As Reos Partners works with change makers around the world, we see tremendous frustration among people dedicated to working on clinical care, the well-being of children, addiction, gender-based violence, and other issues of health and equity. Too often, despite years of their best efforts, progress is elusive. In fact, as you probably know firsthand, many indicators are getting worse. Why?
Consider this story, from a workshop on violence against women in Australia.
The workshop included police and both government and non-governmental leaders, and we asked a magistrate and a police officer to talk about what they could and couldn’t legally do when handling domestic violence cases. After about two hours of listening, several of the participants became emotional. They were realizing that for many years, the advice they’d been giving to victims was wrong.
What was going on? They simply hadn’t seen beyond their own piece of their complex system. Previous approaches all but precluded the conversation they were now having.
In our experience, conventional technocratic approaches alone are almost never adequate for making progress on stuck systemic challenges. Problem analysis and problem solving are of course vital. But they often sidestep complexity, not to mention the unquantifiable mess of emotions. And issues of health and equity are loaded with more than their share of both.
The conventional approaches are as entrenched as the problems themselves. Often, they’re anchored in ideological perspectives, and we’re all familiar with the resulting clashes. Our partners who are new to thinking and working systemically sometimes at first find it hard to see a different, more open path. What does a more effective approach to health and equity challenges look like? Where do you begin?
Here are some of the mental, emotional, and process shifts that we — after 20 years of global engagement in systemic change initiatives — find to be necessary. Taken together, they enable real progress.
In the face of overwhelming complexity, the conventional response is to try to simplify and to cut the problem into what feels like more manageable pieces.As if the more technical and compartmentalized a “solution” is, the better it will be. But as the story above illustrates too well, such simplifications are often based on only the piece of the system that people work in.The usual result is blind spots that make our efforts more difficult or even doom them to failure.
The participants in the Australia workshop hadn’t looked at the whole picture. Or if they had, it was through the lens of their assumptions. After a break, the conversation resumed: What can we do, together, to change this? Many such conversations later, the Australia example has been key for other countries working to prevent violence against women and children. We’ve extended our successful work there to South Africa and Brazil.
Give everyone a voice
It’s a simple principle: only with a multistakeholder approach can we hope to create something resembling the full picture of a complex system. Gathering and working with a full spectrum of stakeholders is a challenge, but a manageable one.
Other work on preventing violence against women in Australia has drawn in more than 700 people across the continent through dialogue interviews, workshops, and surveys. To explore the issue in South Africa,we adopted a social lab approach that brought together stakeholders from civil society, academia, police services, government, student movements, health services, and both local and international funding bodies.
On a smaller scale, we’ve worked with a 100-year-old mental healthcare institution in the Netherlands as it responds to sweeping changes in the country’s welfare state. The changes prompted a reexamination and overhaul of the organization’s systems and structures. We enabled that by, among other things, drawing members of every level of the organization into a collaborative process of dialogue, learning, and experimentation.
At any scale, it’s imperative to engage people who have been disenfranchised. And that doesn’t always come easily, whether because of traditional top-down models or deep mistrust.
In Australia, for example, cultural barriers and an entrenched, multigenerational legacy of colonialism has sabotaged efforts to turn around the health crisis among Aboriginal peoples. The Aboriginal Health Lab forged cultural alliancesthat challenged assumptions and power differentials. “I struggle with how I see racism within my organization — how I’m exposed to it, and how I contribute,” said one lab participant.“What can I learn, rather than what can I teach?” Personal recognitions like this are the beginning of systemic transformation.
Relatedly, conventional approaches are usually top-down. The result is more blind spots. Part of the remedy is to bring together on equal footing experts, the “nonexperts” they’ve been trying to help, and even people they’ve been trying to hinder. It’s awkward … and often incredibly valuable.
Flip the Clinic, a social lab we organized in the United States, epitomizes this. It’s designed to reverse, or flip, the usual medical relationship by empowering not only clinicians but also patients to contribute and implement innovative ideas. The lab community has initiated more than 80 flips. One on digital health record engagement is on track to reach 20 million patients.Said Atul Gawande, a surgeon and public health researcher, “Flip the Clinic is creating the possibility of a new system.”
Another example of cutting-edge innovation and shared decision-making in health care is the South West Yorkshire Mental Health Lab in the UK. The lab aims totransform carebyempowering people with mental health issues to shape the services they need. In designing and implementing this lab, we brought together more than 50 service users and professionals to collaborate on initiatives to increase patients’ involvement in their own care. The health care providers, often excellent listeners, nonetheless have had to work hard to put aside years of trainingand really hear patients’ own expert point of view.
