Guest blog by Dr. Amina Mohammed Baloni, IPP’22
I got accepted for the Implementing Public Policy Program following a late application, I had first applied for another executive program focusing on women in leadership positions which I thought would be interesting given my current work context. I was initially apprehensive as the course was a seven-month program which involved blended learning. I was not sure how I would cope given the heavy workload I had and the demands of my position coordinating the health sector at sub national level. Looking back, it turned out that this was the course that would be most relevant for my work! I am extremely happy I got accepted and it has changed the way I view the work of implementing policy. I am sold on PDIA and think it is the way to go. I wanted to learn firsthand how to implement public policy in a way that will provide maximum impact on the people who should benefit from it and this was exactly what I got. As we say in Nigeria, we have excellent policies, but implementation has always been a problem! To my relief, this wasn’t just a Nigerian problem but one which different countries across the world experience, whether they were developed or developing!
Key learnings
Our class was very diverse, and we were working on all fields of policy from education, housing, youth empowerment and even in finance. I learnt that implementing policy is challenging especially in the public sphere where there are so many different and contending issues from politics, leadership change, bureaucratic bottlenecks, and citizens interests. We learnt that though we were working on different challenges, we hand similar problems with implementation. Many policies were in existence but many more were never implemented. Very often, those in charge of implementation were disconnected from those responsible for implementing on the ground which meant that sometimes these groups of people were acting in conflict. Insufficient progress in implementation had the effect of making top level authorizers withdraw support from those seeing implementation through. As a result policies are abandoned and there is a rush to develop more policies that would suffer the same fate. Learning about PDIA and using its toolkit, gave us the opportunity to learn by doing, reflecting on what works and what didn’t, embarking on the next iteration, repeating the process again, all the time making incremental gains that ultimately add up to the desired change.
Implementation challenge
My implementation challenge was focused on how to improve service delivery in public health facilities. The health sector has a quality-of-care policy which had been existence for many years but not much progress had been made in implementing it. Public Health services provide a majority of the 10 million or so citizens in Kaduna State with healthcare, many of them out of pocket though subsidized for key populations such as children and pregnant women. The quality of services in public facilities are considered poor by many citizens, this was because of poor infrastructure, inadequate human resources of the right skill mix mainly concentrated in the urban areas to the detriment of rural areas where most of the population reside. Stock outs of drugs and commodities, poor staff attitude and low demand by citizens all combine to discourage citizens from accessing service in these facilities. This has led to poor health outcomes, with insufficient progress made in improving health indices despite many initiatives and interventions being implemented. For many years there have been concerted efforts to improve quality of care, policies have been developed, standard operating procedures have been put in place and many capacity building initiatives have been implemented but we still grapple with the problem.
Progress made and insights gained about the problem through the process
I gained several insights while working on my implementation challenge. First, stakeholders agreed that quality of care was a clear problem and we all agreed that it needed to change. It is also important to get as many perspectives as possible on the causes of the problem, this was achieved by talking to different stakeholders as management staff, those in charge of supervising frontline staff, the people that would translate the policy to day-to-day actions, those that work at facility level, the community and beneficiaries of the service. These conversations provided insights as to why some solutions did not work and what they envisaged would work. The fishbone analysis threw up many different sub issues which needed to be worked on to solve the bigger problem. I also learnt that though we had a consensus on the problem, there were different levels of commitment to doing the work required to bring change. It means that in implementing policy, there must be a concerted effort to rally the team round the goal by providing motivation through celebrating the successes and looking at the setbacks as opportunities to try new things that may work. It is also important to iterate in small steps and break the main goal into smaller goals to avoid demotivation when things do not go well. We must also ensure that our authorizers are kept abreast of our progress, or we may lose the political support needed to push through reforms and policies which sometimes take a long time to come to fruition. The longer a problem has been around, the more difficult it is to tackle, there are many setbacks and sometimes it feels as if no progress is made but perseverance is key. Complex problems can have many entry points and the nature of the problem changes as solutions are being implemented, for example my initial take on my implementation challenge was that it was a simple one but on drawing the fishbone with many diverse stakeholders, it became apparent that the problem was quite complex, and each sub theme had many other branches. Our fishbone changed and evolved as we continued the different iterations and learnings. Another interesting aspect was different teams could work on different parts of the problem and we could make progress faster. However, this requires good coordination of the teams and constant check ins to ensure that we are all aligned.
My approach to policy implementation in the future will utilize learnings from PDIA and its practical application. Digging out the root causes of any problem, wide stakeholder consultation to gain insight into different perspectives of the problem, forging a consensus on the goal to be achieved and most importantly making sure implementation level insights and concerns are given prominence as the success of any policy implementation depends on those at frontline to get it done. Learning from successes and failures to guide future iterations, fostering a learning culture within our organization, and communicating successes especially to authorizers to maintain support for policy implementation are key future take aways.
Already, we have incorporated the use of fishbone analysis to tackle our problems within service delivery and beyond. The four whys are now the baseline interrogation of issues and challenges. We have also reinforced our consultation across all levels of the organization and trying to break the rigid bureaucratic barriers and creating the psychological space for people to contribute, raise concerns and jointly tackle our problems in small steps, learning from our missteps and trying new solutions and seeing the result.
To my fellow PDIA practitioners, the road may be long with many setbacks but if we are to make lasting impact through implementation of policies, we must stay the course, dig for the root causes, celebrate the small wins, learn from the setbacks, and ultimately make a difference in the lives of people we serve!
This is a blog series written by the alumni of the Implementing Public Policy Executive Education Program at the Harvard Kennedy School. Participants successfully completed this 6-month online learning course in December 2022. These are their learning journey stories.