Applying PDIA in Meghalaya, India

Salimah Samji Welcome to the Reflecting on a Decade of Building State Capability Podcast series. On today’s podcast, I have with me Rebecca Trupin and Prateek Mittal. We met them for the first time in the spring of 2020 when they took our PDIA in Action MLD103 course. Welcome, Rebecca and Prateek. 

Rebecca Trupin Thank you. 

Prateek Mittal Thanks, Salimah, happy to be here. 

Salimah Samji Great. This is our first with two people, so I am really excited to have like two different voices here to share their story. So I recall that class very well in 2020 because you were one of the teams that came in with your own problem that you wanted to work on maternal mortality in Meghalaya already in that time period. And I just wanted to just ask, how did you come to that problem and what were some of the motivations you had for taking our PDIA in Action class? 

Rebecca Trupin Yeah. So I think, partly in my case, motivation to take the course was really wanting to get closer to implementation. And what does it mean to be a government in charge of needing to solve an important problem? And so that was just something I hadn’t experienced before. And then another aspect of it was we had done an internship in Meghalaya, and so we met the person who became our authorizer and later our boss, Sampath Kumar. And he, being in charge of the health department, he had this issue of maternal mortality that he was dealing with. So it almost sort of seemed like the pieces were coming together, that here was a problem we could work on together with him. 

Prateek Mittal That’s pretty much it. I think in the rest of the program, I think there was a lot of thinking we had done about specific ideas, interventions for poverty or different issues, but the how was often missing, or at least it was not always clear that how does this happen? And I think PDIA was one of the courses that we thought was really trying to get into, like, how does action happen? Like, how do you sort of start from day one? So we thought that would be a very good complement to all the theories that we were learning in the other courses. 

Salimah Samji Great. So you took this class, you know, it’s a seven week module. And what was your experience in the class? You came in with a clear idea of what you wanted to get out of this class. 

Prateek Mittal Right. I think it was quite surprising just how much we could learn about the problem even in a short span of time. I think initially at least, I was not really sure like how it’s going to work. Like Sampath is in Meghalaya, we were taking the class from Cambridge and there’s a huge time zone difference. And still it was quite surprising that a number of people we were able to interview and how much you were able to uncover about the problem. I think that was quite striking. I think just having that structure that PDIA had about how do you deconstruct the problem, what kind of questions you ask to understand what is the landscape, what is the authorizing environment. I think all of those provided us very meaningful and useful ideas on how do we start to understand what’s happening. And I think you very surprising how much you are able to learn in such a short span of time. 

Rebecca Trupin Yeah. The fishbone analysis that we created during the class is something that we continued to use even like three years later. So it was really possible through that format to dig in quite deeply as to, you know, what are the different causes helping to contribute to maternal mortality. 

Salimah Samji That’s impressive. The fishbone that you start in the classroom still gets used in practice in the context three years later. So, you know, you did this class and then you graduated because this was your second year. And where did you go from there? 

Rebecca Trupin Yeah. So I think it was Sampath probably on one of our calls toward the end of the class probably, who suggested to us, you know, you can come here and keep working on this. And I think initially it felt farfetched. But as time went on, we started to actually look into it. Would it be possible and, you know, how might we actually turn this into a job? And it took a little while. It was also Covid times. And, you know, visa processing was difficult, but we managed to actually make it work and to join him in Meghalaya. So we graduated me and then I flew to India in October. We landed in Meghalaya, I think November of that same year. 

Prateek Mittal Right. I mean, one thing I would add to that story is that I think after graduation, it can sometimes be tricky to just think about what you’re going to do, where you’re going to land up. And I think I remember having a conversation with Michael Woolcock, who had been a mentor and also an adviser for large parts of our thesis, and he was stressing on how important it is to be with the right team because there are many different problems and many different contexts, and all of them are very interesting. But getting an interesting team means that you will learn a lot. And I think we felt that way about Sampath and some of other people we’ve interacted with in Meghalaya that is really interesting. These people are very motivated and we just thought, I think we’re going to learn a lot. So I think that, you know, give us that push to take that gamble that you have just going to land in Meghalaya and we are with good people so we’ll learn something. 

Salimah Samji It is. It’s actually pretty remarkable, right, that that option is available. But I would also say that it takes courage to be able to go with I will definitely learn something as opposed to I don’t know what this is going to be like if I do take this on. So I think both of you were extremely courageous to be able to do that. So you get there in the fall of 2020 and then what happens? 

Rebecca Trupin Well, we basically hit the ground running. I mean, I will never forget walking into Sampath’s office the first day and he immediately had work for us to start doing. 

Prateek Mittal Right. He had a lot of ideas. I think we had some ideas about how we’re going to start doing some PDIA kind of work. Initially, we were thinking about doing some pilots and I think very quickly he got us into the territory of like, no, this is about systems change. So usually will be operating at scale and we need to start working right away. So I think it was kind of like a shock treatment, okay, this is real. It’s going to start happening. And I think even as soon as December, like almost in the month after we landed, he had us organize a pretty big workshop on PDIA for district collectors in the state. So he invited district collectors and district health officials. And we did this our first PDIA workshop, just like a month after we landed there, which I don’t think we anticipated that quickly. 