As the collaboration enabled by both of these labs makes clear, in a system, no single expert is as powerful as the combined expertise of a range of stakeholders.
Slow down with a purposeful detour
Given the urgency of health and equity challenges, the natural impulse is to work faster. While short-term problems do need to be addressed, long-term progress on complex problems requires that stakeholders develop a complex understanding — and that takes time.
Transformative scenarios are one way to develop a complex, and shared, understanding. This structured yet open-ended process is an example of what we call a “purposeful detour.” Over the course of about six months, we guide diverse stakeholders in constructing several possible futures around the issue at hand, combining both rigour and imagination. The resulting stories suggest strategies and initiatives for shaping the future.
In the United States, for example, health and healthcare are in crisis. Better outcomes would require a significant change not only in how health insurance and clinical care are provided, but also in the multiple social, economic, and environmental determinants of health. To begin developing a deeper understanding of the issues, we convened a transformative scenarios process, Possible Futures for Health and Health Equity in the USA.
“If these scenarios are given the attention they deserve … we might get this country on a different path in terms of health equity,” said Vincent Garcia, a paediatric surgeon and member of the US scenario team. “Particularly for those who are disconnected and invisible. But also those who are visible and feel they’ve been left out.”
Let go of “solutions”
The very notion of a discrete solution suggests a neat, discrete problem. At Reos Partners, we never set out to “solve” something like health inequity, gender-based violence, or the obesity epidemic. Rather, we try to shift and ultimately transform the conditions that are generating the problematic situation so that something new, positive, and self-sustaining can emerge.
“We’re very quick to come to solutions,” says Shelley Bowen of Health Futures Australia, which has teamed with Reos Partners, about past attempts to address obesity in that country. “But we completely miss the transformation required to tackle this deeply entrenched issue.” In contrast, Health Futures Australia is a long-term platform for exploring multiple interventions on multiple fronts.
Letting go of solutions also means shifting to a mode of experimentation. We help our partners prototype and launch experiments — as opposed to fully formed programmes — and then evaluate and refine them, as many times as it takes to find what works. This is usually liberating and productive. As a participant in the South West Yorkshire Mental Health Lab put it, “Sometimes all the processes and form-filling-out can take the creativity and energy out of work that is genuinely trying to improve things. It’s been really exciting to be able to go and just try something to see if it works.”
Bring pent-up emotions into the open
Powerful emotions often roil just beneath the surface of many health and equity challenges, and few dare to unleash them. Consider violence against women in South Africa, where that issue and others are tied to the history and continued realities of white supremacy — the “elephant in the room” in so much of our work in that country. More than once, our workshops have been host to tears, anger, and pain of generational force.
We’ve seen that people must get their feelings into the open before they can move on to experiment with new ways of acting, relating, and being. Individual emotional breakthroughs clear the air, the heart, and the head, which in turn clears the way for breakthroughs at the system level.
Collaborate with people you don’t agree with
It’s not always easy to collaborate, even with people you agree with. Rife with emotion and conflicting interests, issues around health and equity often ask even more of us: to collaborate with people we don’t agree with, like, or trust. The parties may never agree, but they must find ways to move forward together anyway.
We call this “stretch collaboration.” As Adam Kahane, a director at Reos Partners, describes in his book Collaborating with the Enemy, we have learned how to help diverse, competing stakeholders move forward with no expectation of harmony or even any definitive agreement on the problem, never mind the solutions. The transformative scenarios process, as an open-ended act of imagination, can enable collaboration even in the presence of widely divergent dogmas and ideologies. As in the case of drug policy, for example.
In 2012, the Organization of American States engaged us to undertake Scenarios for the Drug Problem in the Americas. After first interviewing 75 leaders across the hemisphere, we convened a scenario team comprising 46 people engaged with security, business, health, education, indigenous cultures, international organizations, the justice system, civil society, and politics.
As Colombian president Juan Manuel Santossaid, the scenarios provided “a refreshingly broad and open set of perspectives on a debate that has become narrowed and polarized between drug ‘warriors’ and ‘legalizers.’ … They simply provide us with realistic options, without prejudices or dogmas.” The result of opening up and reframing this paralyzed debate was unprecedented new agreements on hemispheric drug policy.
Step into the confusion
Thinking and working in new ways, questioning our own expertise, confronting uncomfortable emotions … People at every level of a system can find all this difficult, confusing, even distressing at times. But as practiced guides, we design our processes to give everyone the support and the time they need to feel their way through. On the other side, as we have seen again and again, is a more successful response to the complex challenges we face.
We invite you contact us about making progress together.
photo: (CC) UNICEF Ethiopia/Flickr