So if we are looking at simple interventions in a stable / identical environment, or what might be called the plan and control domain, randomised control trials, traditional cost-based ’value for money and results-based management approaches work great. Vaccines are perhaps the best example here. And as the ongoing MSF campaign on reforming GAVI suggests, a focus numbers and bean-counting can be of vital importance to ensuring effectiveness.

But we may find ourselves managing interventions that are more complex, in stable contexts. We can also think about situations where the intervention is simple but the context is dynamic. In both of these instances we may need to move away from blueprints towards a more adaptive management approach, trying out multiple parallel experiments and monitoring progress and rates of success and adapting to context. In HIV-AIDS responses, the optimal mix of responses is key and almost always locally determined (see previous Aid on the Edge post here). Also increasingly relevant are global malaria responses which need to adapt to the changing patterns of incidence and the evolution of resistance (ditto here).

Finally, in environments where our interventions are complex and the context is dynamic and diverse, we have to take a leaf out of the book of those who work in high risk environments – professional crisis managers, military and so on. Programmes to rebuild health systems, especially in fragile states, are a good example here. Here we need to be doing action research, real-time assessments and learning by doing.

This is not a rigid framework and there is overlap between the different areas. But different approaches to results can be shown to be more or less effective in different domains. In general terms, you can do a detailed RCT in the bottom right quadrant, but it may be a thankless task and not the best use of resources. You can do an RCT in the top right quadrant, but it could well prove to be a necessary but not sufficient condition for success. And so on.

(This also helps think about the concerns of one side of the tug of war – that there is a pressure to push development to the top left domain, and a widespread misapplication of the top-left tools for the other domains.)

Obviously this is a preliminary framework based on reflection and discussion, and is open to critique and debate. The key principle is that a more nuanced approach to results will have to be based on a systematic assessment of, at a minimum, our interventions and the context we are working within.

IV: Taking the Results 2.0 agenda forward

This kind of framework can also be used to think strategically about our overall portfolio of projects and programmes. How is our overall spend allocated between these ‘domains’? What are the implications for risk? I think there is a useful analogy with investment portfolio managers are used to diversifying their portfolios in order to reduce their exposure (see diagram below).

We urgently need to develop new ways of analysing the different elements of our portfolio. Through this we can start to unpack and understand the diversity of our efforts, and ensure we don’t take a ‘one-size-fits-all’ approach to results and all that entails.

There are a number of follow-on issues about how we might take this area of work forward.

  • We will need to refine or adjust the draft ‘portfolio of results’ framework, based on more in-depth analysis, discussion and debate. Of course, we may need something completely different to what is proposed here (all feedback, however critical is warmly welcomed!), but the key is that we need something to bring diverse constituencies and approaches together.
  • We need to think about which sectors are amenable to a portfolio type  approach to results, where we can pilot a ‘Results 2.0 process’ and we need to think about what new kinds of tools and methods might be required. I think health would be a great sector to start on.
  • Different kinds of interventions will need different kinds of information, which will call for different tools for managing this information. New kinds of tools and techniques will be necessary. Importantly, these should help to consolidate and simplify, rather than just increase, the reporting and administrative burden on the sector.
  • We urgently need to think about how this affects development communications, and how we can start to develop more sophisticated framing and messaging of positive and negative results, based on the different elements of our portfolio. This will be perhaps the hardest part of this new results agenda, as it means that we will have to tell our key stakeholders things like ‘we don’t know’, or even worse, ‘we failed’. This may mean riding with punches in the short-term. But this will also mean we will need to think hard about what different stakeholders expectations are, and how they can be best met. The overall legitimacy and sustainability of such efforts demands greater involvement of national governments, civil society and poor communities.

I want to close with this thought from a cross-country study of results-based  management looking at Western countries – that results are not an end in themselves, but are a means by which to establish trust in the system. I would add: and within the system.

Because we do so many different things in development, we have to do different things to earn trust of our diverse constituencies. (We may also have to accept that in some quarters, trust will never be established, but that is another story.) What we cannot do is move forward without finding ways of trusting each other, whatever our methodological or conceptual background and prejudices.

Bringing our diverse opinions and ideas together to test their relevance and appropriateness seems like an essential first step.

* This is the summary of a talk I gave at the June 2011 IDS-ODI roundtable on results with the UK Secretary of State Andrew Mitchell, revised following useful comments from participants. Special thanks go to Robert Chambers and Simon Maxwell for thoughtful and constructive feedback.