Rebecca Trupin We definitely didn’t anticipate. I mean, that was actually really an interesting learning experience because we had about four hours, I think a little bit less than four hours to run through an entire PDIA sequence. To be like, here’s an introduction to PDIA. I don’t know if you guys want to include that in one of your course modules at some point. It makes you really learn what does it mean to go through the sequence and it makes you really think through what are the important parts of each step and what is valuable about it? How do you want to think about it? So that was a really great exercise for us and they responded really well. Like we were actually, I think, quite shocked to see people who are used to being in meetings where just one person is talking and kind of lecturing and they were getting up and participating and writing on flip charts and writing on footnotes.

Prateek Mittal Yeah, the level of engagement was amazing. I think how people were really playing with it and getting into it and finding a lot of useful insights from it was, yeah, something that we could not have predicted. 

Salimah Samji You know, you talk about having an authorizer because you already did a summer internship in Meghalaya. How was he open to this idea? Because, you know, when we talk about doing PDIA, we usually have three things that we look for as what we say are non-negotiables. And one is an authorizer with an itch. You had that in Sampath. A problem, you had many. And then a team. Right. Because these are problems that you cannot do alone. You need a team to be able to solve this. So the authorizer part, how did you convince I mean, it’s incredible that you landed and a month later you were doing this workshop and getting, you know, the rubber hits the road immediately, but you had that piece of authorization. And what was it in that relationship that made him open to saying, yes, I need a different approach to this problem?

Prateek Mittal I mean, I can start. So I think one thing that’s interesting is that particularly to very senior bureaucrats who have been practicing for a long time, I think there are many elements of PDIA that really resonate even if they haven’t been using the language. There’s almost like a sense of familiarity that they already have about how change happens and where does it get stuck. So I think honestly, I don’t think we had to do a lot of convincing. I think a lot of what we were talking about, I think a lot of authorizers were already quite convinced that it’s important and that it doesn’t happen enough. Even though everyone recognizes the value of exercise around constructing a good problem, being able to diagnose it pretty well, being able to think about what is working even within our own context, like what are the positive deviances, even without having the language. I think people appreciate that. It just doesn’t happen often enough, so we didn’t have to convince him. He was just like, How are we going to institutionalize this? What would it take for this to stick as an organizational practice? And I think that’s where the challenge was, that that’s where we met him. 

Rebecca Trupin Right. I think his biggest question about what we were doing was not the content of PDIA, but would we have the right approach to be able to bring others along. And so, in fact, he did sort of give us a try out first before throwing us in front of the district collectors with just a smaller group of health officials. And that went quite well. And so we did the same thing again then but, you know, on a larger scale. And that remained and still remains today the central challenge that I think that he and we face is how do you not just sort of bring people on board but also keep them there and maintain that momentum. 

Salimah Samji Great. I love how you iterated even on your workshop. Try it on a small scale before you run with your district collectors. So they come, they feel engaged. And then what happens? 

Rebecca Trupin I mean, so then the subject was maternal mortality and infant mortality. That was the topic that we came in with. And then a key part, I think that also one of the parts of PDIA that really resonated, that resonates with Sampath but that resonates with other authorizers is this principle of regular meetings, regular reviews, weekly meetings. So that was something that fairly quickly. So, you know, Christmas holidays came, everyone went home. We came back in January and almost immediately started trying to institutionalize a process of reviews. And so in some ways, it mimics the PDIA weekly review process. In other ways, it was a bit different. So in a way, we had nested PDIA teams in Meghalaya. But one thing that was also, I guess, unusual, unexpected for us, a bit of a challenge is that the boundaries of those teams were not very strict. So we had sort of a team at state level, which really included Sampath, but as not just an authorizer, but a team member and several other important folks in the health department. But then we also had teams at district level. So when we had that first workshop, it was almost with sort of the proto PDIA teams. And then those teams kept coming back together. So for a while it was weekly, especially during Covid, because the subject was not just maternal mortality at that point, but also dealing with the Covid pandemic. And so you had essentially kind of like 11 district PDIA teams of a sort coming together, reviewing what is the data showing about what’s going on, discussing what sort of problems they’re running into in terms of implementation, what are they trying in a way, using the PDIA sort of questions, sometimes deviating also. But we had that practice starting up and then we as the PDIA team at state level started iterating a lot on the format of that meeting. How to use that meeting so it would actually discuss the right sorts of issues and not get stuck or not sort of go off into a tangent, but really unearth where problems were happening and try to pull them apart and try to diagnose them and understand them. 

Salimah Samji And what did that lead to? All of this iterating and learning along the way. 

Prateek Mittal Right. So I think eventually what we got was this system of regular reviews, which I think, and these still carry on, so I think is almost like an organization practice right now. And what is happening right now and has been happening for some time is that we have these different district teams who make their own presentations about their own data on middle and child health indicators. And in the process, they present what they see are the challenges and what are they trying to do to get around them. So very similar to like a PDIA check in that, you know what is working well, what are we struggling with? What are we going to try to do next? I mean, something that happens with varying levels of success because, you know, sometimes it’s harder for people to talk about challenges. Sometimes, you know, it’s just about the data. But I think what has happened as a result is that people have gotten much more comfortable talking about data. And I think that’s kind of like a spillover impact of PDIA, is that it makes you more comfortable to use data in your problem. Right. Because you’ve deconstructed it and you’re better able to say we are getting these maternal deaths because this is a problem and this is how we can use data to share that story. So that happens a lot. And the other thing that has happened a lot is people talking a lot about the problem. So one of the things that Sampath really tries to push is that we should not talk about schemes. We should talk about problem solving. He keeps trying to push start. You know, as implementers, we are not implementing schemes, right? We are here to solve problems. So if you don’t solve problems, there’s no point in someone telling me that this so-and-so program, the scheme was implemented. And in health in particular, we have seen this change over time is that people do talk mostly about the problem now. So there was a time when, you know, scheme implementation was still the metric or the indicator on how people would assess their performance and how they will tell the story of what’s happening. But now people tell the story of what’s happening to problems, right? So we start with what went wrong and what are the indicators that actually matter. And then from that we initiate the conversation, right, of where we are and where we want to go. 

