At Devex World, development leaders begin to embrace what they don't know

WASHINGTON — The challenge rings tragically commonplace to global health and development professionals: A mother in Uttar Pradesh, India, pregnant for the fourth time and having lost one child already, needs adequate medical care to ensure a safe pregnancy and birth.

“How do we save [this mother] and her baby during this pregnancy?” asked Sema Sgaier, co-founder and executive director of the Surgo Foundation, at Devex World on Tuesday.

The answer is straightforward — three antenatal visits to a government hospital; the right medical supplies at the right time; health care professionals who know the steps to keeping pregnant mothers and their babies healthy.

But in Uttar Pradesh, an Indian state that has proven stubbornly dangerous for pregnant mothers and their babies, those steps didn’t seem to be adding up. Though the nurses had adequate training, they simply weren’t using it. Instead of completing the 25-step checklist that she had been trained to complete, the patient’s nurse only completed three steps, the Surgo Foundation discovered.

“Actually, they know all the steps they have to do. They just don’t do it,” Sgaier said.

In the old world of development, an organization might have resorted to its standard playbook, concluding that what is needed is simply more of what they had already been doing.

For an industry better known for furnishing donor-funded projects with expert consultants, producing authoritative reports or advising governments on how to develop, a surprising bulk of the most cutting-edge thinking — and the most transformative products and services — is emerging from organizations willing to admit what they don’t know.

For many of the leaders and organizations who brought their visions of the future of development to Devex World, that willingness to challenge orthodoxy — and to relinquish some control of the agenda — begins with letting go of development “beneficiaries” and finding better ways to serve development “consumers.”

The Surgo Foundation is a relative newcomer to global development. With only 11 staff and a budget of around $10 million, it does, however, claim behavioral thinker Malcolm Gladwell as one of its trustees.

Surgo’s employees are behavioral psychologists, data scientists, and machine learning experts. In Uttar Pradesh, the organization wanted to find out why the nurse had not followed through — what, from her perspective, was preventing health care professionals from providing patients with the full range of health services that might save their lives.

The answer, they found, was not that nurses lacked training, but that they had stopped viewing preventing risk to patients as their primary goal. Fending off the risks they themselves faced had crowded out their ability to focus on patients. Their working environment was stressful and characterized by “punitive supervision,” which would see them blamed if anything went wrong. Their first instinct was not, “how do I deliver a comprehensive suite of care to this pregnant mother?” — but instead, “how do I save myself from being blamed?” Sgaier explained.

The gap was not training — though training remains critical — but a dysfunction in the accountability system that was distorting incentive structures inside Uttar Pradesh’s health care facilities. An organization less willing to sacrifice its own preconceptions about the best solution, or too preoccupied with implementing its own plans to question them, might never have found out that nurses in Uttar Pradesh faced workplace barriers that no amount of additional training could overcome.

“The great revolution in consumer marketing over the last 25 years was the notion of market segmentation — was an understanding that there may be a very wide variety of motivations within what seems like a monolithic customer group,” Gladwell, who also spoke at Devex World, told Devex. “What if we think about the mother in a village in rural India with the same kind of sophistication as we think about the upper-middle class Chevy buyer in the suburbs of New York?”

The organizations and companies that are applying this consumer-based approach to development have the potential to transform the choices available to people living in some of the most impoverished parts of the world.

Only 31 percent of adults are covered by credit bureaus, a crucial prerequisite to accessing financial services including loans. Tala, based in Los Angeles, California, uses data from smartphones — such as app usage, or how people organize their contacts — to create credit scores and financial services for underserved people in six countries. Tala uses smartphone data to understand people’s behavior, but only rarely interprets that data as disqualifying for credit, said Shivani Siroya, Tala’s founder and CEO.

“We have a belief at Tala that if we can weed out fraud, then we can actually lend to about 95 percent of the population … If you take fraud out, then what you’re using data and data science for is actually customization,” Siroya said.

Except in those cases where Tala’s analysis concludes that someone is likely to engage in fraud, the data they collect is not a means of identifying riskier borrowers, but instead, aims to paint a clearer picture of variation among potential customers and their preferences.

“How do you segment this customer, and then how do you price appropriately, and how do you actually determine — do they want a consumer product? Do they want a small business loan, an education loan — and then we start to open those possibilities. But everyone then gets the choice of credit,” she said.

For development donors and their implementing partners, a shift from designing and delivering programs for “beneficiaries” to designing products and services for “consumers” begs some hard questions. At a time when technology grants individuals the power to broadcast their aspirations, and organizations the power to learn more than ever about the communities they strive to serve, the development industry’s power and accountability structures can still constrict organizations’ ability to act on that information.

Donor-driven health and development programs still tend to privilege risk-avoidance and control over responsiveness to a broad and diverse base of development “consumers,” said Karl Hofmann, president and CEO of PSI.

The diffusion of consumer-powered health technologies such as self-administered HIV tests, available at a CVS in the United States but not in South Africa’s Johannesburg, Hofmann said, is hampered by “necessity for excessive control” and a tendency to doubt consumers ability to take responsibility for their health.

“How can we trust that the person doing the self-test will not harm themselves? How can we ensure that they’re connected to the right medical support? We can’t possibly trust the consumer with this technology — which is exactly what people said about home pregnancy tests,” Hofmann said.

That power dynamic may shift, whether or not development organizations wish it to. Official development assistance budget are stagnant, and health and development organizations across regions are rethinking business models built on more diverse funding sources — including consumers themselves.

“Consumer-powered health care means we better understand our consumers — and I’m talking about consumers in Zambia, consumers in Kenya, consumers in Myanmar,” Hofmann added.

“The reality is, they’re going to have needs we can meet and we hope we are effective at meeting, but the subsidy isn’t going to be there all the time to meet those needs. So we better be able to get resources from them.”

While much of this conversation is driven by data and technology, its fundamental message — that development organizations should learn about people and listen to what they want — is hardly a revolutionary concept. And yet it has proven difficult to internalize and act upon in some of the places where foreign aid donors have poured most money — often with mixed results.

In Afghanistan for example, international organizations too often approach their work as though it’s being done in the absence of a state, said Rula Ghani, the country’s first lady.

“They need to be aware of the changes happening on the ground, that a government is establishing itself and starting to have programs, and that people are buying into these programs,” Ghani said. “I’m very grateful for all the generosity and wanting to help, but from now on you need to make sure that whatever you’re doing, you have asked the Afghans what they want.”

“Maybe I am seeing my role here at Devex [World] more as saying, OK, technology’s good. It’s not bad, but please let’s not forget the human being,” Ghani said.

While Ghani explained that a large part of Afghanistan’s current challenge is to reconstruct a sense of history and tradition that can serve as a foundation for the country to move forward, others have grappled with more destructive forms of tradition, and how to overcome them.

Jaha Dukureh successfully campaigned to ban female genital mutilation in The Gambia. Even in this work — with such a strong and proven case for local and national leadership — grassroots leaders struggle to find support from a prevailing aid architecture built to avoid risk and prioritize compliance.

“For me, as a young African woman, every single day I have to keep getting reminded that we’re not trusted to take care of our own issues even though we’re delivering solutions in our community,” Dukureh said, calling in from The Gambia.

“I constantly have to remind the donors that for us, this is not a career option. This is our life. This is about our children,” she said. “For us, whether the funding is there or not, this our life, and we’ll show up and do the work.”