When Evidence Goes Unheeded
A conversation with Critica advisor Olumide Elegbe about international development, global health, and learning from data
Recently we had a chance to sit down with Critica advisor and international development and global health expert, Olumide Elegbe. Elegbe is a senior strategic advisor, technical specialist and thought leader for health and international development organizations. We discussed a wide array of topics with a special focus on why we sometimes fail to adapt our practices even when the evidence clearly shows we should.
Critica: Do you see practices that aren’t evidence-based in international development? If so, why do you think these persist?
Olumide Elegbe: International development is one of the most altruistic professions that one can go into. I cannot remember ever speaking to a person who told me that they chose a career in global health or international development to make a fortune or that it is just a job. Instead, most people have chosen to work in these fields because they want to change the world.
This of course in turn also means that we rarely see people switch industries. Often, even when they do retire, these same people do not leave the field but rather become consultants to organizations that they previously worked with either as employees or competitors. So you get a situation in which there’s often a lack of diversity of perspectives.This often means that development organizations do not respond to shifts in the landscape around them. Some are simply averse to change as they expect things to return to how they’ve always been while others are so focused on what they’ve always done that they are unaware of the changes.
Critica: You mentioned “shifts in the landscape.” What are some of the major ways this has happened recently?
OE: In 2008 at the height of the financial crisis, donor governments (including the U.S.) faced a difficult challenge on meeting their commitment, given the financial difficulties they faced in their own countries. Everyone was affected by the crisis. There was mounting pressure from taxpayers to “fix the problems at home first” rather than taking taxpayer money abroad. At this time, there was also an uptick in private sector investments in international development. Private sector involvement in development was evolving. We had moved from corporate social responsibility to a new norm where social and development challenges were being woven into the core business of corporations. Slowly and steadily, we started to see alliances form between corporations and donor governments who saw an opportunity for partnership with the private sector to leverage their shrinking pot of development dollars.
On the programmatic side, the models that have been employed across the health, education, economic development, and other subsectors of development were seemingly inadequate for the evolving context in developing countries. In health, the disease burden was starting to shift and the needs of the population were changing.
Critica: How has the landscape in global health specifically shifted? Has the field responded to changes in the landscape and to growing evidence about what works and what doesn’t?
OE: There’s a growing middle class in Africa and Asia and a real shift in lifestyle. Partially as a result of this, it’s now projected that by 2020, noncommunicable diseases will be the biggest killers in sub-Saharan Africa, and this is already the case in parts of Asia. Despite this, the programs with the largest funding continue to be for infectious diseases. In many countries in Africa and Asia we now in fact see a “double burden,” with high rates of both infectious and noncommunicable diseases.
On the micro level, the global health and development community seems to be very good at gathering the evidence base and best practices from randomized controlled trials and employing models that have worked for a particular need and exporting those. Where we seem to need improvement however is in reshaping the broader dialogue to advocate for our beneficiaries, using this robust evidence base, for a larger change in the focus of health and development programs. For example, can we change the dialogue so that non-communicable diseases like mental illness, hypertension, and diabetes are funded rather than just infectious diseases like HIV/AIDS, malaria and Ebola? For a group of people who talk a lot about evidence, a closer examination reveals that despite all of the lessons learned, the translation of these into more targeted programming has been slow. There is more to be done to ensure that the evidence generated is used to change the way international development work is done.
Critica: Aside from the lack of diversity of experience, what are some of the factors that you think contribute to this slow change?
OE: There are a few big issues. One has to do with how international development work is funded. Most nonprofit organizations have gotten really big by working with the same funder to grow their programs. This has meant that they have adapted all of their work to satisfy that one funder. This also means that there is often very little diversity of thought in programming and it’s hard for non-profits to adapt when they learn new things and collect new data. There’s also a missed opportunity to learn from others and integrate evidence generated from one organization to the next.
There’s another major structural issue around who pays for this work versus who benefits from it. Usually the person who pays is different from the person who benefits and sometimes these groups have very different motivations and understandings of the problem. In a situation where the need of the beneficiary is different from that of the payer, new evidence seldom translates into action. In many cases, the greatest needs of the beneficiary are not addressed, even if addressing them would lead to true development.
Finally, there’s definitely a major issue of perverse incentives. The evolving landscape of development needs generalists as much as it needs specialists. We need people who are able to understand the interplay among health, finance, education, and other areas, but these areas are usually funded separately so they often operate in competition with each other. As a result, people tend to hyper-focus and work in isolation, even though all the evidence would suggest we’d be better off working collaboratively. This is one of the most fascinating paradoxes of development and a difficult topic to discuss. Most people working in development resent the idea that we are motivated by any financial gains when in reality, even with the best intentions, we are all motivated by financial incentives. When we cannot even have these discussions about financial incentives it becomes basically impossible to address the broader challenges that may be tied to them.
Critica: What can we do, if anything, to address some of the issues you discuss around perverse incentives, lack of diversity in perspectives in development, and the difficulty of translating evidence into action?
OE: Thank you for that really important question. To put it simply, I’d say better use of data, open dialogue, and fostering diverse professionals are key. Open dialogue is especially important in my opinion. Before we can create the right solution, we need to accurately diagnose the problem. We need to be deliberate in our gathering of data and we need to better collate information that allows us to ask the difficult questions about whether we are truly delivering for our beneficiaries. What does the end result look like and what can we learn from what we’ve done in the past? We also need to be able to talk more honestly about the fact that it costs money to do good work and also be open to adopting more efficient models. In addition, we need to think more broadly about how to make development organizations more flexible and responsive. Perhaps development work needs to be funded differently.
I also think we need to do much more hiring across sectors, including from the private sector. Development organizations that hire from the private sector will have staff who come with a different understanding of strategy and efficiency. Cross-sector work allows for tremendous personal growth for a wide range of employees and would also hopefully result in improvement of conditions for our beneficiaries, new markets for the private sector to explore, and the ability for government dollars to be used far more efficiently.