Rebecca Trupin Right. And we did see people starting to respond to this sense that they had more experimental freedom and that they were expected to try different things to solve problems at their different levels. And one sort of push that kept coming from the state was that you at your level, you can also solve this problem. You don’t simply have to pass the buck up the chain of command and assume that somebody, if you a block that district will solve your problem or if your at district state will solve your problem. And of course, state has the default of Delhi will solve our problem. But so all of that was being pushed in a different way. And so we saw, you know, some quite interesting experiments. One of the issues that keeps women away from delivering in hospitals, for example, which is one of the drivers of maternal mortality, is sometimes around, say, traditional practices. And so there’s a belief among some groups in Meghalaya that you don’t want to cut the umbilical cord with any sort of steel or metal implement. It seems sort of basic, it seems potentially small, but it was, you know, having an impact on whether people were comfortable to come to a hospital for delivery. And we saw experiments where they found that if you have a sterilized bamboo implement, people are more comfortable with it culturally and maybe more willing to come to hospitals for delivery. So you saw sort of interesting experiments like that where people are really sort of taking ownership of a problem at their level and trying to find ways to get around it. We also saw that at state level, they were able to think much more deeply about what was going on. And so it really engendered a lot more creativity also from the state of just what are some of the things that we can be doing to overcome challenges. And so a major program that came after about a year or year and some months was something called the Chief Minister’s Safe Motherhood Scheme, which really tried to tackle something that has been reoccurring again and again. But no one had sort of figured out how do we one, highlight the problem, identify it, and then actually start working on it. And so this is a program that provides funding for medical officers at primary health facilities to be able to bring women to facilities for delivery. It also provides funding so that health workers can reach hard to reach villages. And finally, it also has provided funds to set up basically transit homes, places for people to stay close to the facility so they can come in advance. And these are run by self-help group movement. So there’s many different sort of innovations that got put together in this program. And it’s something that is regularly spoken of by officials at different levels as being a game changer in the way that they’re able to work. It’s just provided a lot more freedom and flexibility for them. So things like that have been really exciting to sort of watch develop out of the system. 

Salimah Samji This is really commendable. I think there are several things that I’m taking away just from what the both of you have just said. One Prateek this point of moving from a scheme, you know, for our listeners who are not familiar with India, India runs a lot of programs and they call them often centrally sponsored schemes or just schemes in general. And there are programs that they offer to people and they tend to often be a solution to a particular problem that is one idea that you could use for this problem. So I think even turning that on its head to we’re not going to be solution focused, let’s not chase a scheme if it isn’t delivering the results were looking for, but let’s flip it around and start with the problem. What is the problem the scheme is trying to address? Right. And I love how Rebecca, you kind of finished that tail end of this conversation with that led to creating a completely different scheme, which is a solution or an idea, but based on the learning of what was happening. And also this point of reminding people in government or outside of government, whether they’re the mothers themselves or the public health workers going out to talk to these mothers who are having children, that they are agents of change and they do not have to sit there and wait for something to happen that they can create things, that they are able to do that. And I think that’s really incredible to hear. Because one of the things, you know, when we were trying to decide 11 years ago what to call our program capacity was a word people use often, and we chose capability because of that empowerment factor. It’s not just capacity. It is that empowerment. It is that agency. Because when you give people that agency, it is unbelievable what they are actually able to do with that. 

Rebecca Trupin Yeah, very much. That’s something that I would say was a learning for me coming into this and starting to do it on the ground in Meghalaya was this question of sort of who is in your team, who is part of that group that is innovating? Because of course, you know, in the classroom setting we are obviously limited by who we can get, who we can speak to. But even after we arrived in Meghalaya, something that was very striking is that unlike in many cases, many officials may just sort of stay in the capital. Sampath is someone who regularly goes out to the field and goes as rural as he possibly can, which is in Meghalaya, very, very rural to connect with people who are as close to the problem as you possibly can be. And so that practice, that piece of PDIA of, you know, bring the people who are close to the problem, bring them in. It’s one thing to sort of state that. It’s one thing to sort of practice it part of the way. And some people think, okay, maybe if I’ve gotten a few government officials together now, I’ve got the people who are close to the problem and Sampath kind of taught us actually no there’s another level that you need to be thinking at, and it’s not enough to think about it once either. You need to keep thinking about it and keep going back. So it’s now become something that is really kind of enshrined in the approach that Meghalaya is taking, this concept of field visits of just make sure that you’re doing them very regularly to all different parts of the state, engaging with as many people as possible, including people who are not just in whatever sort of particular department that you may think of as involved. So Sampath has also charge of a few other departments, the Rural Development Department and another department dealing with women and children and sort of another innovation that he brought into the process we were doing around health reviews is adding those departments in. And so that’s been something that has happened over just the past year and it’s been quite remarkable and definitely a challenge because it’s not something that many states are used to doing. How do you get departments that are used to operating separately with their separate programs? How do you get them to come together? So you have those challenges of horizontally, how do you come together to collaborate? And vertically, how do you come together to collaborate? 

