Last year, we hosted four incredible interviews with folks driving radical collaborations across the globe. Our world has transformed so much in the time since, but the wisdom of these great leaders sustains. Take a listen.
We are actively engaged in the dialogue and debates of our space: on issues of social justice, global development, and democratic innovation, and on the ethics and methodological evolution of design, mediation, and co-creation practice. More of our writing can be found at Medium.
In celebration of the launch of our new website, we’re taking a look back at Reboot’s three-and-a-half years of growth and change—and looking forward to our plans for the future. Over the last two weeks, we kicked off with Our Story and What We’ve Learned. This week, we’ll be looking ahead.
Experimenting with our model and examining our results is a constant process for us. After three years of learning, over the last several months we’ve developed a new strategic plan that builds on the work we’ve done thus far, and focuses on expanding uptake of Reboot’s empirically-backed ideas across our broader community of practice.
As we often get questions from clients, partners, and candidates about our trajectory, here are a few of the areas that we’re planning to grow (with your help!).
This new website is one of the major steps in an effort to increase our advocacy among our community of practice. From the outset, we understood that our mission would be best fulfilled if we paired the empirical evidence drawn from our consulting projects with strong advocacy for change. When we first started, however, we didn’t have much evidence of our own and had no desire to join the ranks of those who advocate without having ‘the ground truth.’ As a result, our external communications have been small compared to all that we’ve wanted to say.
That’s changed now that Reboot has learned through more than 30 projects in 17 countries. We feel confident taking stronger and more public positions on the issues we care most about. We know that the open inquiry and context-specific design that we have brought to our projects can benefit many more organizations than we can serve directly. We’ll be much more active as contributors and participants in the community, and hope that we can help decision-makers and fellow practitioners in their attempts to serve the public good. We expect this to also produce more opportunities for feedback and learning amongst our team, further improving the quality of our practice. To extend our efforts, we’re actively looking for partners with common interests who may want to collaborate in helping our shared knowledge reach a wider audience.
We have seen some of the greatest impact when we’ve worked with and between multiple actors, including international donors, governments, grassroots advocacy groups, and local communities. It is our ability to understand these group’s varying incentives, capabilities and perspectives that allows us to better align those factors towards social progress. One client called us the “systems integrator” of governance, and we agreed with the importance of this role.
Moving forward, we plan to more formally embrace this value add by pursuing initiatives where we can serve as an independent bridge among these diverse actors. We’re not quite sure what this will look like in practice, but we’re brainstorming with collaborators on how we might gain the financial independence to allow Reboot to function in this role without the support of a client resourcing.
Having worked with some of the world’s largest bureaucracies, we’ve learned that operational processes can significantly hamper or enable delivery of impact. Increasingly, we have been working with our clients to help them understand how they can do better, more innovative work through adapting their operational procedures. Funding and contracting modalities, and the incentives they impose, frequently prevent responsive, effective problem solving and lead to poor outcomes.
From conducting an institutional ethnography of a major bilateral donor to informing policy dialogues on how to approach performance evaluation of public financial management systems, we’re excited to help our partners ensure their organizational physics aren’t a barrier to impact.
We’ve had the great fortune to work with some amazing clients and collaborators, and have cherished these experiences. But in these past years, we’ve also learned the constraints associated with sitting in the consultant chair.
Increasingly, we see opportunities to advance our vision of inclusive development that are not attached to an existing client or partner. We get frustrated when these opportunities for impact pass by because we can’t rapidly identify a client with the interest and unprogrammed resources. Even more heartbreaking are those instances where a successful initiative comes to an end to the dismay of all parties solely because of resource availability. While we’ll continue our consulting work, and the success we’ve built, we’re finding new opportunities that may give us the chance to address some of the consulting model’s limitations.
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In setting these new goals, we are in many ways back to where we started—cautious optimists with lofty ambitions. We have come this far thanks to the support and inspiration of our trusted clients, colleagues, and the spirit of debate and improvement that defines the broader field. We’re looking forward to deep discussions and hard work for years to come, as we continue building a 21st century social contract together.
In celebration of the launch of our new website, we’re taking a look back at Reboot’s three-and-a-half years of growth and change—and looking forward to our plans for the future. Last week, we kicked off with Our Story, the first post of a three-part series. This week, we’re outlining some of the most important lessons we’ve learned about what it takes to run an enterprise that’s able to balance mission and business.
So without further ado, here are five lessons we thought were worth sharing…
Every time a new opportunity comes across our desks, we use a matrix to decide whether or not to take it on. At the very top of our list of criteria is the client’s alignment with our values. It’s not just a Boolean ideological rule, e.g., “We don’t work with tobacco firms.” It’s a deep examination of whether our fundamental vision and approach to development and social justice aligns—not just with the organization as a whole—but with the specific counterpart team we’d be working with. It’s important that both parties bring complementary views and values to answering tough questions throughout the project, even if that means swimming against institutional and political pressures.
We apply similar thinking to the promises we’re willing to make to our clients and partners. If we can’t field the best possible team to try and tackle an initiative, we would rather pass on a project than bring anything other than our best.
Many exciting opportunities have unfortunately passed us by. But following these rules makes sure we keep our for-profit social-enterprise in line with our original values and goals. We have all seen firms grow to a size where they need to “feed the beast,” eventually having to take on undesirable projects in order to sustain the desired rate of growth. So we manage our pace closely, even as we grow ambitiously, to mitigate the risk of having to take on work that doesn’t align with our values.
