EPISODE 2: Not for the few, but for the many
In episode two of Sea Change, "Not for the few, but for the many", we hit the road to see what societal platform thinking looks like in real life, learn from experts about how grassroots organisations scale up, and then meet a group of doctors and researchers who have re-imagined how to bring medical expertise and skills to remote regions and communities. And finally we meet the people building the infrastructure necessary to make systemic advancements in education.
Note: Sea Change is produced for the ear and designed to be heard, not read. Readers are encouraged to listen to the show to get the full experience. The transcripts are meant as support documents and may not include inclusions from the day of recording and may contain errors. The audio version is the final version of the show.
Samyuktha Varma (SV): Hello and welcome to Sea Change, a three part series brought to you by the creators of In the Field. We’re your hosts - I’m Samyuktha Varma and I’m Radhika Viswanathan. Sea Change is a co-production of Societal Platform and Vakku. In this second episode, we’re going to hit the road to see what societal platform thinking looks like in real life, learn from experts about how grassroots organisations scale up, and then meet a group of doctors and researchers who have re-imagined how to bring medical expertise and skills to remote regions and communities. And finally we meet the people building the infrastructure necessary to make systemic advancements in education.
RV: Isabel Guerrero is an economist with impeccable pedigree. She’s been a World Bank country director in seven countries including India, Mexico, and Colombia, she was also one of the World Bank’s six regional vice presidents. She was always driven by a keen interest in poverty, a problem that has many faces, many dimensions, and one that is affected by a multitude of factors. Through her career she came across many organizations, committed ones, working close to the problem, at the grassroots level and saw that they were able to do incredible things.
Isabel Guerrero (IG): I managed a huge portfolio, 39 billion dollars, um, but I could not get to innovations that were coming from the base of the pyramid. I saw a lot of amazing work being done by organizations um, but they were not able to scale, there’s a lot of things we could help governments to do like build roads bridges, build schools, but when it came to things that required change in behaviour like teachers showing up at school or people moving from open defecation to using toilets we did not have the tools that were needed and a lot of grassroots organisations did.
SV: This gap that she describes, between the things that big organizations and agencies can do, and the context specific, evolved, ingenious innovations that come from locally based grassroots organizations, is well observed in development work. And it’s a problem many are trying to solve. It’s a problem of scale, of finding out how to get these innovations to grow, reach more people, and to make a greater impact. This interest in the evolution of organisations, particularly grassroots organisations in the development sector led her to set up Imago, named after the final stage in a butterfly’s life-cycle.
IG: When you're really dealing with the base of the pyramid, it is absolutely full of market failures and government failures... and if you think of a remote village it's very difficult for example for a bank to go into a remote village, there’s asymmetries of information in economics we call this market failures. There's government failures in the sense that it's very difficult for the government to reach the last mile, and so when you are in a situation like that and you are trying to make it, um, at scale, you might succeed when you are small, but as you get to scale these failures come to really bite you as an organization.
RV: Grassroots organizations often have limited resources and they may bootstrap a lot of their management systems trading them for more time with communities. Many are also rich in amazing stories of trans-formative work with but very often they don't have data systems that allow them to translate those stories into numbers that they can then unlock and share in a manner that others can learn from and adopt.
SV: So how can organizations scale? We asked Isabel to tell us, because of course, she teaches a course at the Harvard Kennedy School on how to scale.
IG: One way is just to grow, to scale by getting stronger, stronger human resources systems, and grow. um, a good example of that is BRAC, in Bangladesh which reaches 135 million people, it's one of the only NGOs that has been able to get into that range.
SV: The second way is to replicate a model that has proven itself.
IG: You give standards, you give business models, you give methodologies, and that replicates through the world.
SV: Microfinance is a good example of that, the Grameen Bank and BRAC in Bangladesh and Accion in Latin America, have been the pioneers of getting financial services to the poor. What they had was a formula, and it was replicated through the whole world.