Salimah Samji Yeah, that’s, it’s actually quite inspirational to hear of all of these changes that are happening also incrementally and as you learn. But you know, this idea of talking to people and we also learn ourselves and we also iterate over time. And one of the things that we absolutely do in the class that you took now is every student has to talk to at least two people every week for them to realize just how valuable it is. And we don’t put limits on who the person is because we’ve seen ideas are everywhere and people get ideas from any conversation. They don’t even have to be people who are involved in the problem. It could be in Sri Lanka, someone’s father. That’s a real story. In in one of our classes, it was the child of the participant who was the student in the class who had an insight from their child. It is just about being open to having conversations about these problems that really do allow the emergence of ideas, of discussion, of thoughts. And once you get bitten by that bug, that’s it. You are forever transformed and you will never take this status quo for granted. You will constantly review and check. We were working with a city team that was working on the problem of homelessness, and I have a distinct memory of one of the participants who was on the police force. He said they were out in the area where there was homelessness. It was raining and he had a thought, You know what, we’ve never asked the people who live here what they think of this homelessness situation. And in the rain, he says, I’m just going to go across the street and knock on the door and have a conversation with the guys there to ask them, What do you think about this problem? And he said it was a transformative thing that he did. But again, it’s that kind of experience that when you see what can happen when you talk to somebody else about this problem, it is often always magic because you will learn something that you did not know. And the more you do it, the more value you derive from it. 

Rebecca Trupin Yeah, I think that’s one of the very intangible and extremely important parts of PDIA that I also wouldn’t have predicted before I started it. I would say it also it does remind me of something that is a challenge that I think we continue to face, which is that because there’s something experiential about PDIA, where once someone starts to experience doing it, then only do they, and the more they experience it, then only do they come to really understand how profound it is. Whereas and I think this has come up in other discussions you’ve had, if it’s just described to you, you may think, well, this is common sense. We should of course we should do these things, but it’s another matter to actually do them in practice. And then then you start to realize. But that has also made it challenging to tell the story. So that’s something that we still also find it challenging in Meghalaya that, you know, when we’ve had successes, say with reducing maternal and infant mortality and there have been some pretty significant reductions recently, but it is very hard for people to describe how that happened and why that happened. There tends to be sort of an impulse to say, well, you know, we did the solution and then the listener and even the teller will sometimes focus on the solution rather than the process that was the real innovation that got them there. So that’s something that we continue to find a bit of a challenge. How do you do that? Because there’s something just so experiential about it. 

Prateek Mittal Yeah, and same is true for field visits. I mean, because when we talk about, when Sampath would talk about, you know, we should go on field visits, I think on paper everyone agrees that, yeah, we should. A, it doesn’t happen often enough. And when it does happen, like I think almost every field visit that Sampath goes through and I don’t think there’s a single one that he feels like he didn’t learn something very new and very useful. And I think most of the time he would call us either on his way back from the field visit directly with you. Like, I have so much information I just want to download you guys because I just learned that this and this and this is happening this and this and this is not happening. And you know, and I think every time he finds so much value from it. So I think it’s again, like people feel that it’s easy to discount processes like PDIA because they sound commonsense sometimes, but because it doesn’t happen often enough, the story can sometimes get lost. And even if it does happen, people might fixate on a particular solution, as Rebecca said, that, you know, maybe it was this particular program and that’s how we got reduction in maternal deaths and we’re trying to tell the story that, no, it’s because all of you guys took the initiative and you were trying different things and you will have to keep doing that. This program is working now. In the future, new sets of problems will come up. And the idea is that is the organization capable to keep doing PDIA when it needs to, to be able to come up with new solutions for new problems. But it’s not just about one time, one problem. Right. It’s about building a habit of solving problems. 