As a people-first organization, we rely on an incredible team to solve tough challenges. We are unjustifiably lucky to have such brilliant, passionate staff dedicated to this work, and have seen time and again what factors are the most crucial to success. Skills and experiences matter, but we find that intangible qualities—psychographic, ethical, and personal—are often the factors that make or break a candidate’s ability to thrive in our environment. At the top of the list are humility and generosity.
Pursuing social change is challenging and rarely glamorous, especially as we eschew quick-fix solutions. Addressing corruption in a resource-poor, conflict-affected context, or advancing human rights and social cohesion in a newly democratic state—these things just don’t happen overnight. The work can be frustratingly slow. Maintaining humility, putting others before self, and putting in the effort even when the results may not be realized in our lifetime—that’s what it takes to do this work well.
We often get asked whether we’re a design firm, a management consultancy, or a social enterprise. But the best description we’ve found is: “Reboot is a social impact firm dedicated to inclusive development and accountable governance.”
While it’s honest, it’s a bit wordy, so we understand when our colleagues offer other labels. We’ve been called an “ICT4D firm,” an “open government shop,” and (our favorite) “a radical, anarchist collective for good governance” (this was from a client we deeply respect; we took it as a compliment).
The truth is that we very purposefully work in and draw practices from all of these fields and more, without subscribing to any single one. Our work is predicated on the idea that there is no single magic bullet that will solve social challenges rife with geographic and institutional politics. Identifying with a single field or school of thought is a kind of myopia.
We’ve adapted tools and approaches from various disciplines. While we have drawn perhaps most heavily from the practice of human-centered design, we recognize the limitations of traditional design practices, and our various projects have drawn in methodologies used in economics, public financial management, applied ethnography, journalism, and more. We don’t believe in blueprint approaches, or applying global “best practices” from one context to another. Because we take an ethnographic approach to research and participatory design, our analysis and interventions are uniquely tailored to the contexts in which we’re working.
We embed as deeply into our client and partner organizations as possible—an entryistic approach that has helped us address social issues at a scale and speed that would otherwise be highly challenging for an organization of our size. If we set out to build our own infrastructure and staff, our impact would be limited by the rate of our growth. Instead, we’ve been able to leverage the resources and minds of the world’s most influential organizations such as national governments, the World Bank, and the United Nations.
We also work hard to get executive buy-in throughout the process. As a result, we’ve continued to grow our collaborations with several clients over the years. We consider it part of our mission to help our client counterparts influence dialogues within their own organizations about how governance and development work should be done. The type of access we’ve gained and relationships we’ve built with senior decision-makers would have been far more difficult had we worked as a grantee or outside advocate. Ensuring support from leadership also makes us and our work better; it forces us to fit our bright ideas through real-world constraints and increases the likelihood of sustained commitment to whatever we’re working on.
Although we’ve had success with our model, we recognized from the start that this was just one approach. As a young organization, our capacities and experiences are constantly, growing. Thus, we believe that our model should also consistently be challenged, to make sure that it remains the right one for us.
For example, we set out to work with large institutions—namely, governments, multilateral development organizations, and international NGOs—because of their reach, resources, and influence, and what these factors meant for improving human development. While we’ve been happy with the results this approach has produced, we’ve begun to feel it is too limiting given the many other paths to achieving social progress.
To that end, since 2013 we’ve experimented with working with different kinds of organizations, including small non-profits, advocacy groups, philanthropic foundations and technology startups. In this work we’ve also trialed several different models of collaboration. Beyond our standard consulting model, we’ve made grants, provided pro-bono or in-kind services, worked as part of larger consortiums, taken on short-term targeted assignments, and served as mentors and trainers.
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Drawing from what we’ve learned, we’ve spent the last several months detailing out plans for Reboot’s next three years. We’ll share more about those in part three of this series.
Looking around our offices today, it’s hard to believe how much Reboot has changed in more than three years of practice. From our beginning—two people, a home office, and a quixotic quest—we’ve grown to a 20-person collective of “practicing theorists”, with 34 projects in 17 countries under our belts. We’ve helped leading global institutions and grassroots community groups alike set policies, develop processes, and deliver services to alleviate human suffering and advance social justice.
This week, as we celebrate the launch of our new website, we’re proud to highlight our growing capabilities, and keen to contribute our theories and models to the wider community of practice. So to that end—as well as to show our appreciation for our brilliant staff and the inspired partners who have trusted us with their missions—we’re taking this opportunity to look back at Reboot’s growth, offer a glimpse of where we’re going, and pass on a few of the lessons we’ve learned along the way.
This post marks the first of a three-part series and starts at the beginning: how we came to be, why we exist, and what our model for change is.
Reboot officially opened its doors in 2011. But the seeds for Reboot were planted a year earlier, when Panthea and I met at a geeky, weekend barcamp on government transparency.
I was working at the Center for American Progress, Panthea at the UN. We found a common frustration with our field; we had seen firsthand how many government and development organizations, despite significant resources invested, were not always effective at meeting the needs of the communities they sought to serve.
It was not for lack of effort. We knew how deeply our colleagues were invested in their work and committed to their missions. It was the tools, theories, and ways of working that we believed were too often ineffective. And we joined many others in hypothesizing that our basic model of democratic governance needed significant rework.