IG: And the third one is to collaborate which is you form a network of people … to change the system that we are working on or to do systemic change, and so I think, systemic change is when you have a change that actually shifts the environment where each of these individual organizations are working in a way that is makes it easier to go to the next level.
RV: Shankar Maruwada is the CEO & Co-Founder of EkStep Foundation, which is trying to bring a big change in the education sector by improving access to learning. He’s spent some time thinking about scale and about the inter-connectedness of effectuating systemic change:
Shanka Maruwada (SM): Think of this metaphor, there is a net, a very heavy net. The net has nodes which are connected to each other. the net is very low right? Now imagine you’re trying to lift the net by taking one node or a group of nodes and lifting it right, you have temporarily lifted the net. But the moment you let go, it comes down. The education system in India is a bit like the net, it is extremely interconnected, it’s in a state of equilibrium, which means the network of actors the way they interact with each other is in a state of equilibrium.
RV: So how do we begin to think about lifting the entire net - how do we re-imagine distributing the resources required to bring equilibrium?
RV: Around twenty years ago, Dr Sanjiv Arora, a gastroenterologist began treating patients for Hepatitis C in the state of New Mexico in the US. New Mexico is a geographically large state, with a low population density, under twenty people per square mile. Many people in rural areas were medically underserved and when he began treating patients in his clinic in Albuquerque, he could treat maybe 150 patients a year, and there was an eight-month waiting period to see him!
SV: And so, he decided to try something new. He formed a learning community by bringing in primary care physicians and nurse practitioners from rural areas of New Mexico, that he and a panel of expert doctors would meet with for a couple of hours every week online through video conferencing. They would present cases and there was a communal sharing of expertise and learning. This became a project - Extension for Community Healthcare Outcomes or Project ECHO. Dr Oliver Bogler is the COO of Project ECHO:
Oliver Bogler (OB): The immediate benefit was that the nurse practitioner or the physician in the rural area treating the case got the information and recommendation but then they also over time became skilled hepatitis-C experts and in the course of about a year or a year and a half or so they got to the point where they were confident enough to treat Hepatitis C by themselves in their communities. And they became a local resource, and the capacity in the state for treating Hepatitis C increased by more than five-fold.
RV: Project ECHO introduced systemic improvements to Hepatitis C treatment. Dr Arora did not create gastroenterologists he created Hepatitis C experts - so while the expertise was limited it directly addressed one of the core problems the physicians and nurses in those clinics were seeing. And now they were able to manage it better! ECHO’s model has been highly effective in increasing the reach of scarce expertise - and consequently improving patient care, reducing costs and stress, and most importantly expanding the reach of medical care to underserved areas.
OB: Before project ECHO patients would have to travel many hundreds of miles to access treatment, this was expensive and difficult. After Project ECHO only the patients that really needed the expertise of the university team had to travel and most of the more typical cases could be treated where they are and the patients didn’t have to leave so costs were saved stress was reduced. And in fact Dr Arora’s wait time in his clinic went down to two weeks from eight months.
RV: A recent report on healthcare workforce in India by the WHO pointed out that there were on average 36 doctors with a medical qualification for every 100,000 people in India, and incredible regional disparities when it comes to access to medical expertise.
OB: The reality is that demographics, investments and training patterns in medicine mean that we are never going to generate as a world the number of experts in complex diseases that we need to manage these diseases. There just will never be enough experts to manage for everybody so we have to think of a different way of managing these complex diseases, and we believe that Project ECHO can be an important part because it deploys the expertise of a scare expert across the entire system. This kind of learning is ideal for complex situations, complex diseases and complex other kinds of issues and services and they’re dynamically complex.
SV: The ECHO model, effectively moves knowledge rather than moving the people, the patients, or the doctors, and it’s different in the way it imparts skills.
