Beyond Scaling Up: A pathways approach


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This presentation was given at the 'Beyond Scaling Up: Pathways to Universal Access' workshop which was held at the Institute of Development Studies, Brighton on the 24-25 May, 2010. This event was co-sponsored by the Future Health Systems Research Programme Consortium and the STEPS Centre. Leach presented on a pathways approach.

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  • STEPS Centre – not a small agenda Want to share with you elements of our pathways approach and why we think it is important in relation to two of the so-called ‘crises’ arou d which policy and public imaginations alike are mobilising.
  • Start with a basic problem….
  • Start with a basic problem….
  • World endlessly complex and dynamic, but useful for analytical and practical purposes to think in terms of systems
  • Narratives of crisis are part and parcel of this. Could look at the so-called ‘financial crisis’
  • Narratives of crisis are part and parcel of this. Could equally look at the so-called ‘financial crisis’
  • Narratives of crisis are part and parcel of this. Could equally look at the so-called ‘financial crisis’
  • Beyond Scaling Up: A pathways approach

    1. 1. The STEPS Centre’s pathways approach in thinking about dynamic health systems Melissa Leach Introductory presentation to conference on ‘Beyond Scaling Up’, 23 May 2010
    2. 2. How can we identify and build pathways to sustainability – that link technology and environment with reduced poverty and social injustice – in a complex, dynamic world?
    3. 3. Addressing health problems <ul><li>‘ Rolling out’ and ‘scaling up’ of ‘solutions’ (‘silver bullets’) </li></ul><ul><li>Presume that interventions are straightforward (technical-managerial) and act on a relatively stable, predictable (and uniform) world </li></ul><ul><li>Yet in practice, both interventions and the worlds they engage with involve far greater complexity and dynamism </li></ul><ul><li>…… A mismatch - Missed targets; c ycles of ‘failure’ as dynamics undermine assumptions of stability; emerging backlashes from nature, politics; mires of disagreement </li></ul>
    4. 4. Complexity in health systems <ul><li>Health systems as ‘actors and institutions that influence health’ </li></ul><ul><li>Widen to include knowledge, technologies </li></ul><ul><li>Don’t just ‘act on’ but also interact with ecological, social, microbial processes </li></ul><ul><li>Hence – health systems as social-technological-ecological systems </li></ul><ul><li>Complex systems - networks of many heterogeneous components that interact non-linearly, to give rise to emergent behaviour </li></ul>
    5. 5. ‘ system’ environment System: Social, institutional, ecological and technological elements interacting In dynamic ways A STEPS systems perspective
    6. 6. Dimensions of framing:   -Scale and boundaries (e.g. local, national) -Key elements and relationships (e.g. are informal drugs sellers in or out?) -Dynamics in play (e.g. attention to which shocks and stresses) - outputs, goals   - perspectives - interests, values (what is the health system delivering and for whom? Narrow vs. broader ideas of wellbeing) - notions of relevant expertise (e.g. biomedical knowledge, or also traditional?) Systems are framed – understood and represented – in diverse ways
    7. 7. Pathways of change <ul><li>Pathway – the particular directions in which interacting social-technological-ecological systems change over time </li></ul><ul><li>With complex systems there are multiple possible pathways </li></ul><ul><li>And path dependencies - evolution is very sensitive to initial conditions or to small perturbations </li></ul>
    8. 8. The shaping of pathways <ul><li>Which pathways unfold, in which directions, towards what goals and with what distributional effects, shaped by governance </li></ul><ul><li>Political, institutional and power-knowledge processes – whether involving states, international agencies, regulators, NGOs, health users or citizens groups – and interrelationships among these </li></ul><ul><li>But not in entirely controllable, predictable or linear ways – there will always be uncertainties, feedbacks, unintended consequences </li></ul>
    9. 9. Shaping health system change: four challenges and pointers <ul><li>Taking three Ds seriously </li></ul><ul><li>- Recognising Diversity, choosing amongst Directions; considering Distribution; </li></ul><ul><li>Integrating social-political-technical dimensions </li></ul><ul><li>- social aspects of technological ‘fit’; organisational innovations </li></ul>
    10. 10. <ul><li>Dealing with complexity and uncertainty: </li></ul><ul><li>Adaptiveness, rapid learning, building from past experiences, flexibility, responsiveness </li></ul><ul><li>Dealing with multiple, contested goals and framings: </li></ul><ul><li>Deliberation, more inclusive participation, transparent discussion, social learning; humility over basis for action, more plural interventions, reflexivity in knowledge claims </li></ul>