Fellow participants have also blogged on the meeting:

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How do you solve a problem like Malaria?

Posted in Biology, Campaigns, Evaluation, Evolution, Healthcare, Innovation, Institutions, Knowledge and learning, Malaria, Public Policy, Strategy, Uncategorized on January 27, 2011 | 9 Comments »

Big thanks to Alanna Shaikh and Bill Brieger for feedback and comments.

Debates about malaria eradication in the aid blogosphere, along with recent scientific evidence, highlight the urgent need to improve our understanding of the complex dynamics of this terrible affliction and to use it to adapt ongoing eradication programmes.

A nearly hopeless case?

According to the WHO, one in every five childhood deaths in Africa is due to the effects of the disease and an African child has on average between 1.6 and 5.4 episodes of malaria fever each year. A child dies every 30 seconds of malaria. The latest estimate from the 2010 World Malaria Report is that in 2009 the disease killed almost 800,000 people and afflicted 225 million others. And while a 2009 global malaria risk map suggests that while risks are worst in Africa, there are  clear indications of dangers in many other countries too.

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Last week Chris Blattman posted a justifiably scathing response to an article in Guernica, which had suggested that attempts to eradicate malaria are ‘nearly hopeless‘, and that current global attempts to do so are doing more harm than good.

Chris put forward an eloquent and moving counter-argument which included the following points (a) disease eradication is one of the few successes of big aid (b) we can’t simply let malaria take its toll and do nothing (c) presenting malaria as a symbol of African honour – as the Guernica article does – is at best inaccurate and misleading and (d) development is the key to successful eradication.

Many (myself included) would agree wholeheartedly. Evidence suggests that the cessation of malaria control programmes can lead to severe epidemics, as in Swaziland in 1984-85, or Madagascar in 1987-88. Shortfalls in ongoing responses have also led to resurgences in Zambia and Rwanda. Much of what is presented in the Guernica article can be dismissed as bizarre, confused or just plain wrong. However, one point made is worth looking at in more detail.

Premature pronouncements and cheap mainstays

The author suggests that current approaches to malaria tend to be narrowly focused on a limited number of technical solutions, or the search for such solutions. Think bednets, drugs or the investment in the development of vaccines.

In fact, this narrowness in the focus of malaria programmes appears to have been a relatively constant feature over the last 40-50 years. In 1969, the Pearson Commission (the source of the ubiquitous 0.7% of GDP aid target for donor countries) pronounced the disease ‘virtually eliminated’. Today it is hard not to see this declaration alongside Chamberlain’s ‘peace for our time’ as one of the most premature statements ever (as well as a little disingenuous from the standpoint of developing countries).

A 2008 Lancet review cited in Malaria Matters tells us more about the failures of the first eradication effort:

[the 1960s eradication campaign] was far too monodimensional, relied too much on DDT [insecticide] spraying, and  neglected the palpable problem that the delivery infrastructure was not  in place in too many parts of the malarious world.”

It goes on:

The emergence of widespread mosquito resistance to DDT, and parasite resistance to the cheap mainstay of therapy compounded the difficulties.” (emphasis added)

In short, narrowness of responses allowed evolutionary dynamics to play out at various levels, changing the efficacy of those responses. This problem has not gone away. As clinical microbiologists Richard Carter and Kamini Mendis see it, for the most part, the types of tools that are available and are used for malaria control today are the same as those which were available during the ‘virtual elimination’ era.

This point does need some nuancing. There was one approved insecticide during the first eradication effort, whereas there are now a dozen. The use of treated nets – which weren’t around in the 1960s – has been responsible for large drops in some countries. But even in those countries there is growing acknowledgement of the need for a better combination of responses to make further progress. ‘Cheap mainstays’ will not do the trick. As noted on Malaria Matters:

The malaria lifecycle is complex, and health systems designed to deliver malaria interventions [are] equally complex (and challenging), which means we cannot and should not expect a magic bullet in the near future.

If we want to better understand the complexity of malaria, a good place to start would be to understand the evolutionary dynamics at play.

Exploring evolutionary dynamics

Resistance to responses – whether among mosquitoes or the parasite itself – has been identified as an evolutionary phenomenon. Biology 101 tells us that all populations of organisms display genetic variation across members which enable some to handle particular environmental stresses and opportunities better than others. Natural selection has been shown to favour the evolution of pathogen populations that can resist the drugs and insecticides in their environments.

