The Skoll Centre’s Apprenticing with a Problem awards support individuals to engage in experiential learning and deep immersion around the challenges that they seek to tackle.
Oxford MBA alumna, Melissa McCoy, is a 2016-17 awardee whose apprenticeship took her to South Africa to learn about the real challenges faced in the healthcare system, from those who experience it first-hand.
About two years ago, I started trying to solve South African public healthcare challenges before setting foot in the country. For my Oxford MSc Computer Science thesis project, I built a low bandwidth-optimised online telehealth platform and a machine-learning based triage tool for South African patients to solve issues of doctor scarcity and misdistribution. While this sounds logical, I jumped into creating a solution before truly understanding the problem space.
The Skoll Centre’s Global Challenge competition, which resulted in an Apprenticing with a Problem grant, was a huge blessing. It gave me the resources and thought space to understand South African healthcare challenges from several angles and ensure I was tackling the problems in the right way.
The resulting research that my team and I completed focused on visiting 15 healthcare facilities, spanning several characteristic types:
Primary, secondary, and tertiary levels of healthcare
Gauteng, Western Cape, North West, and Mpumalanga provinces
Remote rural, rural, and urban geographies.
The research also focused on speaking with four types of stakeholders (doctors, nurses, facility managers, ICT professionals) that represent the various healthcare system perspectives.
While our findings around the problem space were extremely valuable (and are fully detailed in our report), we also took away some surprising insights:
Willingness to embrace change: Contrary to our initial beliefs, people in the public healthcare system in South Africa do not enjoy the status quo. They are cognisant of the challenges and inefficiencies in the system. They also believe that while there is a lot that rests on the powers that be, there is a lot that they can do themselves to bring about change. Our visits were viewed with optimism and most facilities were hopeful and confident that our suggestions would be beneficial for them. A system that is not cynical and is open to feedback is bound to see progress in due course of time. The positive attitude of practitioners and the administration alike towards embracing technological improvements was a huge motivational factor for us.
Bottom-up, Organic Tech Solutions: While many facilities lacked digital infrastructure to allow for referrals and sharing information, healthcare facilities & professionals devised their own ways to facilitate these processes. Doctors had created WhatsApp groups to discuss difficult patient cases. Nurses had equally formed networks among themselves and would send SMS messages to each other to communicate bed occupancy and information about referred patients.
Learning from field interviews is hard: We came into the research with several pre-conceived ideas around the core problems and the appropriate solutions to solve them. We wanted to validate if our hypotheses were correct without biasing interviewees in the process. In Rob Fitzpatrick’s book, The Mom Test (which we referenced often), he summarises the challenges of this process well: ‘Trying to learn from field conversations is like excavating a delicate archaeological site. While each blow with your shovel gets you closer to the truth, you’re liable to smash it into a million little pieces if you use too blunt an instrument. I see a lot of teams using a bulldozer and crate of dynamite for their excavation. They use heavy-handed questions like “do you think it’s a good idea” and shatter their prize. At the other end of the spectrum, some founders are using a toothbrush to unearth a city, flinching away from digging deep and finding out whether anything of value is actually buried down there.’ We botched at least a dozen conversations with stakeholder, by either introducing our concept of interest too early or never bringing it up and getting their true thoughts. This was a skill we gradually improved upon with every interaction.
Overall, the exploration was invaluable and one-of-a-kind. It set the stage for how our company, ConnectMed, planned to work with the South African public healthcare system, as well as how we now think about engaging the Kenyan system.
Melissa recently completed her MSc Computer Science and MBA at University of Oxford on a Rhodes Scholarship and is now working on a Africa-focused digital health venture, ConnectMed, in South Africa and Kenya. She previously worked in the Americas and Africa as an engineer, entrepreneur, and consultant.
By Julian Cottee, Skoll Centre Research & Insights Programme Manager
Our previous blog looked at ‘Six Reasons Why Research Matters for Social Entrepreneurship’, ranging from gaining a deep understanding of problem and solution landscapes, to innovation, and a critical birds-eye view of the sector. The Skoll Centre has since been exploring research for social entrepreneurship through a series of seminars led by impact-focused early career researchers from across Oxford University. Each has discussed their own research experiences and drawn out lessons for better aligning research with the needs of the social innovators.