We felt that the deepest challenge was in the public sector’s indirect accountability chain. Private corporations face a straightforward litmus test: do consumers believe a company’s offerings add value to their lives? If the answer is “no,” then consumers simply go with another company and offering.
But in the public sector, there’s rarely another option when critical social services don’t deliver. When stakes are highest—usually for citizens of certain income brackets, ethnic backgrounds, and geographies—the choices are often most thin, and the failure of a public service has dire consequences. When an infant in rural Nigeria dies because she lacks access to clean water, where can her grieving parents turn?
Private companies, which live or die by the quality of the services they provide, have long employed a variety of means for understanding and serving people’s needs. Our mission was to find a way to bring these tools and techniques to the service of those delivering public benefit, and to design services and interventions that effectively met people’s needs. Similarly, just as companies are constantly learning to optimize their infrastructure and internal processes around consumer satisfaction, we wanted to help governments and development institutions optimize their policies and practices around improving human well-being.
When people ask, “What does Reboot do?” the answer is long, because, depending on the engagement, we may act as a management consultancy, grant maker, research and design shop, program implementer, and/or strategic communications firm. In short, we have done a great many things in a variety of different places, but broadly we can say our work falls into three core areas:
Implementation: We stand by our designs by working with our clients and partners, including civil society organizations, private sector, and target communities, to implement programs that promote human development.
It’s a model that has been fulfilling in terms of our mission and values, although it’s not always operationally easy. Each of our three areas of work requires different operational models, and we adapt staffing, financial structures, and logistics management as necessary. This is also one of the reasons why many organizations focus only on one of these three elements. And, indeed, our advisors and many business books have counseled against this approach. Specialization is a safer business model.
But we started Reboot to create change, not run a business. We saw that operating across these distinct but overlapping realms makes us more thoughtful, more well-rounded practitioners. We’re able to design better programs, manage their effective implementations, and contribute back to global conversations because we are invested throughout the process.
We also made the choice to operate as a consultancy because we saw that our impact could be greater by assisting major public sector and development organizations in achieving their missions. We knew these institutions’ strengths, and saw opportunities where they could operate better. By working with them as advisors and implementers, we saw a more effective and sustainable path to influence global development practice.
Additionally, we are proud to be a for-profit social enterprise. Working under contract with our partners means we have direct accountability for the success or failure of our ideas. The global development space is prone to lively debates and constant experimentation around how to better deliver on its promise. If our results can’t withstand this competitive market of ideas, then we might as well all go home.
Thus far we’ve been fortunate in this regard, which has allowed us to be able to invest 100% of what (relatively little) profit we’ve gleaned back into our mission. As soon as we were able, we began providing pro-bono services to mission-oriented organizations and have recently expanded our charitable activities to include offering catalytic grants to early stage social enterprises. We’ve also used our profit as working capital to finance a staff that works without the constraints of being tied to specific project funding and as the resources to advance our advocacy. So we think our case demonstrates how for-profit can easily be for-good.
Thankfully, the market response we’ve seen in the past few years suggests that we may be on to something.
Our consulting projects and pro-bono engagements are allowing us to explore approaches to fulfilling what we call a “21st century social contract”. We are humbled and amazed by the incredible opportunities and lessons offered along the way.
We started an organization—as most founders probably do—because we were frustrated about the way the world worked, and because we thought (perhaps naively) that we could do something to change things for the better.
Today—well, we remain frustrated and still naïve, though hopefully less so—we are channeling our frustration more constructively. Through our work, we have been able to translate our vision and theory of change into actionable practice. In the process, we have played a part and taken steps, however small, toward creating the world we want.
From our very first project, conducting research on financial inclusion for an academic institution, our capabilities have grown: We’ve brought the perspectives of marginalized populations to design policies and programs in Tunisia, Pakistan, and Nicaragua. We’ve worked on human trafficking, public sector governance, media development, civic innovation and other diverse issues. We’ve established an office and discovered a wonderful community of partners in the Niger Delta. And we’ve helped advance inclusive development in several troubled and post-conflict states; this includes supporting a transitional government to administer legitimate elections in a newly democratic state still plagued by unrest.
None of this would be possible without the commitment and passion of our team—the more than 20 brilliant, talented thinkers and doers in our ranks (and we’re looking for more), as well as 20-plus collaborators and partners who have contributed in generous and insightful ways, both large and small.
Equally important are those who entrust us with their important challenges. We are thankful for our clients, whose values and perspectives align with that of our work, and who welcome moving beyond a traditional client-vendor modality towards deeper partnerships to achieve collective goals. They have come to us with some of their most difficult issues and important initiatives, and given us the space to ask tough questions and experiment with approaches in our joint pursuit for better answers. We are deeply grateful for their trust and for the opportunities they have provided.
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The most important part of all this is how we do it. So up next, we’ll talk about our model and the important lessons we’ve learned to date. Stay tuned part two!
Zack will be at the United Nations on Wednesday, May 28 as part of the Social Innovation Summit: a global convening of tech, investment, philanthropy, international development, and business leaders. Zack will judge a start-up pitch competition for social innovators to connect with investors for partnership development.
UNICEF Innovation has selected Panthea as one of 9 global leaders in innovation to watch. UNICEF will feature Panthea and Reboot between now and the end of the year, highlighting Reboot’s work and developments that will lead to global change.
A new brief from the World Bank, co-authored by Merrick Schaefer and Panthea Lee, features Reboot’s MyVoice SMS reporting tool. Titled “Making Mobile Feedback Programs Work“, the brief highlights initial outcomes from a pre-pilot exercise conducted in 2013.