Salimah Samji Right. It is really about building the capability to do this. If you could do it for one, you can do it for many more. That doesn’t mean that it’s going to be easy. And each problem or parts of the problem will be challenging in different ways. But yes, that muscle that you build. Right. And it really is about muscle. But I think to your point of PDIA is experiential is a very important one. So there’s two parts to that, and I’m going to kind of chat about both of them. One is the PDIA is experiential. And then the second one is how do you talk about success in PDIA? So I’m going to start with the first one is PDIA is experiential. You know, in 2015, we offered our PDIA online course for free for the first time. And what we learned is we had two different audiences. One was people who wanted to understand it conceptually and others who wanted to do it. And so we went from one course to two courses, and one was a conceptual one, and another one was do PDIA. Right. So people who actually have a problem will work in a team and work through the process and understand the process. And we offered it only twice the conceptual one because it became imminently clear to us that this is not conceptual. People take away the wrong things they completely don’t understand. And we shut the course down. We continued the other practical course till 2019 when we decided we were going to take a break and think about what we wanted to do with this course. And so we had already had that experience. And one of the reasons why we decided that if we were to teach PDIA, we don’t do workshops because we can talk until we’re blue in the face, nothing’s going to change. And I think this leads to the second point that you had, which is how difficult it is to talk about success. We are, as humans, so hard wired to sell solutions. We are so hard wired to find that champion who’s going to save us. And if you look at any successful story, it is never one person. The narrative is always about that one hero or heroine that comes and saves this, not how it actually takes. We like to use the word multi agent leadership like there is no problem that has had only one person that solved it. Whether it is we like to use the case of Singapore, whether it’s Lee Kuan Yew, it wasn’t just him that led to the success. It was a variety. And we can name all of the people who led to it. But no, no, no. Most people will say, no, it was only this person. And that’s just not how success happens. But I think there is this idea in people’s heads that they want a simple story, and complexity is too difficult to be able to deal with, even though that is the reality of the success. And it’s much easier for people who don’t value process or don’t understand how process is everything. It’s not about the results. It’s the process. If they don’t understand it, it’s very difficult. So even the people that you are saying who haven’t done the experience of PDIA to start to value it, they’re only going to look for the solution because that is how they’re hardwired in their brain. And it’s not right or wrong, it’s just the way they are. And until they go through this experience, do they really realize that no, actually, it’s process. And while we can’t replicate that particular solution, we can replicate that process again and again and again and again. And it will lead us maybe not the first time, maybe not the second time, maybe not the third time, but maybe the fourth time it will get us to where we want to go. And that’s what we’re really in the business of teaching. And I think also it’s not for everyone. I think it’s one of the things that we also say and why even within the Kennedy School, we tried to teach PDIA in a core classroom and realized we can’t do that because they don’t want to learn this, and instead created the PDIA in Action class which is an optional. You choose to do this. We cannot force it down your throat. You have to be open to learning a different way or be an authorizer also, like Sampath who’s seen that what you’re doing isn’t working. Like we are failing and we are failing every day. We need to do something different. That’s when they can be open to try a different process. But forcing this down someone’s throat is not an effective strategy for PDIA. 

Rebecca Trupin Yeah, I mean, definitely that resonates with the experiences that we’ve had. I will say the one thing that’s been interesting is sometimes it’s unexpected who will take it up. Like, sometimes it’s hard to predict. And so, I mean, one of the surprises in Meghalaya is that political leadership has often been more receptive for some reason of this idea of like, how can we basically how might we do some sort of radical change? Like, let’s try something just totally different, totally new. Whereas, you know, beforehand you might have thought maybe they’d be the least receptive, but actually they’ve been quite receptive. But something that has definitely been a challenge to what you were raising is just the sort of assumption that there will be a leader somewhere who is going to just fix everything. And so something that we also struggled with as soon as we arrived is almost you could say it’s a lack of people, a lack of team. You mentioned the non-negotiables that you all have for working. So we were missing one of those in a sense. I mean, not fully missing. We had a team of high level people. But something we’ve often found is that there’s sort of a missing middle. You have almost like an hourglass shape to your state where there are a number of people at the top. There’s a huge number of people at the bottom, at the front line. And then you have this sort of narrowing of the middle where the middle management should have been and they’re just sort of not there. So that’s sort of something else that we’ve been working on, something we’re hoping that will sort of stay behind us, which is a team that we’ve been slowly building together with Sampath of people who can sort of help facilitate the processes who have, you know, had the chance to experience PDIA like processes over the last several years in different sectors. And who are there to support authorizers and also champions in the system. But even that, of course, that is its own sort of PDIA process of how do you build up this group of people? And it’s definitely not something I would have predicted would need to be done before getting involved in this. I sort of assumed well, you build your team out of whoever you happen to find who’s there, but not this idea of, well, actually, sometimes you’ll need to sort of create your team from scratch if you find that there aren’t people there to sort of help draft guidelines, help document what’s going on in the field, help put together programs. If those people aren’t there, you may have to actually create them from scratch. 

Salimah Samji Yeah, I think that’s really beautiful because just like authorization where you may have it, you may not and you need to build it, The team is similar, you may not have it and you need to build it, but just like authorization, just because you have it doesn’t mean it’s going to be there forever. You have to maintain it. And that also requires effort. And the same with the team. You have to maintain it. And I think something that you said earlier is then you struggle with keeping them motivated. And that is just a fact of life. Yes, teams have moments of up and they have moments of down. And working in the team is not obvious and it is not something that is taught. And without wanting to generalize, many people do not have good experience of working in teams. And so this is something that is a craft and something that needs to be taught also of how do you actually build psychological safety, which is something Amy Edmonson talks a lot about. How do you build psychological safety in your team so that you can actually the hole can be larger than the sum of the parts, which is what you want a true team to be, to bring your full self so that these ideas can emerge, so that you can have innovation. And that becomes really, really important of how you teach teams to just stay on course and how you motivate and how you support each other. But also it’s not just psychological safety, it’s also accountability that becomes extremely important and not just accountability to your task, but more than the, you know, Monica Higgins, who works with us on one of our programs, talks about internal accountability or felt accountability. That in a team is much more important is that as a team member, I am committed to my team, right? Feeling that accountability, that I am letting my team down. Or can I ask my team for help because I can’t do what I was supposed to do this week is really important aspects of this, and this is hard work. You know, policy is about people and it takes effort to be able to figure all of these things out because we are not all the same and the world is better because we are not all the same. But that just requires a lot more effort. 