As the Lancet article cited above notes, resistance has evolved at two distinct levels. The malaria parasite evolves, developing drug resistance. One team of researchers has found that “Drug development programs exhibit a high attrition rate and parasite resistance to… drugs exacerbate the problem. Strategies that limit the development of resistance and minimize host side-effects are therefore of major importance.”

Specific parasites also adapt at the molecular level, according to the antibodies encountered in the host’s immune system. There is also the prospect of inter-species infections, whereby – for example – parasites mainly responsible for malaria among chimpanzees find ways to adapt to new human hosts, facilitated by greater human penetration of forest environments.

Mosquitoes also evolve to adapt to changing physical environments, human behaviour and pesticides. As described by Bill Brieger on his excellent Malaria Matters blog:

…Resistance to insecticides in [a mosquito sub-species] is receiving increasing attention because it threatens the sustainability of malaria vector control programs in sub-Saharan Africa. An understanding of the molecular mechanisms conferring… resistance gives insight into the processes of evolution of adaptive traits and facilitates the development of simple monitoring tools and novel strategies to restore the efficacy of insecticides…”

There have been numerous calls for more studies into how insects exposed to pesticides undergo strong natural selection and develop various adaptive mechanisms to survive.

Of course, human populations have also have co-evolved with malaria, and developed different kinds of resistance. The protective effects of the sickle cell trait is certainly the best known example, but there are others that have been identified, including genetic variations in the populations of Thailand and New Guinea which prevent against malaria-induced miscarriages. However, humans adapt genetically less quickly than the malaria parasite or the mosquito – waiting for or relying human evolution of resistance (as the Guernica piece seems to imply) is clearly not an adequate fall-back option.

Professor Karen Day, who has studied the historical evolution of malaria, is clear about the importance of this line of inquiry:

…From Ronald Ross’s discovery that malaria is transmitted by mosquitoes came the idea that we could control malaria by impacting the life span of the mosquito. If we can better understand the evolution and diversity of malaria, we may find an Achilles heel in the parasite or new ways to thinking about control….”

Slow take-up, slow scale-up?

However, while there is some basic research attempting to bring an understanding of evolutionary dynamics to the design of better drugs, pesticides, and even vaccines, there are still questions as to whether this knowledge is ready to be applied in programmes and at the necessary scale. The overall global malaria response may still be relatively limited in terms of its repertoire of responses.

For example, a 2009 study notes that the Global Malaria Action Plan (GMAP) of the Roll Back Malaria initiative sought to spray 172 million houses annually, and distribute 730 million insecticide-impregnated bed nets. The study concluded that if this was implemented with existing insecticides, with no acknowledgement of the scope for evolutionary response, the program would create unprecedented opportunities for the development of resistance among mosquitoes, and may also create new variants of mosquitoes.

The World Malaria Report 2010 shows that global efforts to prevent malaria through bednets and sprays reduced cases from 233m in 2000 to 225m in 2009 and 985k deaths in 2000 compared to 781k deaths in 2009. However, tellingly, the statistics also show that several African countries saw a resurgence of the disease – in part because of resistance and changing contextual factors.

Researchers at Maastricht University have argued that a fundamental issue is that much malaria modelling does not take into account evolutionary dynamics. By modelling global malaria as a complex adaptive system, the researchers have been able to review the efficacy of malaria strategies, and were also able to assess the potential implications of climate change.

Overall, their conclusion was that continued changes in human behaviour (such as in agricultural methods or urbanisation, which presents its own set of challenges), as well as human impact on the environment, will mean malaria will continue to evolve and confound current interventions in areas of high prevalence. They also make a complementary point to Professor Karen Day’s – eradication and control strategies that do not take account of these complex evolutionary dynamics may well make things worse, and could ‘substantially exacerbate the significance of malaria in coming decades’.

Some of these fears may be becoming reality. An article published in Science magazine in October 2010 suggested that the mosquito strain that is responsible for most disease transmission is in the process of rapidly evolving into two genetically distinct species. The hypothesis is that the two species are evolving in different directions in reaction to differences in environment and the challenges they face. The Imperial College researchers confirmed fears that this development is likely undermine efforts to control and treat malaria – conventional strategies are unlikely to be effective against both strains.

So what?

Forty years ago, malaria eradication failed at least in part because of a lack of diversity in the mechanisms employed, and the related evolution of resistance. Although global responses are broader than before, there are still questions about whether they are diverse enough, and whether the full breadth of approaches and knowledge are being applied at scale. Narrowness in responses may, in the worst case scenarios, be making human populations more vulnerable to malaria.