OB: One thing that distinguishes ECHO from all other modes of distance learning that I’ve seen is the incredibly high social element - in distinction to for example a MOOC or a Khan Academy or an online video based learning where you have access to tremendous resources, is that all ECHO learning takes place in the context of a community of a social community. And we believe that humans learn better in a community, they learn better when they’re working as a group to solve a problem, if they work iteratively and get sort of what we call high frequency low dose learning and the learning is reinforced.
SV: Project ECHO follows a hub and spoke model and has around 222 hubs across the world, from Canada, the USA and even in India.
RV: Until a couple of years ago most patients suffering from Hepatitis C in the North Indian state of Punjab had to travel to the capital, Chandigarh, for treatment where the main hospital was able to around 1200 patients a year. The government launched an integrated public health program that included ECHO. And it worked quite effectively. Here’s Oliver again,
OB: In the course of about 2 years by working with about a dozen regional hospitals across Punjab they’ve now expanded the capacity for Hepatitis C treatment to over 45000 with a 93% cure rate. So from 1200 to over 45000 patients being able to be treated. Hepatitis C treatment is not a one shot deal and now increasingly patients are able to receive that care much more locally and we estimate the savings across the Punjab be as much as 10 million dollars a year in terms of the personal costs to the patients travelling and losing wages.
RV: There’s a lot to learn from Project ECHO - it’s an approach that unlocks scarce resources through a model that can be reproduced in many different contexts, and for many different applications. It focuses on empowering practitioners. Their methodology requires the collaboration and partnership of different types of institutions - like government hospitals, primary care facilities, frontline health workers, researchers and so on. This is where societal platform thinking help organisations like ECHO exponentially grow, to take thinks to the next level, to achieve a societal goal, and affect populations at a time.
SV: When people think of affecting change for a deep complex problem, it’s assumed that it will take generations.
SM: What happens to two generations of learners? ...Why not do it now rather than wait for twenty years? But that’s a wish right?
SV: Education like healthcare affects a huge number of people, is a challenge in a large part of the world, and needs scalable solutions. The EkStep Foundation’s mission is the audacious goal of improving outcomes in literacy and numeracy by increasing access to learning opportunities.
SM: But at a massive scale, we're talking about 200 million children in India and in a very specific time frame, by the end of 2020.
RV: EkStep has had a unique journey. They first envisioned an approach based on games to help children learn. But they soon realised that that games weren’t fundamental to learning, and that they had to move away from a product approach.
SM: But they’re like the pickle with the curd rice, they’re not the main meal, they just enhance the taste.So you can’t make a full meal out of pickle but you’ll need that little bit of pickle to make the meal interesting and that, in that pithy analogy was a lot of insights for us.
SV: School Education in India is a complex ecosystem. There are over 10 million teachers, 200+ million students, 23 official languages. Not to mention the fact that India probably has the highest numbers of first generation learners in school! There are different curriculum boards, and a wide range of schools - from super elite private schools to your neighbourhood government one, resulting in a highly varying quality of school education depending on who you are, and where you study.
RV: In India many organisations work on many different aspects of these problems - from school infrastructure, teacher training, to keeping kids in school, and there had to be a more collaborative approach that would help reach their goal of 200 million children. Ek Step’s approach was to build an underlying, open, digital infrastructure that could support and amplify the work of all these actors and enable the co-creation of a wide range of solutions, reflecting this diversity. The solutions could then be created closest to the context in which they need to be applied. They see their approach as one that resolves the frictions between these actors. Nandan Nilekani, Chairman and the Co-founder of Ek Step, explains the three-tiered structure of this infrastructure, or a societal platform.
Nandan Nilekani (NN): The first layer the bottom layer of this infrastructure is a digital infrastructure. now that would vary from use case to use case, so the digital infra for education may be very different for the digital infra for health. But what is sort of common about all of them is that they are designed for scale, they are designed to capture the telemetry of various actions on them and whatever tools are required that are common to all users are put into that layer so different people can use them. So broadly speaking Societal Platform have three layers, base digital layer which keeps improving over time which has as much common stuff as possible, a context creation layer which allows different parties to create solutions to their context, and a context amplification layer which is the layer which takes a solution in a context and takes it out to millions of kids or millions of people.
