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Achieving Lasting Impact at Scale: Behavior Change and the Spread of Family Health InnovaƟ ons in Low-Income Countries A convening hosted by the Bill & Melinda Gates Foundation in Seattle, November 1-2, 2011 Synthesis and summary by the Social Research Unit at Dartington, UK Introduction Two days is not a lot of time, but perhaps 200 “conversation-days” is. practices, or platforms that had the potential to improve family health at scale When 100 people – each an expert in his Five – to reduce child and maternal and also to produce learning for future or her field – gathered together for two mortality and to achieve universal access investments. Such was the impetus for the days in Seattle on November 1-2, 2011, to reproductive health – it began with the Bill & Melinda Gates Foundation’s they were contributing to a conversation evidence base. The Family Health team at support for the project Alive and Thrive, that was several years old and will the Foundation rapidly uncovered more which promotes breastfeeding and child continue for several more. It was about than 700 relevant papers from micro- nutrition in Bangladesh, Ethiopia, and how to achieve lasting impact on family economics, political science, sociology, Vietnam, and its funding of other major health at scale. psychology and other disciplines. They initiatives to improve reproductive health read the papers and began to invite some and save newborn lives in Bihar, Ghana, Much has been said, and much remains of the authors to come to Seattle to Mexico, and Central America. to be said, so it is too early to draw discuss their ideas. conclusions. But the product of these By this stage, the Foundation was discussions has the potential to radically A lot was learned. But the knowledge involved in a lot of transactions – with the change approaches to family health, and tended to be over-complicated. It often experts, with the international aid to greatly reduce preventable maternal focused on the things that interest community, with the governments of and child deaths. academics, which are not always the most countries testing the tracer innovations, relevant for practice. It generally drew on and with the grantees implementing or But before I begin to explain why I am so experiences in economically advantaged evaluating them. excited about the possibilities, let me say contexts. a little about how we got to Seattle and But more could be learned from a how I came to be synthesizing what we These first explorations prompted a more conversation among these communities have learned so far. systematic review of the literature. than from a series of bilateral exchanges. Several studies were commissioned, two When Jeff Raikes became the It is not necessary to be super smart to of which got a good airing in Seattle. The Foundation’s CEO, he brought with him recognize that money alone is insufficient first sifted through what is known about a lot of ideas with fancy names (like to solve the world’s great problems, such the social and behavioral changes that “solution leverage”) that had helped him as the millions of children who die will be necessary to deliver biomedical and Bill Gates make Microsoft one of the needlessly each year. The Bill & Melinda interventions leading to sustainable biggest scale-up successes in history. Gates Foundation can bring a lot of population-based improvements in family These are ideas I will explore in more resources to bear on any challenge – but it health. The second examined what works depth later in this synthesis. also knows that progress depends on in scaling up evidence-based interventions exploiting the best available knowledge. in low-income countries. For now, all that needs to be said is that the Bill & Melinda Gates Foundation So, in 2008, when the Foundation began At the same time the Foundation was came to realize that its progress depended in earnest to think about how it might testing its emerging ideas on what it on bringing together a diverse group of play its part in meeting the United called “tracer innovations”: products, Nations’ Millennium Goals Four and 2 | Achieving Lasting Impact at Scale Introduction experts to take a look at age-old problems Melinda Gates Foundation to go out into through different lenses. the world and bring together what is Contents known about how health innovations And this is where I join the story. The scale up in low-income countries. They I. Starting the conversation 4 group I lead at the Social Research Unit were asked to develop an “actionable II. Impatience 10 at Dartington in the UK acts as a broker framework,” which means a way of of knowledge, seeking to make ideas, thinking, of framing a problem, that could III. Optimism 18 evidence, and action more than the sum be used in real-world settings by people IV. Catalysis 24 of their parts. This task demands investing to improve global family