Using PDIA approach for sustainable and integrated health system strengthening in Nigeria

Guest blog by Aisha Allamin Daggash

My expectations for the IPP Online Program when I signed up was to gain insight into strategies and frameworks that will support my work in getting government to be more effective and efficient in implementing innovative, integrated and sustainable solutions for health systems strengthening in Nigeria. However, this course has exceeded my expectations in combining leadership management and the PDIA, which has equipped me with the right resources, knowledge and skills to build the teams and networks required to succeed in the work that I do.

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Health system transformation in Poland

Guest blog by Robert Moldach

I am fortunate to live in times when Europe and Poland in particular have undergone an incredible transformation. As a child, I remember the street protests my parents took part in, their talks about the Warsaw Pact troops invading Czechoslovakia, and the anti-Semitic campaign of the late 1960s. My student years coincided with the Solidarity uprising and the martial law that followed. The beginning of my academic career fell during a time of darkness and total economic collapse of the system. Then, in 1989, came the country’s revival, changes in the political system, and economic revolution. We joined the OECD, NATO, and eventually became a member of the European Union recording an extraordinary rate of economic growth. And while this is an undeniable success, along the way we made countless mistakes, some of cardinal importance. We could have approached challenges better such as social inclusion, coherent territorial development, utilization of existing economic potential, foreign direct investment, and finally understanding the sense of us.

The lesson on the “Sense of Us” is in fact the single most important thing I take away from the HKS Leading Economic Growth program. Are we Poles or Europeans, resettled from the eastern borderlands or residents of this land for centuries, Catholics or communists disguised as democrats? And while we intuitively feel how it is, or rather how it should be, we are divided and polarized as a nation in probably every possible direction. The thing that economically we continue to grow at an above-average rate does not change the fact that our economic vehicle is experiencing cracks, fractures and tears that are increasingly difficult to mitigate.

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Building a coordinated service delivery model in the U.S. using PDIA

Guest blog by Debra Porchia-Usher

Initial Expectations

I entered IPP Online Course with excitement and with the expectation that guidance would be provided to simplify the proposed ‘public policy challenge’ facing myself and my colleagues. The timing was great, as my colleagues and I had recently committed to the design and execution of a coordinated service delivery model of human services. The authorizing team of 12-15 human service leaders, including myself, made a firm visionary statement (“if not now, when”), affirming the commitment to get this done. I was sure that a guidebook would assist the team to develop an outline that would lead to an immediate solution. Essentially, an opportunity made simple and I believed that we, as a diverse team of providers, had all the pieces in place were for immediate action: 1) strong partnerships, 2) a common vision and goal, 3) motivated supporters, 4) County Chief Executive Office support, 5) consultant resources, 6) diverse group of champions, 7) community commitment to pilot the model in four communities and 8) a project timeline. It became very clear in the first two week of lectures and the introduction of PDIA, that our team did not have a clear understanding of the complexity of our problem, nor did we have a concise problem statement reflective of the intended goal. Early on, it also became evident that PDIA offered the Fishbone Diagram as a tool to map out the known and unknown factors. The input of the technical support and from peers on the fishbone identified additional gaps in knowledge, potential missed entry point opportunities and critical stakeholders. In addition, the diagram generated input from the larger stakeholder group which subsequently led to further clarification on the resource gaps and small win opportunities. The use of the Fishbone Diagram promoted an expanded thought process, strategic thinking about the actual problem at hand and extensive consideration of cause and effect influence within both the planning and execution of response to a complex policy challenge. 

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Infusing fresh blood using PDIA in Nigeria’s Blood Services

Guest blog by Adaeze Oreh

When I signed up for the Harvard Kennedy School Implementing Public Policy programme, I thought I knew quite a bit about my policy challenge! I was applying to the programme basically to figure out new concepts and get new tools that would help me as Director of Planning for Nigeria’s Blood Services agency implement those ideas my organisation already had about solving Nigeria’s blood safety problem. You see, my country has a population of over 200 million people and for decades has been bedevilled by a frustrating lack of ready availability of safe blood to meet the country’s needs. This gap has contributed immensely to high maternal death rates, and the large number of children who die before the age of five. As an organisation, we had some ideas in our toolbox to address this, and I hoped IPP under Matt Andrews and the HKS faculty’s guidance would provide the magic bullet for implementation. I was not prepared for the level of insight that the course would provide.