Evidence and impact
Evidence and impact evaluation are top of the list for many practitioners when asked how research can help their work. Anna Custers, a Skoll Centre Early Career Research Fellow, explored this topic in depth through her experiences with a number of randomised controlled trials (RCTs) assessing the impact of poverty reduction measures in the Global South. The RCT methodology, originally designed for evaluating the impact of medical interventions, is now becoming more widely used outside of clinical settings. Social scientists in a range of fields are adopting RCT approaches, and while many policymakers view them as a ‘gold standard’ for evidence of impact, they are not uncontroversial. RCTs are complex, lengthy and expensive to set up, and they can only be used to evaluate a narrow gamut of interventions. Their strength in demonstrating the counterfactual – what happens in groups not receiving the intervention – also raises significant ethical questions. If demonstrating impact through RCTs were to become a routine part of the funding and policymaking landscape for social entrepreneurship, the range of projects would be curtailed, the speed of implementation would be reduced, and additional research funding would be needed. Further discussions revolve around the question of how much evidence is ‘enough’ to demonstrate impact, and to what extent this differs depending on the scale of the initiative being assessed. An expensive RCT might be appropriate for a highly scalable ‘big bet’ intervention that can be widely replicated if impact can be robustly demonstrated, but many, if not most, projects are smaller and more locally specific.
Ideas around the role of research in evidence provision were further developed by Dr Jenny Tran, speaking about a recent Skoll Centre-funded research project that interviewed 31 policymakers, funders and practitioners in the field of social innovation in healthcare in low- and middle- income countries. The interviews probed attitudes and beliefs relating to evidence within these three groups. Among practitioners for instance, responses ranged from seeing research and evidence as an accountability mechanism – “Research is a tool of justice…how are we holding ourselves accountable to our patients?” – to something that just needs to be done to satisfy the expectations of funders – “We do what we have to do”. The funders interviewed also had mixed attitudes towards evidence, with some admitting candidly that gut feeling was as important as data in making funding decisions. Organisations spoke of a lack of time and expertise to collect good data on their impact. One theme that clearly emerged from the interviews was a lack of consensus on how to operationalise a model of data generation and use amongst all three groups that is of an appropriate scale in terms of the time and resources demanded, as well as being robust and rigorous. RCTs were rarely seen to be the answer. Tran’s paper recommends a number of future pathways for improving research in this space, including further elaboration of the concept of ‘lean research’ striking the balance between appropriate scale and rigour; better technical education; and changing the way evidence generation is funded. All of these are ripe for future exploration. In addition, there is little or no attention currently paid to how organisations measure negative impacts, or their incentives for doing so. This too is an area that deserves further study and the development of practical tools for the generation of objective impact measurement.
Two other seminars in the series focused on the role of research not in the generation of evidence, but in others kinds of knowledge creation, through embedded partnerships between academics and practitioners. Kate Roll, Senior Research Fellow at Saïd Business School, spoke on the Oxford-Mars Mutuality in Business project, a large multi-year research project exploring the idea of mutuality as an organising principle for business. The project is unusual in that it is carried out by an academic team in collaboration with the Mars in-house think-tank, Catalyst. The allure of the set-up is clear from the point of view of carrying out research guided by real-world priorities – there is potential for unique access to knowledge, skill and legitimacy on both sides – yet challenges are also many. In particular, spanning the research-practice boundary brings to the fore different perspectives on questions such as:
When is work finished? (medium-rare or well done)
With whom can we meet? (negotiating internal access)
What is a good output? (collaboration, consultancy, opportunism)
Who needs to be involved? (setting boundaries in joint research)
Drawing on the theory of organisational hybridity, Kate explains such collaborations as a case of striving to effectively bring together differing ‘institutional logics’: “as the degree of incompatibility between logics increases, hybrid organisations face heightened challenges” (Pache and Santos 2013). In order to realise the unique opportunities for insight and impact, researchers are obliged to adopt the character of the ‘amphibious academic’. Even if they might be happier in water, like the frog, they too can cope ably on land.
