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Article Article August 25th, 2015

Striving for scale: evidence to impact

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Alix Zwane: There’s a gap between innovation and what’s feasible for large institutions

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Alix Zwane: You have that gap and you need to take a coalition of organisations to bridge that gap

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Alix Zwane: Development programmes should be backed by rigorous evidence

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The link between academia and policymaking is not as self-evident as you might imagine. Not many politicians make the leap from lecture hall to legislature, and policy ideas more often stem from think-tanks or focus groups than laboratory research. But by overseeing Randomised Controlled Trials (RCTs), academics understand what works and why. Unfortunately, the bridge between doing what has proved effective and doing it at scale remains under construction.

So, how can a government, donor or community take a pilot programme that has been proved to work and scale it up to achieve lasting impact on a far bigger stage? Evidence Action, a comparatively recent addition to the development scene, is tasked with helping them do just that. From its base in Washington, DC, it is active across seven countries in Africa and Asia, seeking to deliver evidence-based projects that “bridge the gap between rigorous research and pilot programs on the one hand, and institutionalized programs on the other”. Alix Zwane, who until recently was its executive director, outlines their approach.

“Taking risks and innovating can be very challenging for a large organisations, whether that's government or large firms,” she reflects. “Academics, researchers and small start-ups can be great sources of innovation and new ideas. There's a gap between what those engines of innovation and evidence can do and what's feasible, and doable, for large institutions who've already achieved things at scale. We think you bridge that gap by bringing together new coalitions of organisation that can work together to take germs of great ideas and actually put a service delivery model and a business model around them. You have that gap and you need to take a coalition to bridge that gap.”

Evidence Action takes action

Zwane is keen to stress that while Evidence Action may not be the largest of organisations - “it's not academics or a large service delivery entity” - it possesses the flexibility to facilitate conversations and bring together larger partners. This only happens, however, when programmes are backed by rigorous evidence such as RCTs and are measurably effective. That said, Evidence Action - which works with other NGOs and governments - has a $20 million budget that is used to help deliver services when needed.

“We do implement, but partly we implement so that we know how to help others implement too,” she explains, before citing its school deworming initiative as a case in point. There are more than 600 million school-age children around the world who are at risk of infection from parasitic worms. These infections limit children's participation at school and cause health problems such as anaemia and malnourishment, but teachers can administer deworming pills to their pupils with minimal training and to great effect.

“We help state governments that have budgets for deworming in India, but who don't necessarily know how to get the programme started and get it running in a high quality way,” says Zwane. “We help them think about what capacity they need, what programme management capabilities they need, and we help build the capacity of the state governments to run these programmes at scale. Governments themselves have a role to play in this process. “Leaders in government can serve as champions and ‘fixers' by helping t get a wider set of stakeholders engaged,” says Zwane. “Evidence Action sees government as a critical partner for scale and sustainability.“

Another example exists in Malawi, where the Evidence Action team is helping to address the challenge of unsafe drinking water. Its government was using health workers to add chlorine to water supplies by hand in order to counter the spread of bacteria, but using a dispenser installed at the water source enables a consistently accurate dose to be administered and results in higher adoption rates.

“What we have done is partner with the governments of districts to where their health workers can actually provide chlorine for our chlorine dispensers,” explains Zwane. “This improves the quality of the service for their communities and in doing so increases their capacity to deliver health services. So we leverage each other. The government leverage is the infrastructure that we install with donor financing. We leverage the fact that they already have a ‘last mile' distribution system and they can use that to provide chlorine into our dispensers.”

Scale systems

Having joined Evidence Action from a senior role at the Bill and Melinda Gates Foundation, Zwane is well-versed in dealing with public health challenges in developing countries, as well as the task of ensuring that the impact of development initiatives is felt by as many people as possible. This, in particular, requires a nuanced approach - it's certainly not a case of one size fits all.

“You really have to understand your cost of doing business in a relatively sophisticated way,” she says. “It's understanding your cost of doing business, but you don't necessarily take the cost of the pilot programme and multiply it by 10. A lot of it is really understanding how supply chains can work at a very large scale when you want to maintain quality, but you've got to let go of some of your control.”

Monitoring, too, is important. “Often times the folks who come out of the world of academia and impact evaluation aren't necessarily fluent in the world of monitoring programmes at such a large scale,” she adds. ” We've learned a lot about how to do that in our programmes that we run at very large scale, so that's another area where we often provide a lot of ideas, capacity building, technical assistance and support to others.”

When it comes to monitoring the efficacy of its deworming and water dispenser programmes, Evidence Action has opted not to measure final impacts. “What we focus on is the number of kids getting dewormed,” says Zwane. “We're comfortable with that, because we think the biomedical story about the relationship between deworming, anaemia and fatigue is pretty well understood. It's similar with our chlorine dispenser programme. The relationship between chlorine and drinking water and reduced diarrhoea has been well studied in epidemiology. We focus on doing a really good job of measuring chlorine adoption and feel like that's the right thing for us to be working on when we think about quality service delivery at scale.”

For interventions which are promising but where the evidence is not yet solid enough, however, they take a different approach in order to strengthen their knowledge. “For some of the new programmes that we're looking at, we have invested in more RCTs and we've really tried to measure effects and unintended consequences,” says Zwane. This flexibility is already bearing fruit, it transpires. By the end of 2015, Evidence Action expects that 200 million children will have been dewormed, partly as a result of its help, and seven million people will have gained access to safe, sustainable drinking water services. Staff numbers have surged to 280, with offices now up and running in Kenya, Uganda, Malawi and India, as well as its US headquarters.

“It's about choosing the right vehicle for the programme at hand,” concludes Zwane, who has recently taken up a new role as CEO of the Global Innovation Fund, a $200 million fund providing support for the development, rigorous testing, and scaling of cost-effective innovations targeted at improving the lives of the poorest people in developing countries.

“School deworming really only makes sense as a government programme, with teachers doing the delivery and schools as a platform,” she adds. “For our water programme, we really wanted to run that like a social enterprise. So, I think we're flexible and responsive in trying to not be a hammer in search of a nail - but there is always more to do. We're very eager to seek the partnerships and the new alliances that can help other people and other entities deliver programmes at scale too.”



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