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HIV: Patient Safety and Infection Prevention in India

Guest blog by Vijay Yeldandi 

Why IPP? Honestly because I needed a navigator! After 25 years of doing public health work in India focusing on HIV Infection Prevention, I realized that not everything I did was a resounding success. While some projects were gratifying, in retrospect there were many hard lessons to learn and much heartburn to endure. Many of my friends and colleagues would remark “Oh there goes Vijay again….. where angels fear to tread…. Yes, it is true I have always been an unapologetically optimistic (hopelessly romantic) Gandhian revolutionary going about trying to make the whole world a better place. My anthem is John Lennon’s IMAGINE

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Honoring the memory of a lost child: A father’s inspirational pursuit of policy change

Guest blog by Anjan Chimaladinne

On August 13, 2016, my 16-year-old son passed away unexpectedly and suddenly. My wife and I have established scholarships in his name at his high school and the college he was planning on attending. For the 4 past years we rendered help to several other social causes. In the United States, suicide was the second leading cause of death for persons aged 10–24 from 2000-2017 and mental health is leading contributor for suicides. This issue has been bothering us for the past 4 years and we wanted to help and did not know how to. The Covid-19 and work from home situation opened time and helped me find and enroll in the Implementing Public Policy course. My initial expectation of this course was, it would certainly help me do something in honor of my son, Anshul, and save at least few lives.

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Navigating innovations in U.S. emergency services with PDIA

Guest blog by Ken Bailey

I have been privy to the legislative and public policy process for well over 10 years, mostly with an amateurish understanding and certainly lacking the tools to be consistently effective. Having muddled in this space for a number of years, I have been successful on many fronts, again more through tenacity than with clarity of purpose. I have authored and pushed through several pieces of legislation, most of which have become part law in my State. Additionally, I have played the politics at the regional level, attempting to shape policy positions, largely with mixed results. As to be expected, my overall results have more losses than wins. Though it was not this loss / win ratio that bothered me. What concerned me the most was the idea that there was a better way of doing things that I was not aware of, thus I looked in to the Implementing Public Policy course at the Kennedy School.

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‘Don’t be so invested in the solution that you’re unwilling to change course’

Guest blog by Alexandra Bhatti

What an exciting, challenging, eye-opening learning and growing experience this has been for me. When I first explored the course, I was skeptical about the ratio of theoretical learning versus practice-based learning I would experience as I have spent many years studying “policy” and related fields. Listening to alumni feedback encouraged me to pursue the course, nevertheless.  Immediately I realized this was going to be a fantastic course and it began challenging my biases and the way I approached policy development and implementation – beginning with the “challenge” I identified.

Let’s start there.  My initial policy challenge was trying to operationalize non-traditional vaccine delivery sites and provider types. I soon realized that this was not the actual challenge I was trying to address and had to continue to diagnose the actual problem I was trying to solve for with vaccine delivery systems – and that was that adult vaccine uptake remains low in comparison to children and pediatrics, and further we see disparities in particular population types.

While I think the entire course has proven to be such an incredible learning and growing experience for me, there are few areas I wanted to highlight.

First understanding the pitfalls of problem and construction and deconstruction has stuck with me.  Not only am I more self-aware of those pitfalls, like solution bias, I am also listening for this with my colleagues. I think this is such a critical concept to understand and implement to optimize your chance of success in policy implementation.

Second, is understanding your stakeholders and the different roles needed in policy implementation (e.g. idea people, authorizers, etc.) This helps us not only better understand and profile our stakeholders but also helps us identify gaps. It also is a great first step in understanding the priorities of the stakeholders.

Third, is the supreme importance of a compelling and succinct problem narrative that resonates with the individuals you are trying to mobilize and gain buy-in from. As a scientist and attorney, I often want to create a memo supported by evidence describing how important this policy issue is – and because I am so invested in; however, the decision-makers, whom I am engaging with 1) are not as invested – yet; 2) I have a good 5 minutes max to make my pitch and have to maximize the time I have.

Lastly, being in public health, specifically in the vaccine space, during a global pandemic has been supremely challenging. I felt the sections around time management, organizational norms and burn out, and leadership were so timely and critical for me.  Not only was I trying to implement certain behavior changes (not always successfully), but I also have been sharing these concepts with my colleagues – particularly that of changing organizational norms.

Regarding progress toward my policy challenge, its been exciting that I have been able to rally leadership support around the entry points I am focusing on.  What I have realized is that these different entry points are so different and complex that perhaps in the future, I would narrow my scope further.  Regardless, I have a number of sub-projects underway, focused on addressing the blue boxes in the fishbone diagram here.

