Guest blog written by Allan Franklin, Dana Radojevic, Hesham Gaafar, Lauren Truong
Over the past 8 weeks, we had the opportunity to work with the National Blood Transfusion Service (NBTS) on the lack of safe blood in Nigeria. The lack of safe blood during emergencies such as car accidents or postpartum hemorrhages has led to high numbers of preventable deaths.
Upon learning about our project, we were afraid that our lack of knowledge and experience in public health would limit our progress, but the Problem Driven Iterative Adaptation (PDIA) process showed us how addressing major problems such the lack of safe blood in Nigeria requires learning on the fly, using the diverse perspectives and contributions of our teammates, and constantly reflecting and improving on our work.
Here are some of our key learnings:
Focus on the problem, not the solution.
It is our nature as humans to be solution-oriented and not problem-focused. Is the lack of safe blood in Nigeria due to the low number of voluntary donors the problem? Or is it a combination of supply-sideand demand-side factors? Instead of assuming what the possible solutions could be, the PDIA process slowed us down and forced us to get uncomfortable and ask hard questions. This helped us identify the problem at hand and helped us construct our fishbone diagram.
Dig deep—always ask why
Building off the previous point, once we constructed our problem statement, it’s human nature to immediately jump to solutions. By repeatedly asking why this problem exists, we were able to break down the complex problem into smaller, more manageable pieces. This ultimately helped us identify areas that NBTS could act on strategically and creatively. This process taught us an important lesson: We can make progress on seemingly complex and difficult issues by digging deep and identifying those causal factors contributing to the overall problem. Small strategic actions lead to progress and change over time.
Relationships are important, and people surprise you
As a part of our assignments, we were required to reach out to at least one new person each week. What surprised us was the sheer number of people who were familiar with the issue or knew someone who was working on this very issue. Our conversations with friends led us to discussions with health professionals and ordinary people in Nigeria. This helped us learn so much more about the complexity of the problem as well as identify possible entry points for action.
Most importantly, this class taught us about teaming. Teaming is the idea of bringing together a group of people who have never worked together around an urgent and common issue. This accelerated approach to teamwork was new to all of us. By writing a team constitution, we stayed focused on our common cause, built on each other’s strengths, had open and honest conversations about the directions we were going in, and learned collectively through our successes and failures.
Progress and Insights
Applying the AAA analysis was an interesting and useful step in the PDIA process. Probing the elements of the NBTS’ authority, acceptance, and ability allowed our No Bad Blood team to bridge the gap between the Problem Deconstruction and Crafting Solutions stages.
In practice, there is always a strong temptation to place too little emphasis on deconstructing the problem. Similarly, there is also a tendency to rush headlong into prescribing solutions. There is pressure to get moving, to come up with “the answer” but here lies the strength of the AAA; it gives you pause.
It allows you to take a breath and regroup. To refocus.
This happens for several reasons. First, examining the entire fishbone through the lenses of authority, acceptance, and ability was a novel process. It was challenging. It was uncomfortable. And it worked!
By consistently asking ourselves questions such as:
- Who or what is giving the power to move forward with ideas? (Did the NBTS have authority to act?)
- Was the full array of authorizers, partners, and clients confident that issues of bad blood in Nigeria was problematic enough that action needed to be taken? (Did NBTS have acceptance across the range of stake-holders?) and
- What were the NBTS’ strengths? Did they excel in terms of capacity? Maybe they were excellent at public relations? Perhaps their advantage lay in access to infrastructure?
This exercise forced our team to come up with a more realistic, more feasible conceptualization of the organization we were challenged to assist. Each strand of questions directed our focus into very different areas of the organization, the source of its power/ legitimacy, and ultimately, its potential to evolve.
It is only until we were able to visualize where, if at all, the intersection of these three spheres occurred that we could even begin to prioritize our entry points for action. Why did this work? Simply because we found that the change spaces we encountered through the AAA differed significantly in terms of the size and focus of their intersections. For example, our team ranked staff training and capacity as the first identified entry point as its analysis indicated a large change space. In comparison, the next best change spaces we identified were scored as medium. As a result, these were assessed as secondary entry points or places where our team felt confident in making recommendations to facilitate change at the NBTS.
However, as our team realized, the composition of the change space also provides valuable insight in terms of developing a viable strategy. So, using the example of the AAA analysis of the NBTS’ staff training and capacity once again, we see that the authority and acceptance scores were both large but ability was assessed to be medium only. From results such as this, we learn that the NBTS could invest significantly more in raising particular aspects of its ability.
Words of Wisdom
All of this goes to say, the process is intensive and iterative – but it’s also rewarding! At the start of the semester, our team was overwhelmed by just how complex the issue of safe blood in Nigeria was. We knew we only had a few weeks to address the problem, and it felt almost impossible to do given the massive scope and narrow time constraint. But by the end of the course, we managed to identify three concrete solutions for the NBTS to pursue.
Our advice to other students and practitioners working through the PDIA process is to mindfully compartmentalize your work. It’s important to focus on each individual step of the process, otherwise it becomes too easy to get caught up by the daunting challenge at hand. By compartmentalizing your work to each individual step, the challenge becomes much more manageable. This also includes working through the highs and lows.
There will be weeks when you may feel discouraged because you can’t find the statistics you need or none of the people who you contacted have responded to your emails. That’s okay! In fact, it’s normal. It’s imperative to not get bogged down by the minor setbacks and instead to keep the process moving. At the same time, there may be weeks when everything is making sense and moving along just as you expected. That’s great! Ride that wave of momentum into the next step of the process.
Perhaps the most invaluable component of the PDIA process is teamwork. The PDIA process often moves fast and has lots of moving parts; it’d simply be too much for one person to handle effectively. In fact, your end product simply won’t be as good or comprehensive if you work alone. We recommend that you lean strongly on the diversity of your team’s background to come up with a broad range of questions and ideas throughout the process. The breadth of our discussions with our authorizer and our final ideas would not have been possible had we not had such diversity among our team (and managed to utilize it effectively!). Don’t ever be afraid to offer up your opinions or services – but especially be sure to lend them on topics that you have prior experience with. And make sure to listen in on and take advantage of your team members’ thoughts and work. Your final product will be better because of it.
Lastly, we highly recommend this course to any HKS or cross-enrolled student who is eligible or considering it. From this course we learned invaluable tools that will undoubtedly be applicable in our professional lives. This course is unique in that it is much more “hands-on” than “theory-based.” Each week, we learned the PDIA tools and immediately put them into practice with our authorizer. It was an excellent experience and one that we consider a highlight of our HKS and HSPH experiences thus far.
Watch the video and view the slides of the PDIA in Action event held in April 2021.
This is a blog series written by students at the Harvard Kennedy School and the Harvard School of Public Health who completed “PDIA in Action: Development Through Facilitated Emergence” (MLD 103) in March 2021. These are their learning journey stories.
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