This means supporters of eradication and control programmes must continue to fund research that advances an evolutionary understanding and use it to keep ahead of the disease. This makes the levelling off of aid commitments reported in World Malaria Report 2010 all the more worrying, because much hope now lies in more funding for innovative basic and applied research. At least some of this research should start with the premise that the dynamics of malaria requires a rethinking of global efforts, with a special focus on capacity of existing health systems to deliver a broader range of treatments.

In this area, like in so many other aspects of international aid, silver bullets may well be red herrings. But history and recent research suggests that this is not a battle that should be conceded easily. Rather, as Chris Blattman notes, we can take some heart and some lessons from previous eradication programmes.

Smallpox was famously wiped out in the 1970s, with the last case being in Merca, Somalia in 1977. When the eradication was announced in 1980, the campaign was described “a triumph of management, not medicine”. This was an especially unusual pronouncement given it was made by the-then Director-General of the WHO.

But what exactly did this mean? According to one major account, the DG was referring to the emergent process of adaptation and learning – the evolutionary process within the programme itself – which

…more than any other element in the campaign, [was] the key explanatory factor of the ultimate success of the program… ”

What eventually eliminated smallpox was the combined approach of top-down problem-solving—mass vaccination to reduce disease incidence to certain levels —and bottom-up emergent experimental innovations in early detection, isolation and control - to push towards complete eradication.

Of course, smallpox is a very different disease, and may have been a better candidate for eradication than malaria – exactly because of the evolutionary nature of malaria.

But there is an interesting message here: if we want to deal with the evolving problem of malaria, we also need the global response to adapt and evolve, for organisations involved to think and act ‘outside the box’.

It is not clear what this would look like yet, of course – but it is worth noting that the eventual strategy for dealing with smallpox eradication was not originally employed or even envisaged by the implementing organisations.

Whether current efforts are able and willing to take on such an adaptive management mentality remains to be seen.

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Scan HIV-AIDS Globally, Reinvent Approaches Locally

Posted in Evolution, Healthcare, Innovation, Knowledge and learning, Leadership, Public Policy, Strategy on December 2, 2010 | 7 Comments »

Huge thanks to Alanna Shaikh for peer review comments and edits

Back in 1997, Robert Chambers argued that top-down attempts to manage complex processes of change have not worked in development aid.    

…Development projects can be paralysed by overloads at their centres of control…[generating] dependency, resentment, high costs, low morale and actions which cannot be sustained’ (Chambers, 1997). 

According to a recent post by CGDev ’What Bush Got Wrong on AIDS’, this is precisely what we have seen with the ongoing US PEPFAR programme:

…U.S. foreign assistance should focus on helping poor countries to help themselves.  With PEPFAR, our assistance instead fuels the accumulation of millions of AIDS patients who are unable to support their own medical treatment, requiring lifelong assistance from the United States for their very survival.  Instead of an AIDS program focused on prevention, which would have both protected and empowered the people of affected countries, PEPFAR has engendered increased dependence on the United States…”

Looking at HIV-AIDS responses as a whole, however, there have been some interesting examples of different approaches being used, especially on the prevention side.

For example, the well publicised example of Uganda’s 1990s HIV/AIDS campaign (Cohen, 2003), referred to by some as a social vaccine, is synonymous with the ‘ABC approach’ to HIV/AIDS prevention. ABC stands for ‘Abstain, Be faithful, use Condoms’, and refers to the necessary changes in individual behaviours, as well as the programmatic tools and techniques designed to promote these behaviours.

An intense program of public education, information and skills-building reached into every corner of the country. The evidence shows that a combination of important changes in all three of these sexual behaviours contributed both to Uganda’s extraordinary reduction in HIV/AIDS rates and to the country’s ability to maintain its reduced rates through the second half of the 1990s.

This drastic reduction can be seen as a result of following a ‘minimum rules’ approach to the national prevention programme. Such an approach required those in the position to design the programmes and projects to define no more than was absolutely necessary to launch a particular initiative. The role of grand designer was avoided in favour of the role of facilitation, orchestration and creating the enabling environment that allowed each element of the response to find its own locally relevant form.

Chambers describes such efforts as contrasting with centralised approaches (in ways which Bill Easterly will probably recognise):

 … the key was to minimise central controls, and to pick just those few rules which promote or permit complex, diverse and locally fitting behaviour’ (Chambers, 1997).