SV: This led EkStep to build Sunbird, an open source platform for learning and management designed to support a wide range of applications and solutions. Using it, the Indian government launched a National Digital Platform for teachers called Diksha in 2017 - reaching out to ten million teachers. And Energised Textbooks is one initiative under Diksha. It uses a really simple idea - QR codes printed in textbook chapters help teachers and students access learning material based on the topic at hand, and these could be videos, exercises, or lesson plans. We met with Shankar in June 2018 and he told us more:
SM: As we speak around two hundred million plus textbooks in more than five languages are being printed in five states by the respective state govts and these are being made available free of costs to the children in govt schools. So these are your regular government textbooks. The difference is in every chapter of your textbook, there is a QR code and when you use an app to access the QR code it opens up a world of digital content, not just any digital content, but digital content which is relevant to that particular chapter you’re reading.
RV: Pramod Varma, EkStep’s CTO says, it’s a bit like plumbing. Think of how we get water in our taps. Water from different sources is treated using technical processes and is supplied through a complex network of pipes into our taps; and we consume it without always thinking about its peripatetic journey to our homes.
Pramod Varma (PV): All the child has to worry about is consuming that water in the tap on that day for the topic but the plumbing has been laid by the government, the teacher community is coming together to actually curate and provide quality water on this thing and NGO community and content creator start-ups are working even one level behind them to say, I will provide - but they’re all coming through a shared plumbing so that it’s a uniform experience at the end that the child is getting.
RV: Diksha’s content is curated by teachers from across the country. It’s the teachers who get to attest, validate and confirm the content that is uploaded.
PV: So imagine the power of a trusted curated plumbing on top of which the entire ecosystem is aligned ! Teachers, governments, block administrators, private tuition teachers, content creators, now philanthropists, funders, NGOs are aligned on this, are all working to create a thriving micro-society around this highway.
Boy: Girianand, 7th B
Boy: Kishore 7th B
Boy: Girianand 7th B
RV: What's your favorite subject?
SV: Oh oh oh!
Boy: Science - English! English!
RV: Social Studies?
Boy: Social nahin, nahin!
Boy: Hallelujah ok thank you!
Boy: Tamil, English Math!
Loudspeaker announces the end of lunch break.
SV: Energised Textbooks was launched in June 2018, and the Diksha team is starting to follow up to see how things are working. They do this to understand what the challenges are, and to see where systemic improvements can make the experience a whole lot better. We’re in the southern Indian city of Chennai shadowing a team from the Diksha platform who are visiting govt and private schools as part of their follow up work.
Naveen Varshan (NV): So the school has a strength of around 2400 students and around 73-75 teachers, and this school is from sixth std to eleventh and twelfth. So it has both Tamil medium and English medium, So I think Tamil medium is just one section in all the classes and the rest are all English medium. There are around four sections I guess for each class.
RV: That’s Naveen Varshan, from the team. The school was really noisy. We arrived just before lunch, driving down a narrow lane just off one of Chennai’s main arterial roads. The school is big, two storeyed - and built around a large playground. The walls are adorned with educational paintings - animals, colours, trees and flags. Black boards placed all around carried worldlywise educational statements neatly written in colourful chalk - one said “Silent means Listen. They both have the same alphabets”. BU at lunch, the children were everywhere, and the school erupted in a cacophonous medley of laughter and chatter.
NV: So the idea would be a study around awareness, perception, usage, behaviour, the process they use to the challenges they face, and finally around infrastructure - how they are looking at infrastructure, how infrastructure is helping or not and what is the exact scenario on the ground. So basically, around these seven areas which will eventually help us understand the entire consumption experience at some level.