Dave will be speaking at NYU Wagner’s International Public Service Association (IPSA) 11th Annual Conference on May 2. He will join a diverse lineup of development practitioners in a series of panels under the theme: Navigating the International Development Landscape. Dave will talk about how organizations can learn from monitoring and evaluation to improve their operations and change the way they do business.
We are thrilled to welcome Robin to the Reboot family as Communications Intern. Robin is currently pursuing an MFA in Design for Social Innovation at the School for Visual Arts. Her past experiences include conducting focus groups on health issues in India and leading youth to engage in community-driven projects in Guatemala. Robin is also a skilled events coordinator after her time with environmental non-profit Not Far From The Tree. Equipped with a multidisciplinary, international background, Robin will be boosting our outreach efforts.
Measuring program effectiveness may sound like the bean-counting afterthought to the real work of program implementation. But measuring program effectiveness in the social sector can feel pretty high-stakes for organizations competing for limited funding dollars. And there’s plenty of controversy around how it should be done.
One particularly persistent debate centers around whether or not some programs are too “soft” to evaluate. Are the outcomes of, say, advocacy or empowerment initiatives too subjective, complex, or nuanced to evaluate with “hard” objective metrics?
A recent Stanford Social Innovation Review article by representatives of the Walton Family Foundation argues that this does not have to be the case, declaring “advocacy isn’t ‘soft’”. The authors describe how they have been able to apply logic models and performance measures to their advocacy projects in more or less the same way that they might to direct services programs.
As someone who thinks ways can be found to at minimum approximately measure just about anything, I view attempts to measure advocacy grantee effectiveness as a generally positive thing.
But an acceptance of the assumption that being “soft” is bad, and that all interventions should be evaluated in the same way as direct service programs, isn’t the only way forward. While this can provide a good start for laying out how any intervention can be monitored, many examples of performance assessment still focus primarily on outputs instead of the changes those outputs are intended to produce.
The SSIR article, for example, described a report produced by an education advocacy organization. Evaluation of the report’s performance included tracking indicators like the number of times the report was downloaded and the number of media mentions it received (including one very powerful mention from Secretary of Education Arne Duncan).
But understanding how advocacy outputs lead to behavior or opinion change and, ultimately, to impact is more difficult than just getting creative about which output response metrics feed into performance assessment templates. Sure, I can understand that a certain number of people have downloaded a report. But without digging deeper, how can I know if it was read once downloaded, and then if it changed anyone’s mind? What’s more important: the number of media mentions that a report garners, or whether one mention in particular led a lawmaker to author new legislation or vote in a different way?
We’d do well to remember and embrace the fact that advocacy is political in nature, yielding unintended results and patterns that are difficult to predict and that resist simple measures. Outcomes are based on interactions between individual actors with different incentives, capabilities, and needs all responding to any given intervention. As a result, politics evolves in a nonlinear manner, where one action has numerous effects that may alter the intended trajectory of said action.
Any effort to evaluate such complex interactions demands “trained judgment”, which is based in tacit knowledge and not just a scientific method. And tacit knowledge starts with a deep understanding of the incentives that inform people’s everyday behavior, the institutions they build, and the political landscape within which they operate. Measuring the effectiveness of advocacy efforts as if they were the same as direct service programs sells advocacy, and the complex social dynamics it takes on, short.
Advocacy requires understanding the people whose beliefs and behaviors the intervention hopes to influence. People are subjective, complex, and nuanced. It should follow that an advocacy program attempting to change behavior and how people interact with institutions and each other deserves to be evaluated as both “hard” and “soft”.
Ethan will deliver a keynote speech at the UBC Sauder School of Business Propelling Social Ventures 2014: From Ideas to Impact conference on April 15 in Vancouver. He will speak to ways the public sector and social innovators can work more closely for greater impact, followed by a panel discussion with directors from the Ministry of Social Development and Social Innovation and Social Innovation Generations (SiG) West.
The clearest representation of healthcare is a doctor sitting with a patient. Whether it’s a routine checkup or a serious procedure, direct interaction is central to how health care happens. If you want to improve health outcomes, this interaction is a good place to start: putting new technology in the doctor’s bag, ensuring vaccines or essential medicines reach patients, or simply building new clinics.
But, of course, we know that there are hundreds of other people who make that interaction possible: diagnosticians, administrators, insurers, janitors, receptionists, truck drivers, cooks, regulators, researchers…the list is endless. These are the people who compose a health care system. And the design of such a service delivery system can dramatically impact the effectiveness and efficiency of the care provided.
The global health sector is paying increasing attention to the systems that ensure care reaches people who need it most. Last month, experts from several major NGOs and donors gathered at the Center for Global Development to talk about investments in global health and how an enabling environment can make investments more effective. Though a bit meandering, the conversation frequently came back to the importance of systems strengthening, as I discussed recently on Humanosphere.
However, the event left a big open question around measuring the impact of systems strengthening efforts. This measurement is challenging because health systems are incredibly complicated. They involve a wide range of public and private actors, their performance depends on countless exogenous factors, and they take different forms in every country depending on the population being served and the other institutions in place.
Health systems strengthening may be able to learn from measurement in broader governance reform efforts. There is already a great deal of overlap between the two. When I posed the question of impact measurement to a few of the panelists, Karen Cavanaugh of USAID commented that other development sectors are probably ahead of healthcare in terms of systems-level indicators.
