This article was co-written by Caterina Conte and Gunes Kocabag.
“What is this method called?” was the question the Director of Vaccination in Cameroon’s Ministry of Health asked us after four days of collaborating in a workshop in Kampala, Uganda. She was referring to the systems-thinking approach we had been applying to the work of six African countries (Cameroon, Ethiopia, Liberia, Nigeria, Rwanda and Uganda) to improve the design and functionality of home-based vaccination records. These home-based vaccination records are official documents that caregivers keep and bring to vaccination sessions, so that health workers can accurately record and track a child’s vaccination status.
The focus of this project was to take a user-centred approach to increase the impact these records provide. Yet we quickly learned that even if home-based vaccination records have the most user-centric content and form, all efforts can be futile if the countries’ health systems do not have the structure and resources needed to roll out the developed solutions. To increase the possibilities of real impact, we needed to understand each country’s immunisation system; identify the people, processes and policies involved in the planning, production, distribution and use of vaccination records; and come up with ways to improve this system as well. In other words, we needed to apply a service-design mindset to the challenge of home-based vaccination records.
The energy in the room peaked during the last day of the workshop as Ministry of Health officials and global development partners acknowledged the responsibility in front of them. They had to take the solutions developed during the workshop back to their countries and push for implementation. This is why our participant from Cameroon was so eager to learn more about the process and methodology – to be able to defend it and apply it further when she got back to her country and her colleagues in the Ministry of Health.
However, following the high engagement and the great ideas that came out of the workshop, we learned that, once the workshop momentum had dissipated and country participants had returned to their daily responsibilities, reality greatly complicated implementation. Participants had competing priorities, new roadblocks and gatekeepers appeared, and they struggled to recreate the mindset and approach from the workshop in their day-to-day work.
The truth is that, as external consultants, our work is project-based and we work towards the deliverables at the end of our project timelines, which are often measured in months, not years. This engagement model does not align with the long, unpredictable timelines of implementing global development solutions. With this project in particular, the implementation of the solutions that came out of the workshop could take country teams many months or years. Implementation could also involve a rigorous process of convincing other stakeholders, getting approval and budget, planning the details and logistics, finding the right partners and so on.
In a short-term engagement through a project or programme, we can develop a methodology and help local teams adopt our model. We can tell stakeholders that they need to understand user needs, for example, but, in the end, they are the ones who need to go back and figure out how to do this. We can tell them they should think – and keep thinking – strategically about the entire system, but they are the ones who need to push strategic thinking in a system that imposes constant immediate priorities over them, such as disease outbreaks or budget cuts.
In the aftermath of the home-based records programme, we have been pondering how we could overcome these challenges in future engagements. We came to one answer that we think will address many of the problems mentioned above: instead of one-time, case-specific projects or programmes, invest in long-term local capacity building.
Of course, running projects or programmes that bring in the global development community or external consultants to solve case-specific challenges has its merits and can create targeted impact. However, for the impact to be scalable and sustainable, people on the ground will need to implement, operate, manage and maintain these solutions. Local stakeholders already have the best understanding of the issues on the ground. They are much closer to the users and are immersed in the local context themselves. If their local expertise could be augmented by proven methodologies, such as human-centred design, systems thinking and service design, they could excel at developing and maintaining their own solutions.
As part of the home-based records programme, we looked for local designers and strategic thinkers to invite to the workshop, so that they could keep working with the participating countries’ health officials after. However, the search process was a laborious one. We encountered great initiatives, such as iHub Kenya, Design without Borders in Uganda and the Dalberg Design Impact Group. However, there was certainly not enough of them, and very few with non-Western roots.
We believe we need more of these locally-owned and locally-based agencies that support local capacity building and diffusion of the proven methodologies mentioned above. To make this happen, there first needs to be a transition phase of capacity building through practice. This means changing the way we approach programmes – involving more local talent in projects, transferring skills, knowledge and mindset by initially collaborating on projects for longer periods on the ground, and then peeling off.
Through local capacity building, the development world can eliminate the need for external consultants in the future (too bad for us) and, in the long term, achieve more impactful and sustainable global development with fewer resources. Local capacity building will overcome the above-mentioned momentum loss once the external parties leave, as local stakeholders will feel much more ownership, engagement and “skin in the game” for the solutions developed; and will be empowered to push them forward.
As local stakeholders combine their local expertise with reusable skills – such as how to understand user needs, how to think through a system perspective, how to make a business case, how to test solutions with users, how to empathise with and convince decision-makers – they can apply these skills to solve any challenge they face. More importantly, the solutions developed by local stakeholders will likely be more relevant and realistic since they will be developed by people who come from and are integrated within the local context.