Writing to you from the pandemic lockdown, it’s clear that a key challenge presented by the advent of COVID-19 is our loss of mobility.
Most of us feel this loss in personal terms. But as public health professionals, we’re also expending huge effort considering the consequences of lost mobility across much of the work we do, including—
• Addressing safety concerns for home-bound children whose exposure to abuse is increased geometrically and out of public view,
• Ensuring quality care for women dependent on short- or medium-term contraception, and
• Providing services for those needing continuous HIV antiretroviral therapy.
We see this limited mobility playing out in other circumstances too. Even before this novel coronavirus outbreak, approaches such as adaptive management were frequently hobbled by logistic barriers to the collection of data that enabled managers to be nimble decision-makers. Now, in the age of COVID-19, we’re seeing that centralized control of data’s interpretation is making adaptive management more difficult.
Some will see this as a curse, but it may be a blessing.
To illustrate why we might welcome decentralized adaptive management, I’d like to share a technique used by the Evidence to Action (E2A) Project and Syntegral in Niger. I believe it offers an insight that allows adaptive management to better align its practice to its spirit.
Making Complexity Simple
The lesson starts in 2014, when E2A partnered with government ministries in Niger to launch the University Leadership for Change (ULC) program—effectively linking behavior change efforts in adolescent and youth reproductive health (AYRH) for university students with AYRH capacity-strengthening for clinic staff. In 2017, USAID’s Resilience in the Sahel Enhanced (RISE) program presented E2A and Syntegral with the opportunity to translate and scale up this successful approach into a Community Leadership for Change (CLC) activity in rural districts in Niger’s Zinder region using Community Youth Leaders.
Syntegral was founded on the premise that both adaptation and scale-up are about confronting the uniqueness of every implementation context. When E2A invited us into RISE, it was clear that the “ULC→CLC” adaptation process needed a practical model of complexity suited to programming. Syntegral’s stripped-down model of complexity asks implementers to consider three broad dimensions:
• LANDSCAPE—encompassing typical program features such as resources, capacities, activities, policies, community preparedness, infrastructure, stakeholder requirements, etc.
• TEMPORAL—acknowledging that all the variables in an implementation landscape evolve over time.
• INTERPRETIVE—reflecting the fact that every aspect of an intervention is understood differently by stakeholders based on their prior experience, knowledge, and motives.
FrAME-ing Frontline Knowledge
Emphasizing the interpretive dimension, E2A and Syntegral used the Frontline Aggregated Monitoring and Evaluation (FrAME) system to support adaptive management. Here’s how it worked for RISE:
STEP 1: FrAME started with an interactive voice response survey (delivered over mobile phones) that collected, aggregated, and graphically expressed the weekly likert scaled responses of 140 youth leaders of 10 basic process questions of interest to the ULC→CLC activity. The prompts were purposefully broad, such as “I think I have been given enough resources to do my RISE activities well” and “Young people are responding enthusiastically to project activities.”
STEP 2: After four weeks of aggregating weekly the youth leaders’ responses, the FrAME system generated simple line graphs showing positive or negative trends (or demonstrating a lack of trend) for each question, disaggregated by district.
STEP 3: Managers could then use these 10 graphs as a trigger for asking youth leaders what each graph and trend meant for project implementation and to provide evidence justifying their interpretations. Importantly, youth leaders’ justifications, rather than the accuracy of their interpretations, were what was valuable here. By asking youth leaders to detail how the graphs might reflect what they and their colleagues were perceiving, RISE managers learned that numerous issues off their radar—such as rural safety concerns, local emergencies, village infighting, and glitches in clinic monitoring practices—were posing serious barriers to service delivery.
STEP 4: Using the FrAME dashboard, managers were able to shift resources and workplans accordingly on a continuous basis.
FrAME demonstrated that asking youth leaders for analysis created an opportunity for them to break out of limiting and passive roles. By making their interpretations of trends visible, the project was able to identify problems and focus on solutions.
The “Eyes” (and Ears) Have It: Respecting Local Perceptions
Acknowledging the interpretive dimension of complexity gave E2A and Syntegral a means of tapping into a notoriously underused resource: the perceptions and problem-solving skills of frontline workers. FrAME offered a rapid means of “taking the pulse” of the RISE intervention, raising very community-specific issues to the surface that would, otherwise, go unremarked.
When put into practice, adaptive management can be revolutionary. But too often it continues to over-value the perceptions of managers as authorities. Combining a recognition of interpretation as critical to adaptation, with the fact that we cannot take mobility of supervisory staff for granted, lockdowns show us the relevance of techniques such as FrAME for sharing responsibility for sense-making with the frontline, whose local experience of programmatic context is invaluable.