Generally, governance indicators can take two different approaches:
Measuring governance itself usually means looking at the rules and processes of government—for example, noting whether certain laws are on the books, whether the legislature passes a budget, or whether certain agencies exist and have funding—as well as how government functions in practice. This sort of measurement can be fed smoothly into diagnosis (you can quickly identify the gaps) and reform (you can design and advocate for changes). However, because governance is measured against how government “should” operate, this carries a normative bias that can be hard to justify. It may well miss many positive capacities of a governance system that fall outside its framework, and potentially encourage isomorphic mimicry (the creation of institutions that look like they meet international standards, while performing entirely different functions).
Measuring the outcomes of governance, on the other hand, guarantees a focus on performance. What did the government actually accomplish? This necessarily pushes into other sectors; governance itself accomplishes nothing, except as it improves health outcomes, educational opportunities, employment, peace, or some other end. For example, Matt Andrews has proposed under-5 mortality or birth registration rates as possible governance performance indicators. Though these performance indicators can lead to cross-country comparisons and support advocacy, they aren’t well-suited for diagnostics or attribution for reform efforts.
Clearly, neither approach to indicators is fully satisfactory on its own.* We need each to serve as a check on the other. Measuring outcomes ensures that our measures of governance itself are actually relevant, while measuring governance itself gives us more actionable guidance than outcomes alone.
Translating this back to health systems, we do need both kinds of indicators. The outcomes are somewhat straightforward, and they are the same outcomes that health care is always concerned with, such as reducing disease incidence or saving disability-adjusted life years. Health systems-level indicators (analogous to measuring governance itself) also exist (see the World Health Organization’s handbook on indicators for health systems). Improving a governance system requires a combination of both types of indicators, supported with research to ensure that they are actually linked in a given context.
The need for both kinds of indicators also points to the need for humility about what indicators can accomplish. Indicators are great tools for managing linear, cause-and-effect relationships, but governance and system reforms are far from linear. Relationships between system elements are often complex, dynamic, and dependent on feedback loops that can be easily misunderstood. In such a context, indicators merely point the way to problems. Designing solutions requires deeper engagement, including a certain amount of iteration and muddling through.
This deeper engagement doesn’t lend itself to indicators or a value-for-money mentality, and it can seem far removed from the direct interaction between doctor and patient. But herein lies the hard work of systems strengthening.
* Bill Savedoff refers to this distinction as governance determinants and governance performance. Somewhat analogously, a recent ODI paper from Marta Foresti and Leni Wild call this form and function. Others refer to it as rules-based and outcome-based, with slight variations in emphasis.
Global health efforts in the past decade or so have taken an aggressive and largely successful targeted approach to some of the world’s most harmful diseases such as HIV-AIDS, TB and malaria.
With an unprecedented increase in funding for such efforts in this new millennium, the global health sector has made major gains against particular diseases and other health threats. But funding is limited, and has plateaued of late, focusing attention on getting more ‘value for money.’ Many leaders in this field say they are now seeking to identify the “best buys” in global health.
This was the stated purpose of a recent event hosted by the Center for Global Development (CGD) along with Population Services International (PSI), PATH, Devex, and Merck for Mothers which featured experts from those organizations and others. The event was linked to the release of PSI’s Impact magazine issue on “best buys” in global health, which included findings from a survey of global development professionals.
As Humanosphere pointed out, the conversation at the event itself was unfocused. Participants tried to shoe-horn points about systems strengthening into the “best buys” rhetoric, and no one seemed interested in talking about the survey that was ostensibly the basis for the event. Nevertheless, the event served to emphasize the attention that sector experts are paying to health systems.
Despite the fuzzy rhetoric, it is time to move past targeting the big, diseased trees on the global health landscape to something more akin to comprehensive forest management. Rather than pruning back each threat that arises, we need to cultivate a stronger ecosystem for health.
Groups like Innovations for Poverty Action and GiveWell have done great work to create evidence bases for specific high-impact interventions, and to advocate for funding those interventions. Some of these, like bednets and deworming, have made their way into the popular understanding of global health. There’s also a lot of press around the gadgets and apps of global health tech, from mHealth and tele-medicine to low-cost diagnostic kits. These are all likely candidates for health funding “best buys.”
But experts in the field contend we need to move away from our focus on the trees and better manage the entire forest. That means health systems, service delivery, and community ownership are the most important places to invest in global health.
A country’s health system includes several interrelated parts: physical infrastructure, regulatory frameworks, supply chains, public and private sector care providers, educational and workforce development systems, patient education efforts, community involvement mechanisms, and more. These parts all work together in order to deliver healthcare effectively and efficiently. Improving the system means tackling any number of these elements, depending on the needs of the country in question. It might require better training for community health workers, a new human resource management system for the national government, an SMS-based feedback system for patients, or something else entirely.
The importance of these systems elements isn’t a new idea. Wonks often talk about the distinction between “vertical” interventions (targeting a specific disease) and “horizontal” interventions (building health systems). Similarly, institutions have received attention in development thinking for years.
What seems significant now is the recognition that investment in health systems is more critical than any specific health intervention. We’ve spent the past decade raising awareness and targeting funds at specific diseases, such as the US government’s focus on AIDS through PEPFAR, or the Gates Foundation’s efforts against malaria. Now the pendulum is swinging a bit toward health systems.