However, in specifying such ‘minimum rules’, it is crucial to understand the dynamics of local circumstances and actors. In working towards change and improving the lives of poor people, aid agencies are dealing with huge numbers of interacting problems, factors and actors. As a result, there are inevitably degrees of non-comparability across, and unpredictability within, these complex systems. As Chambers has warned:

…[aid] projects deal with varied environments and idiosyncratic people… The simple rules which then work have to go further, allowing and enabling people to manage in many ways with their local, complex, diverse, dynamic and unpredictable conditions, and facilitating not the uniform behaviour of flocks but the diverse behaviour of individuals’.

This sets some necessary limits on attempts to scale up such ‘minimum rules’ approaches. These are particularly evident in the HIV-AIDS context, where the top down mentality has proved pervasive.

Instead of ‘scanning globally and reinventing locally, as Joseph Stiglitz famously suggested, most HIV-AIDS efforts have attempted to ‘discover the top performers and export as best practice’. Overall, the approach has been less Ebay and more BP – and this ‘pipeline’ approach seriously underestimates the complexity of HIV-AIDS challenges.

For example, subsequent to Uganda’s success, a number of Western leaders backed the export of the ABC approach elsewhere in Africa, for example in Botswana, with considerably less success. The same minimum rules did not have the same effect everywhere.

Moreover, minimum rules mean exactly that – there needs to be the space to allow for localised processes of reinvention. Such innovations can only be effective if they are embedded in economic, social and political contexts.

This was one of the major errors of PEPFAR in the Bush era, interestingly not mentioned by the CGDev blog piece. Ideologically driven approaches to prevention banned and inhibited specific kinds of responses, limiting local adaptations so that funded programmes were consistent with the norms of the US conservative right. This was most notable in Uganda itself, despite AIDS activists arguing that such actions would undermine community efforts to reduce HIV prevalence and HIV transmission.

The pressure of PEPFAR funding requirements led – directly and indirectly - to a third of prevention funds being spent on abstinence-until-marriage programs, sex-workers condemned as immoral, and rising anti-condom rhetoric with some 32 million quality-approved condoms being  impounded in government warehouses. Concerns about donors latching onto dangerous ideas have not gone away, as highlighted by a recent Guardian blog on cash transfers for HIV-AIDS prevention.

Is there any message in all of this for how HIV-AIDS is dealt with in the coming years, apart from wariness of silver bullets? Perhaps it is simply to try and replace the search for ‘best practices to fix the problem’ with a focus on ‘good principles that trigger local invention.’

Whether there is the space and appetite for such a shift remains to be seen.

 

 

This piece was adapted from segments of Exploring the Science of Complexity, an ODI Working Paper published in 2008 http://www.odi.org.uk/resources/download/583.pdf

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War on cancer, war on poverty

Posted in Healthcare, Innovation, Knowledge and learning, Leadership, MDGs, Public Policy, Strategy on October 7, 2010 | 1 Comment »

This weeks presentation is a 2009 TedMed talk by David Agus on the application of complexity science to cancer research. The talk focuses on the limitations of trying to understand cancer using reductionist thinking and how this limits potentially significant advances.

Agus illustrates this dramatically, showing that since 1950, after more than half a century of technological advances, extensive research and new treatments, there has only been a marginal improvement in cancer death rates in the US. As he puts it “in general, we haven’t made any impact at all in the war on cancer”. At the heart of this lack of progress, according to Agus, is that much of this effort has focused on symptoms: “our dictionary for describing cancer is very very poor – it’s basically symptoms, its manifestations…”

Meanwhile, some of the most recent approaches that have helped improve recovery rates have dealt at cancer as a complex adaptive system that is interconnected with the wider system of the human body. For example, Agus cites clinical trials showing that taking drugs usually prescribed for osteoporosis and acne actually reduced cancer recurrence by up to 35%.

Finding more ways to treat cancer as a dynamic system is more important and potentially valuable, according to Agus, than ‘focusing down’ and dealing directly with the specific symptoms.

Perhaps obviously, the talk left me thinking about loved ones who have had treatment for cancer over the years.

It also left me reflecting on potential parallels with how we generally study and deal with poverty in developing countries, which as Bill Easterly reminds us again, has also been a 6 decade-long project facing some serious issues. The direct, reductionist approach to poverty holds sway.  The expectation is that aid agencies will set out a clear programme and not to renege on their promises, despite how circumstances change. This can be problematic in the extreme.

Olivier De Schutter, Ban Ki Moon’s special rapporteur on food, makes the point in a direct echo of Agus’ talk:

the MDGs, as they are currently conceived, address the symptoms of poverty and underdevelopment, but mostly ignore the deeper causes… the MDGs may divert attention from the mechanisms that produce underdevelopment.”

