‘Adaptive’ or not, health programmes aren’t static. Because the world isn’t.

As the development community wrestles with the concept of ‘adaptive programming’, it’s worth remembering that programmes must and do evolve as their environment changes. Our health programme in the Democratic Republic of Congo is a case in point.

 

The Holy Grail of adaptive programming

It is now widely agreed within the global development community that the low-hanging fruit has been gathered. The issues that low-income countries now face – and will be facing in the decades to come – are increasingly complex, intertwined, multi-faceted and multisectoral. The Sustainable Development Goals acknowledge this complexity – in contrast to their predecessor, the Millennium Development Goals, which were largely unidimensional.

The capacity of development programmes to adapt nimbly to changes in their environment, be it the enactment of a new policy, an unexpected outburst of violence, an Ebola outbreak or, more simply, the realisation that the programme isn’t achieving the results it was supposed to, is commonly referred to as ‘adaptive programming’. On the face of it, that sounds rather obvious: someone unfamiliar with the sector might quite rightly say, “But aren’t all programmes adaptive?”

In fact, genuinely adaptive programming is a lot more difficult to pull off than it sounds. For lots of reasons. Changing course should ideally be based on robust evidence that something isn’t working or could be done better, but more often than not, the only evidence programme managers have in the absence of expensive and tailor-made evaluations is anecdotal. The skills needed to implement different sets of activities may require changes in staffing structures, or rapid upskilling, both of which are difficult, costly and time-consuming. Managers are usually contracted to report against a set of indicators established during the initial design and which must be measured consistently to show progress: donors understandably wary of goalposts being shifted will rarely make it easy and straightforward to change reporting protocols. Impact can take longer to materialise than initially thought, making it premature and possibly ill-advised to change course at that point. The list goes on.

But despite all this, a quick reality-check reveals that most development programmes do change as their environment evolves. For a very simple reason: the world isn’t static, so programmes cannot afford to be either.

Our health programme in the DRC: a history of disruption and change

Readers of my previous blogs will have picked up that I have a soft spot for the Democratic Republic of Congo (DRC), and for the flagship health programme we have been delivering on the ground there for the best part of five years in extraordinarily difficult circumstances. During this time, the programme has morphed, or ‘adapted’, on a number of occasions and in a number of different ways.

The programme was conceived with GSK in 2013 as an integrated solution covering most of what public health specialists call the ‘continuum of care’: from family planning to early childhood and covering all stages of the pregnancy and post-pregnancy period. The lack of suitable health infrastructure in the extremely poor and deprived parts of Kasai Oriental and the capital Kinshasa also implied the need for heavy construction work and the provision of equipment and drugs, along with softer activities, including training health workers, mobilising communities for better healthcare and advocating for increased funding for health.

 

But the maths didn’t quite add up. We realised that this scope of work was too broad and would have led programme funding to be spread too thinly. In order to achieve greater impact, we therefore took the decision to refocus the project on newborn and child health, thereby stripping out activities related to family planning, HIV control and some elements of maternal health.

In 2014, with this ‘final design’ in hand, we embarked on a four-year journey to extend the reach of the health system to thousands of people who had been left out of healthcare in its most basic form. We didn’t think it would be easy. But we had no idea what lay ahead.

The first major disruption occurred in 2015 in the form of a significant measles outbreak in the Kasai and Lomami provinces. After 11 confirmed deaths in the near vicinity, the fear of an epidemic was such that the health authorities asked our Signature Programme to step up and support the containment effort. This was a first, relatively mild ‘shock’, which meant resources had to be diverted away from planned activities, such as training health workers.

Meanwhile, a more positive change was afoot: the stated ambition of our Signature Programme acted as a pull factor for other partners, including DFID and the TV channel ITV, both of whom committed additional funding to help us scale-up our activities. These resources were mostly put towards an expansion of the community-based component of the programme (known as ICCM), which changed the shape and identity of the programme significantly. Suddenly, it covered a much larger area – comprising four times as many communities – and was driven by a mission to bring basic health services into villages as much as possible, instead of waiting for patients to show up in faraway health centres.

The celebration was short-lived however. In March 2016, the signs of a major yellow fever outbreak were increasingly clear in several provinces of DRC, including the capital Kinshasa, where our Signature Programme had several major operational sites. The scale of the challenge was much greater than for the previous measles outbreak, and the threat far more serious. After 21 confirmed deaths an international response was triggered to contain the epidemic, and once again mobilised resources from our Signature Programme, including staff, drugs and logistical support.

But this was nothing compared with what was about to come. In August 2016, a violent conflict erupted in the historically stable provinces of Kasai. The killing of Jean-Pierre Mpandi, a local warlord, triggered a brutal insurgency that took the world by surprise. Within a few months, more than 3,000 people had been killed and more than 1 million people had been forced out of their homes. Hundreds of thousands of people remain internally displaced across the Kasai region to this day, according to estimates.

This time the impact of this conflict on our Signature Programme was on an entirely different scale. Operations were completely suspended in most of the Kabeya-Kamwanga health zone for several months, and mobile clinics were deployed instead to provide emergency health services in the most affected areas. Community-based activities ground to a halt and drug supplies were partially interrupted.

This was a major blow. But our Signature Programme recovered. All programme activities resumed, and in 2017 I saw for myself how some of the community sites that had been impacted by the conflict were alive and kicking. Better still, the European Union committed additional funding – to the tune of £4 million – to help our Signature Programme expand into the neighbouring province of Lomami.

As I write, another phase of ‘programme adaptation’ is underway. The biggest challenge facing infants in this new province is malnutrition: it’s estimated that 50% of children under five are chronically malnourished, and 25% severely malnourished. The focus of our Signature Programme will therefore need to evolve and tackle this burden head-on.

This story of disruption, change and adaptation is commonplace in multi-year development programming. Whilst our health programme in DRC would probably not qualify as “adaptive” in the pure sense of the term, navigating the fluid environments of fragile states requires ever greater adaptability and responsiveness, which it has deployed in abundance. Always aim for the best. But do prepare for the worst.

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Comments

  • Eric Sarriot

    Great blog and illustration of the reality of the work.
    It also shows that the line between “development” and “emergency” programming is quite thin — there is a continuum that goes both ways.

    Take home quote for me is “The issues that low-income countries now face – and will be facing in the decades to come – are increasingly complex, intertwined, multi-faceted and multisectoral.” We are — and our donors are — unfortunately very fragmented. “Intertwined”, integrated programming presents governance and management challenges that we are not used to tackling.

    Best.

    Eric