Even if there is broad support for this swing among experts, it may be challenged by our current approaches to funding. The problem with the “best buy” and value-for-money mindset is that it encourages you to look for a clear link between money spent and lives saved. Systems and institutions don’t provide that clear link: such attribution is complicated and easily disputed.
Directing aid dollars toward systems strengthening might be even harder in global health than in other sectors. As Karen Cavanaugh of USAID pointed out at the CGD event, we have been successful in convincing the public that global health challenges are not as intractable as they seem, and are therefore worth tackling. That’s left an impression of simplicity about the interventions needed: delivering vaccines, developing new products, or sending doctors on medical missions are all more straightforward than systems strengthening. We need to encourage a more nuanced understanding.
Part of this nuanced understanding requires seeing how systems strengthening and specific interventions are two sides of the same coin. In any sector, investment in platforms and capacities can make delivery of other products and services possible. Campaigns targeting specific diseases could build on and develop existing system capacity, or could undermine and displace that capacity. Similarly, systems strengthening will have the most success if it produces tangible outcomes on the most critical health issues a system faces. These two approaches should work in tandem.
As health systems receive more attention, we should be able to better understand these nuances. Funding mindsets and mechanisms will be slower to adjust, but shifts there will allow us to ultimately strike the balance between interventions and systems.
This piece first appeared on Humanosphere, a news blog devoted to covering and analyzing issues on global health, aid, and development.
We are delighted to welcome Kerry to our team as Program Manager! Kerry brings a wealth of experience to Reboot from her work in Mexico, the Philippines, India, and the U.S. Pre-Reboot, Kerry managed a variety of projects, including exploration of the economic dynamics of slums with the Rockefeller Foundation’s Strategic Research unit and implementation of impact evaluations with Innovations for Poverty Action. Kerry will oversee research, design, and documentation processes across Reboot projects.
Early this year, World Policy Journal mapped illicit diamond market activities in all their complexity. A 3-month long investigation into the efficiency of the Kimberley Process—an international agreement that seeks to identify and certify non-conflict diamonds—showed that conflict diamonds can pass through multiple subsidiaries in tax havens that are largely deemed “Kimberley Process-certified.” In this way, diamonds are erased of their true origins, making it harder to identify which are conflict and which aren’t.
At first glance, the problem seems to be the inefficacy of the Kimberley Process. Questionable jurisdictions that can erase diamonds of their true origins shouldn’t be certified. Simple as that.
But a closer look reveals a systemic issue that plagues all certifications and standards that are established with the best of intentions. As the World Policy Journal article states:
“The root cause of the problem does not lie in the ineffectiveness of the Kimberley Process as a monitoring mechanism for actual conflict diamonds. It lies in the Kimberley Process’s commendable goal of removing the stain or reputation of “conflict” from diamonds, through a process of certification.”
We live in a world full of certifications. From the grocery store to the airport to the elevator, stamps of approval show us products and experiences have been deemed safe and worthy of our support. Certifications are intended to assign a concept or practice to a class or category; to identify the good and bad, and alleviate concerns. And in doing so, certifications brand credibility and empower consumers and end users.
But while certifications can identify what is working, the illicit diamond trade investigation above shows that they have an equal ability to disguise what isn’t. Putting trust in certifications—and turning a blind eye to the rest—dampens motivation to understand what’s hidden behind the stamp and hold others accountable.
This problem crops up in private and public sectors alike. Countries are signing up for the Open Government Partnership, gaining association with “open government” practices. But what does “open government” really mean when, according to the Committee to Protect Journalists, the Obama Administration’s surveillance activities and fear of leaks deter officials from speaking freely and keep the press at arm’s length? Similarly, what does “corporate social responsibility (CSR)” mean when an Inner Mongolian steel company leaks pollution into a village behind the veil of its sustainability reporting and reputation for strong environmental protection CSR initiatives?
The same idea applies to “best practices” in international development. The implementation of anti-corruption efforts in Uganda since the 1980s has yielded the creation of anti-corruption bodies—the Inspectorate of Government and the Directorate of Ethics and Integrity—that had been proven effective in other countries. But over the years these power structures have been manipulated and undermined. According to a report released by the Institute of Development Studies, an increase in tax revenues initially indicated success in tax revenue authority, but this rate of growth has since flattened and is accompanied by corruption. Successful civil service reform was evidenced by initial bureaucracy downsizing, but this has since reversed. Some believe that international “best practice” anti-corruption efforts implemented in the Ugandan context have assuaged foreign donors instead of truly addressing the problems behind what is often called “corruption”.
While best practices work in certain contexts, the “best practice” label does not guarantee suitability or success. In fact, as UN knowledge management and monitoring and evaluation specialist Ian Thorpe describes in his critique of best practices, following guidelines can in fact deter practitioners from thinking outside the box to look for more appropriate interventions.
The above examples show that certifications, be they labels or standards, have a tendency to create a sense of trust that may evolve into complacency. So how can healthy skepticism make sure certifications reflect reality?
The first step is understanding the certification by breaking it down. This involves analyzing who administers the certification, what their interests are, what stakeholders of all sides and sizes think of the certification, and what systemic factors are outside the certification’s realm. In the case of Kimberley Process certification, the World Diamond Council plays an important role to determine process implementation. Members of the Council include a variety of vested interests from De Beers and other diamond manufacturers worldwide. Groups like Amnesty International and One Sky have found that the process still remains open to abuse.