So what would the ‘war on poverty’ look like if we tried to move away from directly dealing with the symptoms of poverty? One answer might be from the work of John Kay, one of the UK’s leading economists, who advocates ‘oblique strategies’:

paradoxical as it sounds, many goals are more likely to be achieved when pursued indirectly. Whether overcoming geographical obstacles, winning decisive battles or meeting sales targets, history shows that oblique approaches are the most successful, especially in difficult terrain.

Obliquity is necessary because we live in an world of uncertainty and complexity; the problems we encounter aren’t always clear – and we often can’t pinpoint what our goals are anyway; circumstances change; people change – and are infuriatingly hard to predict.

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New York Times Article on Making Sense of Complexity

Posted in Conflict and peace building, Financial crisis, Healthcare, Public Policy, Strategy, Technology, Urbanisation, Water on May 2, 2010 | 1 Comment »

Today’s New York Times Review has a nice piece  on ‘making sense of complexity’ which cites the work of Brenda Zimmerman, noted complexity specialist whose work on health systems has featured on two previous Aid on the Edge posts (here and here).

Here it is in full:

The Great Recession and the wars in Iraq and Afghanistan, arguably the toughest problems we’ve confronted in decades, are nothing if not spectacularly complicated. Trying to size up these puzzles is like gaping at a homemade contraption that has mysteriously evolved into something even its designers can no longer fathom, let alone operate and dismantle. Is there an owner’s manual for this thing? Can it be unplugged? If we figure out where it’s getting fuel, can we starve it and hope it expires?

Look at the military’s PowerPoint slide of the Afghanistan war, a labyrinth of cross-thatching lines and arrows swirling around words like INSURGENTS and COALITION CAPACITY & PRIORITIES. “When we understand this slide,” said Gen. Stanley A. McChrystal, who leads the American effort in Afghanistan, “we’ll have won the war.”

At the same time, we’re learning more about the financial instruments that caused our economic collapse, and it’s now clear that “exotic,” the adjective of choice, won’t suffice. Synthetic collateralized debt obligations are impenetrable on purpose, built for maximum opacity. They’re also lethal mysteries to companies like A.I.G., an insurance firm whose supposed expertise is assessing risk. A.I.G. needed an $85 billion government loan to remain solvent.

You sense that the march toward complexity has turned into a sprint in the debate about health care reform and even the gargantuan oil spill in the Gulf of Mexico, challenges so baroque, and with so many disparate and moving parts, the best you can do is hope that someone in charge understands them. Complexity used to signify progress — it was the frisson of a new gadget, the riddle of some advance in technology. Now complexity lurks behind the most expensive and intractable issues of our age. It’s the pet that grew fangs and started eating the furniture.

Of course, a nagging sense of incomprehension is a perennial feature of the human experience. When a character in “The Winter’s Tale” describes a spectacle that “lames report to follow it and undoes description to do it,” Shakespeare is talking about the reunion of King Leontes and a daughter presumed dead for many years. But the sentiment works just as well as a reaction to events preceding the Troubled Asset Relief Program. The difference is that Shakespeare’s speakers tend to marvel at natural mysteries, and when confronting them the playwright seems to endorse a certain humility. Today, our mysteries are self-created, and humility seems like a response we can’t afford.

“Are We Doomed?” read the headline to an article in New Scientist, a British magazine that last year took a long look at complexity. (Spoiler alert: maybe.) There is a lot of end-of-days talk when it comes to this subject. You will find a strain of it in the work of Joseph Tainter, an anthropologist at the University of Utah and the author of “The Collapse of Complex Societies.” In the book, Mr. Tainter examines three ancient civilizations, including the Roman Empire, and explains how complexity drove them to ruin, essentially by bankrupting them.

Does he look at the complexity of the problems facing the United States and see doom? Possibly.

“Complexity creeps up on you,” he said in an interview. “It grows in ways, each of which seems reasonable at the time. It seemed reasonable at the time that we went into Afghanistan. It’s the cumulative costs that makes a society insolvent. Everything the Roman emperors did was a reasonable response in the situation that they found themselves in. It was the cumulative impact that did them in.”

Mr. Tainter isn’t peddling the nostalgic charms of simplicity, which is wise because there aren’t a lot of people who would buy it. Unless the subject is TV remote controls, most Americans have a fondness for complexity, or at least for ideas and objects that are hard to understand. In part that is because we assume complicated products come from sharp, impressive minds, and in part it’s because we understand that complexity is a fancy word for progress.