Rebecca Trupin Very much. Yeah, I think that is definitely one of the biggest learnings. I had no idea I would get involved in hiring processes and just team building processes to the extent that we did. But it is also one of the sides that has the most reward because new people coming into these environments like we were talking about with field visits, they bring in new ideas, new perspectives, new ways of doing things, but very much, as you say, like so in Meghalaya, we talk a lot about accountability and agency as sort of two halves of the same whole that you want to provide through a lot more agency to people, but that accountability has to be there at the same time to balance it. And I think the nuance also that you’re mentioning about that that should be felt as a team is really critical. And it just feels that so often when we run into an implementation challenge, it’s because something fell between the cracks of one person passing it to the next. A lack of team basically is oftentimes the root of many different implementation challenges. 

Prateek Mittal Yeah, I mean, so to like just go off of that a bit I think where we are in Meghalaya right now. I think we started with some specific problems that you know, maternal mortality was a big problem. And then even in health systems the work expanded a bit to think about, you know, non-communicable diseases just generally about how do you set up a primary health care system. It branched out to early childhood development. So like because there are many different portfolios that are connected to this. So we found ourselves looking in many different spaces and trying to apply similar principles in each of these spaces that we entered in. And then, you know, I think  more like over the past year, we realized that our presence in the system is still temporary, right? And so we started thinking a lot more along with Sampath about how does this become an institution, Right. How does this become like a practice? And so that’s where the push came that we need to build a strong local team, right. Which has practiced this, which has done this in different domains, and they continue to support the state moving forward. And we went on, it felt like we went on a hiring spree, but like we onboarded many people and that’s the sort of stage that we are in now. Where we ourselves are mostly in the back seat right now and sort of working with very motivated young professionals that we have from the state who are learning about PDIA, who are learning about the state, who are learning about different programs, who are doing literature reviews, you know, who are just doing everything from scratch, but taking it on beautifully in many ways. Like, you know, for instance, we have a team which has almost single handedly designing the early childhood development mission, right? So they’re learning about the literature. They’re picking up different ideas. They’re going to different places, learning about what what’s trying things in Meghalaya. And I think that’s been in some ways a very rewarding part of our journey there, where we have tried to build these teams, which are now taking on the part that we were playing so far, to just be able to transition it to them and have them then facilitate the learning and adaptation process locally. 

Salimah Samji I think this idea of how do you create sustainability is a really important one and how do you institutionalize a process? And it has to be the government themselves owning it and taking full ownership and having a team. And you know, we like to use Marshall Ganz’s Snowflake Idea, where there is a core team in the middle, and then there might be multiple teams around that where one person of the team is also a member of another team dealing with something else. And that’s how you kind of really build your team structure to be able to cover the area of what it is that you want to do. But something that is really owned by the locals is really important to sustainability and something that they really do believe in. And I really like your point of view, are now in the back seat and that’s really important, right? In PDIA, when people say, you know, are you a consultant? We hate the word consultant because that is not what we are. We like the word coach because a coach can stand back, can train you and then can leave. Right. And another thing is, sometimes we say we are therapists because we are there to tell you it’s okay, it’s gonna get better, you know, or are there to celebrate when there are moments to celebrate, but never one that’s leading the work. You know, another thing that we like that we take from Heifetz is give the work back. We don’t do any work either. We are making sure that the teams themselves own their work and do the work themselves. So it really is great to be able to hear how you are thinking about this entire process. What are some surprising things that you’ve learned through this process? You know, you’ve actually done a lot in the time period since you graduated, and it really is commendable that you took this, especially learning about how this opportunity even came. Right? It was like, hey, do you want to come here? And here you are to come in to kind of make progress, to actually reduce maternal mortality, to come up with new schemes. And that’s just a few things that you’ve said, which is just really extraordinary. 

Rebecca Trupin Yeah. Gosh, I mean, there’s really it’s hard to answer what we’ve learned in a way, because it’s both hard and easy, because this is by far the most learning I’ve had at any point in my life. There was sort of a before and after coming to Meghalaya and I think sort of a meta learning about all of that is just that It seems extraordinary to me that it took a chance like this to get immersed in this way and to get this kind of exposure for me, I mean, speaking just for myself, I had a fairly privileged upbringing and had access to the best schools and all different types of exposure. But never did I have exposure of this kind. And I think it is the kind of thing that, say, many grads of prestigious programs would dismiss this kind of opportunity to be embedded in a government, whether it’s state, whether it’s local government, city government, then actually trying to deal with real problems and real people in places where you actually have real accountability for those things. It’s not theoretical and there’s just somehow no substitute for the kind of learning that that can involve. So it’s just one of my big takeaways from the whole experience is just the the level of development that most of us have not reached. The person I am now versus the person who started the MPID program at Harvard is just completely different. So that’s just one thing I would say to start off with. 