Successful examples of such collaborations are not numerous. They require connections, funding and abundant engagement and amphibious capability from all partners. Alex Fischer and Heloise Greeff, members of the Skoll Centre’s Research for Action Network, spoke about Oxford’s Smart Handpumps project, a long-running collaboration with NGOs and government. While the project began by exploring the causes and impacts of broken water pumps in rural Kenya, it has since transitioned to address how broken pumps can be fixed quickly and cost-effectively. The project is now driving technological and systems innovation to the point that it has led to the creation of a social enterprise that will service the handpumps sustainably into the future using the technical and institutional knowledge generated in earlier phases. Alex and Heloise described a ‘research-action spiral’ in which innovation and research have circled around each other in a productive dance. These impactful outcomes of the project could not have been anticipated at the beginning of the research process – a powerful argument for research led by problems and not just solutions. Often, following intuitions and blind alleys was just as important for the development of the impact of the project as any planned research pathway. This highlights the value of flexible funding and creative leadership in action-research projects. Universities are an important ingredient in this kind of innovation and research, as they provide safe spaces for the exploration of novel ideas that may not otherwise be pursued. The role of PhD students too is of significant value – unlike research assistants or employed post-doc researchers, PhD students follow their own research agendas within the wider project, generating new ideas and possibilities.
Global Health: Getting from Innovation to Implementation panel
Forging Common Ground – Series of Oxford Student Insights to the Skoll World Forum 2017.
Oxford DPhil candidate in Philosophy, Michael Plant, gives his perspective on the Skoll World Forum session “Global Health: Getting from Innovation to Implementation”.
As you start the marathon, crowds cheer you on. They’re with you for the first mile. And the second mile. Now you’re at the 15th mile. You hit the wall. You need support to keep you going – a glass of water, a single cheer – but no one’s there. Who wants to watch the middle of a long race? You know they’ll be crowds to cheer you across the line, but that seems very far away.
This, argued Barbara Bush, founder of Global Health Corps, is an uncomfortably apt analogy for the problems facing global health as it tries to move from innovation to implementation. People get excited about the start: creating a new vaccine. And people can get excited about the end: making sure that vaccine travels the last mile and gets to the child who needs it.
Yet, in the long distance between those two, cheerleaders are thin on the ground. It’s very hard to get people interested in improving health systems, scaling up interventions and finding better ways to distribute medicines around the world.
Why? Systems simply aren’t sexy, unsexy things get ignored, and so millions of people die or suffer from health conditions we already have the technology to solve.
Hence the question Barbara posed to the three experts on her discussion panel: if we want to improve the ‘unsexy middle’ of global health, what should we do?
Steve Davis, CEO of PATH, argued healthcare innovators should be designing with scale in mind and the road to scale is mostly clearly through health ministers, rather than patients or funders. For instance, there’s little point creating a new drug so expensive developing countries can’t afford it.
Yap Boum of MSF added progress is often slow because locals aren’t invited to be part of the innovation process. How much better could NGOs be if they had locals on their boards who understood the country?
Surgeon and public health researcher Atul Gawande agreed going from ‘zero to one’ – inventing something – was valued much more by funders than taking discoveries and bringing them into the existing systems. At least in part, this is because discoveries feel much more tangible. He suggested a way around this is for funders to focus on scaling an innovation by one order of magnitude at a time, seeing each as a serious and independent goal. Pioneering a new procedure in one clinic should be thought of as a victory. Getting that procedure from 1 to 10 clinics is different second achievement requiring different methods, getting it from 10 clinics to 100 a third, and so on.
As panel discussion moved to questions, the audience wanted to understand why there wasn’t more collaboration between all the different organisations. If so much of global health is just a co-ordination problem, why haven’t we solved it yet?
The problem, it seems, is people having priorities. If, as Atul shrewdly noted, the US can’t even agree on whether to provide subsistence healthcare in their own country, how could we reasonably expect NGOs, governments and donors to all be effectively pulling in the same direction on global health? He suggested we need a unified metric, or yardstick, to compare different potential health priorities and reveal the top priorities.
Two things struck me from the conversation today. The first was: if we’re worried we’re overlooking things because they’re not sexy, what else are we ignoring?