Next, standards and practice need to more accurately reflect one another. The goal should be outcomes—outcomes that meet standards, and even strive to exceed them. Outcomes should be embedded in practice and operations rather than reported certifications with questionable basis. As my colleague Panthea Lee has written before, “open government” needs to be more than releasing thousands of datasets on an open data portal; efforts need to prioritize solid outcomes around social accountability and constructive citizen-government interaction. In that same vein, “CSR” and even “B Corp” need to more accurately reflect sustainable business practices to a company’s core, as Dane Roth explains in his analysis of alignment for more sustainable CSR.
Finally, outcome-oriented practices can stretch and innovate on certifications to make them more relevant and effective moving forward.
“Best practices” may work in certain times and places, but that shouldn’t stand in the way of finding even better, more appropriate practices.
Looking beyond certifications to understand the incentives and situations behind them can motivate understanding of the full story and further improvement. This way, certifications will not cloud the wisdom, creativity, and empathy needed to build lasting public and private sector accountability.
Panthea has been invited to participate in a roundtable discussion focused on mobile content creation on March 18 and 19 in DC. She will present on human-centered design as part of the gathering. The event will convene 15-20 leading thinkers from technology providers, design firms, content creation organizations, academia, donors, and policymakers with a focus on finding action-oriented ways to strengthen the creation of mobile content.
UNICEF has featured Samantha’s recent article on channeling empathy in policymaking. Based on Reboot’s work on policy creation for children’s rights in Nicaragua, the piece explores how understanding the individual lived experiences of those a policy will affect can inform policy design.
Last month, we explored how policymakers can channel empathy in policymaking, using as an example our work with UNICEF to identify diverse needs and challenges of children in Nicaragua’s North Atlantic Autonomous Region (RAAN). Our community-based approach highlighted success stories as well as services in need of redesign. Today, we’ll go to a casa materna, a “maternity waiting home”, in Puerto Cabezas to see how this important resource for women can better serve as a source of medical and emotional care.
The women of the Puerto Cabezas casa materna have come from near and far. They’ve made journeys of up to multiple hours over rough roads, by foot and in designated ambulances. They’ve come to get the care they need as soon-to-be mothers.
There are 88 casas maternas spread throughout Nicaragua, and seven in RAAN. The government has invested in them in recent years in an effort to reduce maternal mortality. Funded by the Ministry of Health, they are a critical bridge linking rural women to modern facilities in Puerto Cabezas and other cities.
Casas maternas are part of a wider model of healthcare present throughout Latin America. The casas are intended to provide a supportive environment for women who are in the final stages of pregnancy, and especially for women with at-risk pregnancies. Women in earlier stages of pregnancy may also stay at these homes to attend prenatal exams when these services are not available in their own communities. While some casas provide significant medical services, their main purpose is to serve as a refuge and link to other sources of care.
The women at the Puerto Cabezas casa materna arrived at a brand new building: walls painted in bright shades of red, teal, and yellow, beds and mattresses for 16 women, a full kitchen, and a small medical exam room. At the time of our research, three nurses rotated to staff the facility 24 hours-a-day, and at least one doctor attended to the women staying here daily. Women are transported to checkups at the local public clinic—right next door—and then to the hospital to deliver their babies.
Contrary to what the new building may have implied, the physical upgrade of the casa materna was not emblematic of a higher standard of care offered. Many of the women reported disappointment with the attention they get from caretakers and doctors. They find themselves on the receiving end of harsh treatment and obligations to contribute to the daily operations of the facility when late in their pregnancy. When the facility’s water tank broke, women were made to haul heavy water buckets from the backyard well. One woman said she was even forced to mop floors just a few days before her delivery date.
Casas maternas are supposed to be places of support, but regulations meant to maintain an orderly experience at the facility end up regimenting the experience, limiting the diversity and quality of personal supportive care women receive.
Many women report feeling bored and confined because they’re not allowed to leave the grounds to run errands or even take a walk without special permission. Some women went so far as to refer to themselves akin to prisoners. Little socializing among residents reduces potential for camaraderie beyond nurse-led “chats” about important maternal and infant health-related topics.
Perhaps most damaging is the restriction on visitors. According to the casa materna model, it is common to allow expectant women to bring along family members and friends to accompany them throughout their stay. But the casa in Puerto Cabezas appears to follow a less inclusive model, running counter to many women’s expectations.
One pregnant teenager was told by a nurse at her local health post that her friend could accompany her to the casa. When the two girls arrived, the nurse on duty said the friend was not authorized to stay and would have to leave. The friend had no way to return to her community, and knew no one in Puerto Cabezas to turn to for help. Fortunately, the night nurse later overruled the previous decision and allowed the friend to stay, but the situation could have easily ended far worse.
When women face experiences like these, they share them with others in their home communities, advising others to not go to casas maternas. A casa materna can be a life-saver and a foundational resource for women. But asking a woman to voluntarily separate herself from her children, mother, and partner during pregnancy is hard enough. How can this woman then be expected to stay somewhere where the care she receives—even if technically high quality—isn’t delivered with compassion?
A service as critical as the casa materna should be built for the women it attempts to serve, with women’s health—both physical and emotional—at its core. Making women feel welcome, happy, and safe is the only way to encourage them to reach out for the service in the future.