Prateek Mittal Yeah, I think we learned many things. I think in a way it helped us that we didn’t go in with a very strong agenda of this is a very particular idea that I’m trying to implement. And so it was good that we just kind of went there. And I remember our first meeting with Sampath and we were like, okay, what should we do? And the only thing we have here is we’re here. But apart from that, we don’t have any grand plans that we’re going to do this very particular intervention, or we have this particular data dashboard that we’re going to implement now and it’s going to solve problems. I think it helped us initially that we were also a bit confused. We’re like, we’re just going to show up and see how it goes. And I think it gave us space to just absorb things that they came along. We’re just learning things every day about how policy making happens, how on the fly sometimes things become. So I think just getting exposure to that was very useful, I think. It’s interesting that comments are a very common thing that people see about governments is that they are slow. There’s that red tape and all of that. And I think comments are very interesting. Sometimes they can move incredibly quickly. So I think it’s like when there’s purpose, you know, as Lant would also talk about things happen and it’s remarkable things happen. Right. Just an example. I think we got ten Kennedy School interns and many of them were working on our then very initial early childhood development mission. And just within a few weeks, they were pulling in the best research there is on what are the best practices on, you know, ECD like and talking to a lot of local stakeholders and were able to pilot some ideas just so that we can learn about what works, what doesn’t work in Meghalaya. And like all of that happened just in a span of two months, right? So, you know, when there’s purpose, we were able to cut through a lot of red tape and just make things happen. So I think it’s not so much surprising, but it’s still very telling for us is that a lot of this work is just about building purpose. And when purpose comes, a lot of things flow from that, right? People find very creative ways, even in governments. Governments can be extremely creative and actually they have to be creative because they operate in very strict constraints. They have all kinds of constraints around procurement and everything, right? So but they can be very creative when they start operating with purpose. But building purpose is hard. And I think a lot of the PDIA process is about going back to the problem idea. Our purpose is to solve that problem. And once you do enough of that, sometimes the job is kind of done. 

Salimah Samji I love that purpose is just so, so, so important. And sometimes we like to use the word public value. A lot of people who are working in government are there for a reason. They do care about citizens, right? But sometimes because of bureaucracy, because of a variety of reasons, they might have lost that spark that led them to doing this work. And what we find time and time again, when you put them back in touch with why they joined public service, you reignite that spark that was already there and then you can just set them off. But another thread that I also heard and what the both of you have said is that openness and that curiosity and that really is so, so important because we often make assumptions. The politicians will not be interested in this, right, Rebecca? This is how we’re going to see and we are often wrong. And so when we just lead with curiosity, we lead with the learning lens, lead with let’s ask. We have nothing to lose and see what happens. You initiate a process that you could never have imagined, just like when you did saying, Yeah, sure, let’s go to Meghalaya and at least we’ll learn something. You didn’t realize at that point It would be like the biggest learning of your life and will really transform who you will become at that point. But you did take that leap of faith. That openness, that curiosity to just learn and experience. But Prateek to your point, many people do say that governments are slow and I agree with you 100%. Our experience is no, that’s not true. They can be fast, but they need motivation. They need purpose. They need public value. They need something bigger. And it’s not incentives of money or pay them more. That is not what’s going to drive them. It’s more intrinsic things of purpose. Why am I here and how can I help others? Because that’s why I’m working in government. That was why I came here. Anything else that you want to share with us? You know, whether they may be challenges, learnings, insights that you’ve had. 

Rebecca Trupin Yeah. So, I mean, one thing that’s related, I think, to the challenges that we’ve faced in how we build teams is how we also sort of fund this work and fund the building of teams. And so one piece that’s been very important for Meghalaya, I think it’s very important for states around the world and definitely states in India, is getting sometimes external funding in order to do experiments, in order to do innovation. So for that reason, there have often been external projects, externally aided projects that have been the catalyst for some sort of new innovation that the state is going to do in public services. And so in that process, you know, there have been some really great things that have emerged. One challenge that has emerged is that because there is sort of this lack of acknowledgment of the importance of team, there’s also oftentimes just sort of a lack of acknowledgment of, you know, of how how would the state actually build that capacity, build that internal capacity. And so the way this is often manifested is the default without, say without funders, the default is that someone in Sampath’s position often has to bring in a consultant to, say, design a new program. For instance, designing the early childhood development mission or any other type of mission or innovation. So that is often a default. And we found that unfortunately in many cases, funders, when they do come, they actually perpetuate and reinforce that tendency to bring in an external person who will just temporarily design that. And we found, you know, that this is problematic in several ways. One is that oftentimes, of course, the consultant lacks the context and lacks connections. And so they’re going to design something that is probably a best practice from elsewhere. But on top of that, even if maybe it’s something that in theory, it might have worked in Meghalaya, it often will lack the local buy in to really actually take off and be a success. The other aspect, of course, is that the consultant is not going to stay or are not going to stay very long to help the state iterate things, sort of lose iteration from the get go. And then finally, it’s a missed opportunity that the state could have invested that experience of how do you design a program and how do you start implementing it? And then how do you start adapting it? All of that experience could have been kept in the state, could have been nurtured within people who are going to stay, who are permanent members of the state, who can then apply that to the next problem they want to solve. And so all of these are aspects that, you know, we’ve been in discussion with outside donors and supporters. And some people, we find they’re getting the idea, but it’s still something that is still very new somehow to the general international aid world. And it’s a bit baffling. 