As someone who’s interested in how best to increase happiness – or put another way, how best to reduce misery – I had hoped mental illness would have been a bigger part of the discussion. Research suggests mental pain can, and often does, have a bigger effect on self-reported happiness scores than physical pain does. What’s more the way standard health metrics, such as ‘QALYs’ (Quality-Adjusted Life Years), are constructed fails to adequately capture the badness of mental illness (see Dolan and Metcalfe 2012). Perhaps due to the stigma, measurement issues, or the complexity of treating them, mental illness is the marathon almost no one is even watching.
Second, if we need to agree on a single metric so we can prioritise resources in global health, it seems obvious to me the right metric is happiness. I take it we don’t value health just for its own sake, but because it helps us live longer and enjoy our lives more. Not all health conditions make people unhappy and, where there’s a choice between reducing unhappiness or ill-heath, we should target misery. Whilst some may worry happiness is too ‘fluffy’, the evidence suggests ‘subjective well-being’, as it’s often called, can be reliable measured. The OECD now recommends countries collect data on it.
Neither improving healthcare systems or mental health care are particularly sexy, which is why they’ve been overlooked. However, as Steve Davis said at the close to the session: our outrage at avoidable deaths and suffering should drive us to do better.
Anisha Gururaj is studying an MRes in the Medical Sciences Division, at the University of Oxford. In June 2016, she and her teammate, Ashley Pople, DPhil in Economics at University of Oxford, won our inaugural Oxford Global Challenge competition. Their topic? Maternal Depression. Anisha describes her account of the competition, how she found her topic and the benefits of undertaking the Challenge.
There are few opportunities where the incentives to be most effective and also do the right thing are aligned. The Global Challenge is one of these initiatives, because it provides the chance—the imperative, really—to delve into the contextual landscape of a problem and the existing solutions as we know them.
I was missing a more holistic understanding, a bigger picture of how solutions to global problems fit into global societal structures.
As it happens, this is the reason I came to Oxford. As an undergrad engineering student, I loved the idea of designing technological solutions to solving problems in global health. But after working on a few projects and actually engaging in fieldwork for low-cost diagnostic devices, I felt that I was missing a more holistic understanding, a bigger picture of how solutions to global problems fit into global societal structures.
The Global Challenge emphasises that an important part of the design research phase for any solution needs to be deep engagement with structural context, often best understood and communicated through visualisations. Why is this important?
First, it enables a very deliberate and specific problem definition process. My teammate Ashley and I spent quite a bit of time upfront exploring larger themes we wanted to focus on, like global health, gender discrimination, and building awareness around mental health, to get a feel for what the broader health landscape looks like. Focusing on the intersections between fields is particularly promising because global issues don’t usually fall within the lines of academic divisions and asking interdisciplinary questions is often not done well. Through intentional scoping, we identified our topic as maternal mental health in specific cultural contexts, India and South Africa, because it was truly a confluence of so many of the fields mentioned above and which was rendered invisible by very specific social factors in both of these countries.
ensuring that we examined the entire landscape reduced the risk of “falling in love” with a particular idea.
Second, the format of the Challenge forces us to question our own underlying assumptions, which is why earlier stage ideas are more conducive to this kind of exploration. As an engineer, I brought a particular bias into my research, just as Ashley did as an economist. For example, I was particularly intrigued by mobile solutions for diagnosing depression, but ensuring that we examined the entire landscape reduced the risk of “falling in love” with a particular idea.
Finally, the Challenge provides a platform to be more innovative about how we research. Academic journals and the results of randomized controlled trials are important. But the most rewarding part of this whole experience for both of us was interviewing a large range of experts around the world, from academics to leaders of nonprofits, to clinicians in both countries, to pregnant mothers right here in Oxford. This allowed us to tap into experiential information that we could not have uncovered otherwise.
Of course, the research and design of visual ecosystem maps is just the beginning—they provide a comprehensive framework with which to engage with solving the problem. But too often we jump into solution-building before taking the time to “apprentice with the problem,” resulting in costly assumptions. Our world of limited resources and increasing need deserves better.
Oxford’s Fierce Compassion – Series of Student Insights to the Skoll World Forum 2016.