Already, I have integrated PDIA into my team’s workstream.  Below you will see a MURAL board that I supported my team in developed and brainstorming through. As I mentioned before, having a narrower scope was one of my lessons learned moving forward. I worked with my team on discussing a policy challenge a few of my colleagues were experiencing at the state level. 

We soon realized that there were two distinct challenges and each needed to have a separate root cause analyses completed. I encouraged the team to go through the 5-why, develop a fishbone, and use the triple A approach to begin to identify potential entry points. Because we went through this process, we realized there were many unknowns still and we were better positioned to identify what those were and begin to plan next steps for addressing the unknowns.

Above all, this course further underscored the importance of perseverance, grit, and flexibility when working to solve policy challenges. We are passionate about our work and often get deeply invested in it, as a result when we are faced with setbacks and delays, it can be disappointing and hard to rally, so to speak.  I did not have immediate success with address my policy challenge but iterating and adapting are the heart of PDIA. My advice is to not let your personal investment in the policy challenge cloud good judgment and inhibit pivoting and changing course as needed.

Perhaps my favorite aspect of this course was the team work. Our Health Group was incredible and inspiring.  We supported and encouraged each other when challenges arose and celebrated each other’s successes as well.  Thank you, HKS, for this amazing and memorable experience.

This is a blog series written by the alumni of the Implementing Public Policy Executive Education Program at the Harvard Kennedy School. Participants successfully completed this 6-month online learning course in December 2020. These are their learning journey stories.

Learn more about the Implementing Public Policy (IPP) Community of Practice and visit the course website to apply.

Tackling Blood Safety in Nigeria

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.

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Improving Nutritional Outcomes in India

Guest blog written by Saachi Bhalla

When I applied for the IPP online course, I was hoping to help strengthen my understanding and capacity for policy analysis and to spend dedicated time in identifying ways of making progress on complex public policy issues. I was particularly interested in engaging with ways of identify formal and informal power relationships and processes which can lead to strong policy implementation and action by policy makers.

In particular, I was keen to explore how to build on the capability-accountability of state and non-state actors and how to shape processes for convergent action across ministries to impact nutrition outcomes in India. 

The course’s approach of teaching theory combined with the space to work on applying theory to one’s own implementation challenge is what was particularly attractive. 

My biggest learnings from the course include:

  • Understand the problem: define, redefine, and unpack the problem. The approach of constructing and deconstructing the problem, drilling down till you are really identifying the root causes and what are the smaller pieces that constitute the root causes. Asking the five whys and drawing up the fishbone has been such an enriching process. I find that I am using the fishbone diagram as an approach in much of my work now, beyond the policy challenge I have been working on through this course. 
  • Understand the change space: related to the learnings from constructing and deconstructing the problem and drawing up a fishbone, I find that understanding the change space is critical. The 3 As – acceptance, authority, and ability – helped in understanding what is critical to be able to act on policy challenges, but even more importantly, it helped me in identifying where to start. This has possibly been the most important learning for me from the course. I’ve learnt from colleagues at work about the concept of relentless incrementalism but have always questioned about where to start. This framework and analysis of change space has helped me with a tool to be able to answer the question. 
  • Practice leadership: this course has provided some rich resources and the reflective questions within modules have helped me think about myself as a leader, reflect on what constitutes leadership, and how to practice those skills. The multi agent leadership model made me think about how the same person could play the role of a leader and a follower simultaneously. Being cognizant of what role you play where, who are the others involved, and what role could they be playing, can help in building allies and recognizing when more efforts may be required to bring critical stakeholders along.
  • Learning as critical to success: the idea of short feedback loops and actively learning what, how, and why has been at the back of my mind for long. This course has helped me in articulating it better and defining a process through which this can be practiced. 
  • Importance of a collective voice: aligning on vision, engaging with legitimate sources of knowledge, understanding what we are projecting are important for success. Having a collective voice helps in building traction for a narrative and support for the aspects of the policy challenge we are trying to address. 

My implementation challenge relates to improving nutrition outcomes in India. My problem definition was that Malnutrition remains a rampant problem in India despite evidence- based policies to address it. The major causes to this relate to poor multi sectoral governance, program design not allowing attention to be paid to address the causes of malnutrition, public finance management systems which limit effective spending on nutrition, and information asymmetry and social/gender norms impacting both govt leadership as well as community behaviours. 

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