Just about every profession has become more complicated in recent decades. The sheer volume of data and rules that must be grasped by a certified public accountant, for instance, has exploded, says Gary Giroux, a professor of accounting at Texas A.& M. The bible of the business is the portentously named “Original Pronouncements,” a book that at its heftiest a few years ago ran to roughly 10,000 pages.

A century ago, Mr. Giroux says, there were no accounting courses, let alone “Original Pronouncements,” because accountants were just guys who double-checked the math of corporations to ensure there wasn’t internal fraud. What happened?

“There was no income tax until 1913,” he says, “and before the New Deal, there was no Securities and Exchange Commission.”

It’s been fashionable for some time to bash accounting for its encyclopedic list of rules and standards, which is perhaps why a public relations rep at the Financial Accounting Standards Board can come across as a little defensive when asked about the size of the group’s most famous door-stopping tome. But you can’t understand where all those regs came from without realizing that they made possible, and mirrored, the growth of the economy.

Which gets to the worrisome part of the complexity of problems we face today. Instead of improving our lives, it’s vexing them.

What we need, suggests Brenda Zimmerman, a professor at Schulich School of Business in Ontario, is a distinction between the complicated and the complex. It’s complicated, she says, to send a rocket to the moon — it requires blueprints, math and a lot of carefully calibrated hardware and expertly written software. Raising a child, on the other hand, is complex. It is an enormous challenge, but math and blueprints won’t help. Performing hip replacement surgery, she says, is complicated. It takes well-trained personnel, precision and carefully calibrated equipment. Running a health care system, on the other hand, is complex. It’s filled with thousands of parts and players, all of whom must act within a fluid, unpredictable environment. To run a system that is complex, it’s not enough to get the right people and the ideal equipment. It takes a set of simple principles that guide and shape the system. For instance: Teach everyone the best practices of doctors who are really good at hip replacement surgery.

“We get seduced by the complicated in Western society,” Ms. Zimmerman says. “We’re in awe of it and we pull away from the duty to ask simple questions, which we do whenever we deal with matters that are complex.”

Those complicated financial instruments that helped bludgeon the economy, she says, should have been subjected to elemental tests: Is this good for consumers? What are the risks involved?

Of course, nobody at Goldman Sachs or any other large financial institution meant to wreck the economy. The United States military didn’t invade Iraq or Afghanistan thinking that one day its efforts would be mounted on a bewildering PowerPoint slide. The engineers who designed the BP oil platform that exploded and sank and produced one of the largest oil spills in history built it with multiple back-up systems.

But complexity has a way of defeating good intentions. As we clean up these messes, there is no point in hoping for a new age of simplicity. The best we can do is hope the solutions are just complicated enough to work.

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Complexity and Healthcare: Reformer, First Change Thyself

Posted in Healthcare, Public Policy, Reports and Studies, Strategy on March 26, 2010 | 1 Comment »

One of the biggest stories this week is that US President Barack Obama has signed a landmark healthcare bill into law – the largest expansion of the US federal social safety net since the 1960s. But work by leading healthcare analysts around the world would indicate that the safe passage of the bill is only the starting point.

In a paper for the Commission on the Future of Healthcare, Sholom Glouberman and Brenda Zimmerman illustrate how attempts to intervene in complex health care systems often treat them as if they were merely complicated, or even worse, simple.

The table below sets out the now well-known framework which they use to make these distinctions. Glouberman and Zimmerman argue that such conceptual mismatches between reforms and reality can compound healthcare failures in dramatic ways. They give a number of examples of how this has happened in the Canadian Medicare system.

The authors liken the pervasiveness of existing ‘complicated’ approaches to healthcare reforms to an often-told story of a man who is stumbling around near a lamppost:

…He is asked what he is doing and says that he is looking for his car keys. “Oh, where do you think you lost them?”
“Down the block near my car,” he says.
“So why are you looking for them here?”
“Because the light is better.”

They continue:

The sophistication of our models, theories and language for complicated problems can be as seductive as the lamplight. They provide better “light” and clarity and yet can lead to approaches that are ill-equipped to address complex adaptive systems…” (emphasis added)

They aren’t the only ones to see potential for complexity science in bringing about healthcare improvements. Paul Plesk, Director of the Academy for Large Scale Change at the UK’s NHS Institute of Innovation, uses the same distinction between complicated and complex systems as a way of demonstrating how ‘directed creativity’ can be utilised in change processes. The World Health Organization has also been using complexity approaches in its work on knowledge management, and on analysing disrupted health systems in conflict-affected countries.