MBA student Neil Yeoh gives his perspective on the Skoll World Forum seminar session ‘Post-Paris: A New Era in Global Sustainability?’.
It has been just over five months since 195 nations signed the UN Paris Climate Change Treaty – a pivotal step towards global sustainability. However, doctor as every month passes and the champagne stops flowing, people scratch their heads as they consider “the real issue – how do we get there?” – framed by Mindy Lubber, President of Ceres.
A panel made up of the most distinguished climate leaders of today including former president of Ireland and UN High Commissioner for Human Rights – Mary Robinson – discussed this very issue. And amongst the dialogue, five overarching themes emerged:
Changing the conversation – a bigger mindset shift is needed
Pushing for policy change – the world will not self-correct
Enabling access to finance and technology – developing countries cannot do it on their own
Inspiring a larger movement – communities can achieve change
Managing industry change – the transition from dirty to clean will be challenging
Far from the detailed implementation plan everyone was hoping for, the audience may have left dissatisfied still debating how we will get there. However, these feelings and thoughts reveal the true complexity of the challenge that lies ahead to make the treaty a reality. Climate change touches countless nodes of the world’s ecosystem and will need unprecedented global coordination and cooperation to alter course.
But I believe there is hope! If the world’s leaders were able to find common ground on the urgency of global sustainability, the rest of humanity – activists to sceptics – will surely find common ground in the fact that climate change is a real threat to our children and grandchildren. I, as I’m sure many others, can relate to and be compelled to act on that.
From left to right: Dipender Saluja – Managing Director, Capricorn Investment Group (Moderator); Mary Robinson – President, Mary Robinson Foundation – Climate Justice; Thom Woodroofe – Climate Policy and Communications Advisor, Independent Diplomat; Mindy Lubber – President, Ceres; and David Blood – Senior Partner, Generation Investment Management.
Oxford’s Fierce Compassion – Series of Student Insights to the Skoll World Forum 2016.
MBA student and Skoll Scholar, discountRitesh Singhania gives his perspective on the Skoll World Forum seminar session ‘Healthcare as an Engine for Social Transformation’.
Is healthcare about disease management or delivering health?
While it is so important to provide quality affordable healthcare to communities at the bottom of the pyramid, can healthcare alone improve the lives of the people?
This is how we began the session with Gary Cohen, co-founder Healthcare Without Harm; Tyler Norris, VP Total Health, and Rebecca Onie, Co-founder Health Leads. It was very thought provoking to start the session broad, with questions that make us challenge our own thinking about the fundamental role that healthcare can play in the lives of local communities.
It is difficult to set up a medical clinic in the middle of a village community in rural India and expect the community to grow. Illness treatment or disease management in segregation can only have a limited impact in the lives of the people. To give an example – most of the women in rural India still use firewood for their cooking energy needs, leading to massive amounts of smoke within the four walls. This smoke is inhaled by just not the women of the family, but also by their children. As Annie Griffiths, from Ripple Effect Images highlighted during her fantastic opening plenary at the Skoll World Forum, that more children (under the age of five) die due to breathing problems, than diarrhoea, dengue and pneumonia together. Thus, while setting up a medical clinic in a remote village definitely has value addition for the community, it is important to understand the needs of the community and set up a cross-sectoral relationships with other areas of development for a healthier life-style of people.
I would like to share a small example from my days back in India, where we used to set up small scale power plants in the Indian Himalayas to generate clean electricity and cooking charcoal (by-product) from flammable pine needles. We would employ local women in the villages to collect pine needles and remunerate them both in the form of cash and cooking charcoal. Women in the villages are normally responsible to meet the energy needs of the family and spend the entire day gathering firewood. By employing them to collect pine needles, for the first time we were not only empowering them with money, but also offering a cleaner source of cooking fuel so that they do not have to go but down trees, in the fragile Himalayan eco-system. Thus, trying to create an impact at every step in the value chain by not only offering cleaner electricity to people, but also a cleaner cooking fuel and employment.
Similarly, healthcare offerings in the local communities have to be integrated with the needs of the community so that we can actually see a difference in the lives of the people – better, healthier people for a brighter future.