Prateek Mittal I mean, so I mean, to just add to that story, I don’t think there’s any aid agency which would say that building state capability is not a priority for them. I think usually many aid projects do sometimes have a dedicated component. Also just like building capability or capacity building. You know, it could be named in many different ways. I think what can sometimes be missing is how. Right again, like sometimes the intention is there, but it’s not really clear what we do here. And I think we may need a PDIA just for aid agencies like, you know, how do they start working with governments? And I think for us in Meghalaya, at least one thing that we thought would be good is that we want to have a strong local programs team very early on and have them take the lead in designing the project. Right. And the idea here is that if they design the project, they will also take ownership of change and adaptation that has to happen, right? You’re not going to get it right. ECD mission is going to have challenges. Other mission goals are going to have challenges. But if you have a team which has defined it, they are in a much better position to also make those changes, to learn about what’s going not going right and to make those changes. So they’re not just coming into a program that has been predesigned and their role is just to implement, but they are actually in the driver’s seat from the beginning. So I think that’s just an example of a practice that is working for us, right? And sometimes there is resistance because sometimes the team you get, you know, they’re young professionals that people are like, these are not experts with decades of experience already. It’s like, that’s fine, that’s completely okay. They can work with those experts, right? We can get those expertise. They can guide them, the experts can guide them. But we still want them to be in the driver’s seat. But I think we need many more such practical ideas of how aid agencies can better work with governments on building state capability. 

Salimah Samji I really love your idea of we need to PDIA how funding and aid agencies can actually work with governments. And I think you know the point that you make is you are 100% right, all of them really say they care about building state capability, etc.. But if you look across the spectrum and we’ve all at building state capability in our prior lives worked for some of these aid agencies so are very familiar with them. They create projects, they build scaffolding and never ever lay a brick. Not one. So that when the project ends or the consultant leaves, you pull the scaffolding down and nothing is there. So if the idea really is to build capability, then you need to think very differently. And I think there’s no one answer. And it needs to be something that needs to be clear. And I wonder if it’s even thinking about return of investment. Right? You talked about using data. If you just look at the amount of money that has flown in on these consultants to do things and nothing has changed, maybe that can be something that’s illuminating for them to see. Okay, maybe if we hired people here to do this, to actually work here, that might have led to better than this, because this is nothing. We put up scaffolding, we pulled it down. There’s nothing to show. And it’s not about what they did while the consultant was working. It’s what was the problem they were trying to solve. And have we solved that problem? Like what progress that we made. That’s the metric to be measuring. Not did the consultant come and create the strategy paper. That’s easy. And Prateek, I really like your point of expert versus expertise. And when we say in PDIA, it really is curiosity that is one of the key skills and the soft skills that we are looking for people who are working in this process because you don’t fail because of lack of expertise. You can always find and bring in the expertise you don’t have, but you do fail when you don’t have these skills of being open, being curious to ask questions, to listen. It’s one thing to ask a question and it’s another thing to listen to the answer to the question that you’re going to get right. And it’s those things that matter a lot more and those kinds of things that you do and agency, but you do want that kind of capability that I think we can do this and we can do it ourselves. We don’t need that savior to come in and do this for us. We can at whatever level we are within this government, be able to solve this problem ourselves. My final question for you is what are some words of wisdom that you would share? You know, you’ve been practicing PDIA for many years now in the state of Meghalaya. What are words of wisdom that you would share with our listeners? 

Rebecca Trupin So I think one thing that I just have found really valuable about the PDIA process and structure, which I think other people probably will resonate with, is just that it does give you somewhere always to start. And so I think coming into this and even over time, it’s something that has grown for me is the willingness to step into unknown territory. We started off in health. I didn’t have much of a health background. We sort of got comfortable with that. And then suddenly, you know, climate change, rural development, early childhood development, finally education. These other sectors started to come in. And one thing that is really empowering about PDIA is that it gives you a place to start and to start going into those areas. And so I guess this is sort of advice to myself as well, advice to like anyone working in government, is that with some of these frameworks, you don’t have to have the answers initially. It’s kind of to what you said, if you have a curiosity, you always have something that you can start building from. So that would be one sort of takeaway I think that I find very useful about the PDIA process. 

Prateek Mittal Right. I mean, I would still say we’re still way too young for any words of wisdom. But I think what’s been helpful for us is to keep thinking about the problem. I think it’s a reason why it’s called problem driven. And I think being honest, as we sometimes also call it, purpose driven, iterative adaptation. And I think that also goes very well with PDIA. I think oftentimes when we’re struggling to figure out what do we do here, I think coming back to the purpose, coming back to the problem that you’re trying to solve has been very helpful. And I think that sometimes gives us space to just step back and say, okay, you know, you went too far into the weeds of a particular idea or a particular program. And then getting lost in like, are we actually making progress? Is the right path and then being able to step back and say, what is the purpose? What are we trying to achieve here? And is there a blind spot then that is emerging? I think this is the kind of work where it can sometimes be surprisingly easy for blind spots to emerge where you just get too much into a particular branch of the problem that you’re trying to work. So I think just being able to step back periodically and looking at your fishbone or looking at the bigger picture has been very helpful for us. 

Salimah Samji Wonderful. Thank you so much. This has really been a tremendous conversation. I have enjoyed it thoroughly. Thank you.

Rebecca Trupin Oh, thank you. You know, we learned so much even from this. Yeah. Thank you so much. 

Salimah Samji It’s always about learning, right at the end of the day you’re always constantly learning. 

Rebecca Trupin Thank you. 

Prateek Mittal Thank you so much. 

Kathryn Lang Thank you for listening to our podcast today. If you liked it, please check out our website bsc.hks.harvard.edu or follow us on social media @HarvardBSC. You can also find links and other information under the description of this podcast.