SV: We had the opportunity to listen in to Naveen’s interviews. One of the teachers talked about how much her students enjoyed the material on diversity that she used in one of her classes. The QR code accessed cultural songs and videos from different states in the country, and she said it made her lesson a lot more engaging and fun.
NV: One teacher mentioned was she used to be a very she’s still a very strict teacher, that’s her own perception of herself but she says now students actually look forward to her class since she has started to use the Energised Textbooks.
RV: Most of the teachers told us that they used their own devices in classrooms because infrastructure seemed to be a challenge. Schools like this one, have few digital resources - projectors, tablets, high speed internet connections. Some may have a single smart classroom that is equipped with all that can be reserved, but that’s rare. But this resource gap is still a problem. Pramod sees things differently. Diksha was built so that it can be used offline, all of its content can be downloaded. And he explains how these gaps actually offer an opportunity for markets to work alongside the government and society to support this initiative. And they also have a second project that provides a local intranet for local and offline use.
PV: One of the reasons why Diksha really works well is the underlying technology used for Diksha is built for offline use, and the third is very important interesting work we are doing is what we call a local internet. What we have done through a project called open rap dot io is providing a local Wi-Fi enable edge computing, a tiny device that looks like a Wi-Fi router but has a full-fledged edge computing capability and the entire design, entire code necessary to run it is open source.
SV: Secondly, he points out that the open source technology built for android gives ample choice for schools to choose their own devices and to allows for a local entrepreneurial ecosystem, to come in.
PV: Why open source it? Because we want a local entrepreneur to say ok, I will give you ten open rap devices for your school and I will maintain it. And that means if something goes wrong, I will give you a small annual maintenance contract.
RV: And as for the lack of devices, Pramod says that there are many ways, but that the important thing is that states have choices. They are seeing states adopt different strategies from procuring smartphones for teachers, or providing a shared set of devices, to build a Diksha lab of sorts.
And this underlying infrastructure could be used across sectors, beyond education.
Sanjay Purohit (SP): A social platform brings individuals to itself and connects them. A societal platform brings actors and entities responsible for social infrastructure to come and play together. they of course in turn interact and work with individuals but it's important that the objective of the platform is not to define a solution and then have individuals come and play on it.
SV: Audacious goals can only be achieved one school, one healthcare centre, one teacher at a time. Sanjay Purohit, whom you just heard is the chief curator of Societal Platform, and he explains that a core value of this thinking is to let co creation drive solutions that make sense, that fit and reflect the values and the culture in which they are trying to work.
IG: The only way that you can be successful in scaling is there's two things, thinking about scaling your impact not necessarily scaling your size and the second thing is making sure that as you scale, whatever you're doing, whatever structures you are putting in place has to be aligned with your values. if it's not aligned with your values, things are going to go awry.
RV: The biggest challenge with taking good ideas to scale, is that the model tends to be too rigid, and too often top down, unable to adapt to the context. It’s an issue that comes up in many conferences, academic journals, and the brown paper bag lunches and watercooler conversations of social organisations.
SV: Thinking at scale using societal platform thinking is very different from thinking at scale. Building for the many is about kindling a sense of agency for all - it’s about opportunity, access, and affordability for all. As philanthropists Nandan and Rohini Nilekani explain,
NN: One of the key attributes of a SP is not the distribution of solutions. We're not saying this is the solution, we're distributing the ability for you to create solutions, so that’s really very important. That you’re empowering each organisation to create their own solution and that’s how you get scalability across a diverse environment.
Rohini Nilekani (RN): If we have to do diversity at scale, not diversity in small pockets, which can't discover each other, but if we have to allow diversity to play at scale, I don't see how we can do it without the use of technology. Information technology is what we are basically talking about. I think it can allow you to enhance precisely those things that we hold dear, at least that's why I am a convert. I think some organizations are coming into that belief system.
SV: In our final episode, we meet the people championing, and fostering systemic change and new approaches to big development goals. We‘ll hear from leaders across philanthropy, government and the social sector who are deeply invested in collaboration.