The Healthcare Commission paper sets out four clusters of differences between complicated and complex systems, all of which  have relevance for healthcare reforms.

Theory of systems First, the theory of health systems is enhanced by ideas of real-world systems which behave in nonlinear and  unpredictable ways. It isn’t just a case of pulling levers, and ignoring noise and fluctuations. Instead, the key is to embrace uncertainty, tension, noise – to work with these factors as givens rather than as aberrations.

Causality The second set of differences is about how change happens, specifically how causality is not one-way but dynamic with multiple feedback processes. This means accepting dynamics of change as two-way, unpredictable and never-ending:

Evidence The third set of differences relates to evidence, and how complexity means that certain kinds of evidence – much of which would be dismissed if health systems were seen as merely complicated – needs to be understood. Specifically: outliers, historical anomalies, and patterns of behavior and relationships all need to be examined and understood.

Planning and decision-making The fourth area relates to planning and decision making, and how overall system-wide properties emerge from many small-scale decisions. Therefore the key is not to plan everything in advance, but to put in place a process of strategic learning that will allow for corrections, shifts, and even wholesale changes in approach.

 
A number of case study examples are cited in Healthcare Commission paper, with the two most detailed ones covering the French healthcare system, which was ranked best in the world by the WHO in 2009; and the Brazillian healthcare system, specifically in relation to the HIV-AIDS response in the 1990s.
 
Both of these case studies illustrate how the approaches taken to theory, causality, evidence and planning were different to those suggested by a ‘complicated’ view of the world, and were also more successful in terms of health outcomes in those countries. Especially interesting for all those interested in complexity in aid is the account of how, in the Brazil HIV-AIDS case, a complicated worldview was heavily pushed by external aid actors (notably the World Bank), and was rejected by the Brazil government in favour of a more complexity-oriented perspective.
 
These ideas would appear to be highly relevant for the effective implementation of the new US bill. The challenge faced is three-fold:
  • to articulate an approach to the complex issues faced in changing healthcare systems
  • to resist the technical bias to analysis which assumes the problem is a complicated one
  • to resist political influences that promote particular approaches and mindsets, and reduces engagement with complexity
This last issue is perhaps the critical one in the current US context. As the World Bank-Brazilian Government example illustrates, political context is vital in enabling these challenges to be addressed. In the USA, there has been widespread opposition to the bill, and vehement calls for the bill to be scrapped. The implementers will be under enormous pressure at all stages to demonstrate the bill is working - ambiguity will not be tolerated, and the smallest sign of failure will be picked up to score political points.

In the face of such vociferous opposition, the need to question existing assumptions and mindsets may seem irrelevant. But it is arguably even more important in such settings. As Muhammed Yunus, founder of Grameen Bank, put it recently, when talking about the rise of microfinance: “[the] greatest challenge has been to change the mindset of people.”

In this light, perhaps the true test of the healthcare reforms will not merely be new legislation, budget and policy frameworks, technical fixes, unseen compromises and political victories. Perhaps the true test of the reforms will be whether they bring about change in mindsets.

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A Complexity Science Primer

Posted in Healthcare, Reports and Studies on January 5, 2010 | 3 Comments »

For all ‘Aid on the Edge’ readers wanting a straightforward, clear and above all short introduction to complexity science, your wishes have been answered with a well-written 16 page primer, adapted from Brenda Zimmerman & co’s work on health systems. It doesn’t answer all complexity-related questions, but it is certainly a very useful entry point for those starting out their journey on the complexity sciences. As the abstract notes:

This paper is called a ‘primer’ because it is intended to be a first step in understanding complexity science. In house painting, the primer or prime coat is not the finished surface. A room with a primer on the walls often looks worse than before the painting began. The patchy surface allows us to see some of the old paint but the new paint is not yet obvious. It is not the completed image we want to create. But it creates the conditions for a smoother application of the other coats of paint, for a deeper or richer color, and a more coherent and consistent finish. As you read this primer, keep this image in mind. This paper is not the finished product. Ideas and concepts are mentioned but only given a quick brush stroke in this primer. You will need to look to the other resources… to get a richer color of complexity.

Download the paper here, and do share any thoughts and ideas using the comments function. And for more reports on complexity with specific relevance to development and humanitarian work, take a look at the Publications page of this blog.

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