Adam participated in Nigeria’s first Health Hackathon on February 22. Joining him was Nkechi Okwuone and Ambrose Ariagiegbe from the Edo State Open Data Team. The event sought to inspire new and profitable applications for addressing health challenges in Nigeria. The event was made possible by a number of organizations, including the Private Health Sector Alliance of Nigeria (PHN), and hosted at iDEA Hub in Lagos.
Nonso spoke on contextualizing open data at Lagos Social Media Week on February 20. His presentation highlighted lessons learned from Reboot’s involvement with open data in Nigeria. The event was hosted by BudgIt at CC Hub, and included presentations from other innovative organizations including Shine Your Eye and Stop the Bribes.
During the 2013 holiday season, Mazda launched its Mazda Drive for Good Campaign to raise funds for St. Jude’s Children’s Research Hospital, the American Heart Association, the American Red Cross, and a collection of charities supported through the Mazda Foundation. Similar company efforts to support social causes, such as Nivea’s donation to the Breakfast Club of Canada, have long been part of corporate social responsibility (CSR) efforts.
But it’s hard not to wonder, why is a car company is putting its efforts toward addressing medical research issues?
Business and CSR “align” when the selection of social causes, methods of intervention, and implementation partners fit with the existing expertise and resources underlying a company’s business success.
For example, Pfizer capitalizes on its expertise in the pharmaceutical manufacturing business by donating medicine to a wide range of health initiatives in developing countries. Through its RTC Fellowship program, pharmaceutical giant Merck draws on its employee’s expertise in health issues to support public health NGOs.
It’s reasonable to think that a company with health industry expertise would be better aligned than a car company to support health-related causes. A health product company can donate medicine at production cost or provide expertise to a medical research or public health NGO. Greater value, same or less cost. On an individual level, people from related sectors—like health care product developers and public health workers—can share experiences and knowledge, fostering empathy between partnering organizations and bolstering long-term partnership success.
So how could a car company’s CSR initiatives achieve alignment with social causes and the goals of NGO partners?
Thinking hypothetically, the Global Alliance for Clean Cookstoves could benefit from engineering skills. Many car companies have been perfecting cleaner burning systems and efficient production methods for years, overcoming design and production challenges in the process. These companies could give not only money, but also valuable knowledge, to save children and their families.
But companies are not charities. And the jury’s out on whether or not CSR can provide strong return on investment (ROI). CSR initiatives live outside core business activities and hold a tenuous position within the company, replaced if the championing manager leaves or cut first if finances become tight.
But when CSR initiatives align with business goals and resources, a stronger case can be made for maintaining these programs and opportunity for increased ROI is greater. CSR initiatives don’t have to drive a company’s success, but to be sustainable they do need to address the business reality of ROI.
When alignment is achieved, companies earn consumer trust, directly benefitting business and brand. CSR initiatives have struggled to overcome consumer skepticism for years. Consumers believe only 5% of companies deliver on social responsibility promises. This is likely in part because, say, car companies are engaging in CSR for medical research. “Saving children” may beat “fixing stoves” on the PR front, but without alignment and with an increasingly informed consumer population, skepticism triumphs and business takes the hit.
In the past, CSR has been a way for companies to do good.
Alignment presents a sensible and compelling narrative of a caring company that is, to its core, good.
And it’s not just the company’s ROI that benefits. Social ROI for implementing partners increases when alignment is achieved. Non-profits may find more interests, skills, and experiences in common with companies that pursue initiatives related to their business practices. Cultivating empathy between partners through shared experience and channeling relevant resources greatly benefits social causes.
When a relationship based on empathy and skill-sharing is achieved, a company is more likely to commit to a particular issues or initiative. Longer engagement with an issue presents more opportunity for companies to gain potentially profitable experience or understanding to support a feedback loop whereby philanthropically driven actions can drive business growth and vice versa.
If a social cause and business goals align, it may even be possible to integrate the cause into overall business strategy. CSR can transition from a PR stunt to a long-term market research, brand expansion, product development, and business growth asset.
For example, Danone, working with Grameen bank, developed a yogurt to help address nutrition issues in Bangladesh. Danone entered a new market, learned about expansion into developing markets, and established a flagship initiative to attract socially-minded hires. All while increasing access to nutritional food for the poor in Bangladesh.
Widespread acclaim quickly transitioned to criticism when the new enterprise functioned at a loss and did not have the magnitude of impact hoped for in rural communities. It is common for new ventures to struggle, and Danone was dealing with the added challenges of developing a sustainable business to support a social cause in a country it had no prior presence in.
But what’s especially worth noting is Danone’s response: Danone revised its model of intervention and expanded with its own long-term business goals in mind. It is doubtful that such dedication and ability to respond would have emerged in a Danone project supporting animal shelters or another issue less relevant to Danone’s core business.
Not every aligned CSR initiative will lead to a new revenue stream, nor does it have to. But alignment allows companies to apply their resources to a social cause in a way that increases potential for ROI. And if the social cause does find its way into the business portfolio, the commitment will greatly benefit both company and social cause.
There is always potential for good when companies donate money and time to causes they believe in, no matter how disconnected from their business. But companies could do so much more with aligned CSR.
When the Honest Co., a toxin free baby product company, donates supplies and employee time to Baby2Baby, a nonprofit providing products for children to families in need, that makes sense. And CSR should, ultimately, use resources in ways that are efficient and that make the most sense, to value both social cause and company.
If we allocate our resources most wisely, with alignment in mind, benevolence can be good for business, and business can be better for us all.