health. exchanges among all of the people with a V. The conversation continues 30 role to play in improving children’s lives. Gentle pressure-testing of this model But different disciplines, academic acted as a catalyst for what turned out to Participants 34 traditions, and cultures use their own be about 50 important ideas about how to languages, their own sets of nouns, verbs, achieve lasting impact at scale, the core and adjectives. While the sounds may be theme of this conversation. similar, the meanings are different – so some translation is needed. (I think of this Because no synthesis can encompass all process of translation as like helping a that happened in those 200 conversation- Spaniard talk to an Italian. The structure days, I offer here a review. I bring to the of the language is the same, as are many task the frailties of potential of the words, but the scope for misunderstanding, of personal excitement misunderstanding, particularly in the and impatience and optimism. I also spoken word, is huge.) bring the strengths of a content-neutral approach. I aim to report what I heard, My role, Dartington’s role, has been to not what I hoped to have heard. I am facilitate the conversation, to find trying to hold up a mirror for the people Achieving Lasting Impact at Scale: common agreement about the most who joined in the meeting, to provide a Behavior Change and the Spread of important words and what they mean, so window for those who could not attend Family Health Innovations in Low‐Income that we can put our newly shared but are anxious to find out how it went, Countries vocabulary to use to produce solutions and to find words that will help us talk A convening hosted by the that would not have emerged from and understand each other a little better Bill & Melinda Gates Foundation, Seattle, reviews of the evidence, or evaluations of in the future. November 1‐2, 2011 large grants in Africa, Asia, and Central America, or from one-to-one meetings Michael Little, Synthesis and summary by the with experts in the World Bank, the Social Research Unit at Dartington Social Research Unit at Dartington, UK governments, or aid agencies. Co‐director: Michael Little Seattle was the first of many conversations that will, we hope, lead to significant improvements in child and Photo credits: maternal health throughout the world. I All images from the convening in Seattle: am mindful that our meeting room in BMGF / Natalie Fobes. Seattle was hardly big enough to Cover, clockwise from top right: accommodate a tenth of the people who BMGF / Olivier Asselin; can contribute, which is why there will be BMGF / Prashant Panjiar; many other opportunities to take part in BMGF / Natalie Fobes; important discussions this year and next. Nicholas Christakis; BMGF / Olivier Asselin; Center stage at Seattle was a framework BMGF / John Ahern. for thinking about the scaling of impact in Page 11, Cutting the umbilical cord: the Global South that emerged from one BMGF / Sarah Elliott (Ethiopia, 2009). of the systematic reviews described above Page 21, Graphite and diamond: and prepared by a team from Yale Nicholas Christakis University. Betsy Bradley and her Page 29, Water: BMGF / Michael Prince colleagues had been asked by the Bill & (Lusaka, Zambia, 2009). The Bill and Melinda Gates Foundation, Seattle, November 2011 Achieving Lasting Impact at Scale | 3 Gary Darmstadt, Melinda Gates, Bill Novelli, and Nicholas Christakis trade ideas on behavioral change and social networks at the Seattle convening Photo: Bill & Melinda Gates Foundation / Natalie Fobes I. Starting the conversation How can we make progress on improving the health of mothers and Part of the Foundation’s commitment has been to start a conversation that would children around the world? Money, science, and political will are essential, draw in expertise from around the world. but none is enough on its own. Real progress may come from bringing the The colloquy got underway in earnest in best minds together, exploiting our diversity, working with users – and Seattle in November 2011 with a meeting taking to heart a song about mustard seeds and sunflower oil that brought together more than 100 experts: specialists in family health and government; experts in public and private Convening in Seattle, Innovation, to make effective prevention sector scale-up; scientists who explore November 2011 and treatments applicable to the diverse behavior change, social networks and the contexts in which children and mothers spread of ideas; philanthropists seeking to In the mid-1990s, Bill and Melinda Gates die around the world, is another. pump-prime invention and innovation; read a New York Times article on the ministers, public servants, practitioners, widespread death of children in Fundamental to success is the idea of and policy makers responsible for developing countries from diarrhea scale.

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