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Finding “What Works”: Theory of Change, Contingent Universals, and Virtuous Failure in Global Mental Health

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Abstract

Global Mental Health has developed interventions that strive to work across great difference—variously conceptualized as cultural, socio-economic, geographic, or pertaining to the characteristics of health systems. This article discusses how the evaluation framework Theory of Change (ToC) facilitates the production of ‘global’ knowledge across such differences. Drawing on 14 months of multi-sited fieldwork among Global Mental Health actors in Europe, North America and South Africa, it traces the differential use of ToC in GMH interventions. While much critical scholarship of Global Health metrics holds that techniques of quantification rely on universals that necessarily betray the “real world”, ToC unsettles these critiques. It comes into view as an epistemic and relational device that produces ‘contingent universals’—concepts that are true and measurable until they stop working in the field, or until the parameters of ‘what works’ shift to a new iteration. As such, Theory of Change produces actionable—rather than true—knowledge attuned to open-ended change, both desirable (impact) and unforeseen (adaptation). Its effects, however, are ambiguous. ToC presents us with a horizoning technique that enables what I call “virtuous failure” within the evidence-based paradigm. It may equally harbor the potential to disrupt distinctions such as bricolage (tinkering) and design (planning) and their respective politics, as it may tie neatly into audit cultures, depending on its use. The article analyzes the novel stakes of reflexive evaluation techniques and calls on anthropology and critical Global Health for renewed empirical engagement.

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Notes

  1. I conducted 73 expert interviews and participant observation among public health researchers, policy makers, clinicians, health economists, psychologists, lay health workers, and data managers within the GMH community. Ethics approval has been received from McGill University, REB 478-0514.

  2. He writes: “In other words, instead of deducing concrete phenomena from universals, or instead of starting with universals as an obligatory grid of intelligibility for certain concrete practices, I would like to start with these concrete practices and, as it were, pass these universals through the grid of these practices.[…] Let’s suppose that universals do not exist. And then I put the question to history and historians: How can you write history if you do not accept a priori the existence of things like the state, society, the sovereign, and subjects?” (Foucault 2008).

  3. More precisely, to the work of American management professor Donald Kirkpatrick at University of Wisconsin, who developed a model for the evaluation of management training, which he later generalized to a four-step model for education evaluation (Kirkpatrick 1975).

  4. While Carol Weiss’s ToC maps followed linear successions of inputs and outputs, complexity and systems thinking gave rise to ToC pathways with multi-factorial inputs, and multiple feedback loops (Coryn et al. 2011). Comprehensive reviews on the uses of ToC have been compiled by actors like DfiD (Vogel 2012), Comical Relief, Oxfam Australia. The Center of Theory of Change and its software TOCO posts a list of clients ranging from USAID, the Rockefeller Foundation, public school boards, the Girls Scouts of the USA, catholic charities, and NGO’s like the Hunger Project to companies like NEXUS.

  5. Economic historian Morton Jerven at a conference in London once made fun of the imprecision of aggregate indicators by giving the example that a singular indicator for a complex phenomena like the weather would not help people decide how to dress (given that the weather is made up of temperature, wind, likelihood of rain etc.).

  6. As a colleague working in the realm of global health security remarked to me: “Entire careers are being built on the failure of the Ebola response. Literally, gazillions of publications.”

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Acknowledgements

I would like to thank my interlocutors across the GMH community for their time and generosity in helping me understand their practices. This article resulted from a workshop on the ‘Historical and Ethnographic Perspectives on Global Mental Health’ in June 2017 in Florence, organized by Anne Lovell, Ursula Read and Claudia Lang. I would like to thank them for their helpful feedback as well as for the intellectual community they created. The manuscript benefited from the insightful comments of David Reubi, Liana Chase, Darcie DeAngelo, Nicole D’Souza, Julianne Yip, Fiona Gedeon Achi, Raad Fadaak, Adam Fleischman, Nicole Rigillo, and Tobias Rees. A special thanks goes to my new intellectual community at UNC Chapel Hill for the wonderful comments I received from Peter Redfield, Jocelyn Chua, Mara Buchbinder, Harris Solomon, and especially Nadia El-Shaarawi.

Funding

The research for this article was supported by a doctoral award from the Social Science and Humanities Research Council (SSHRC), a fieldwork grant from the International Development Research Centre (IDRC), the Graduate Award of the McGill Wolfe Chair for scientific and technological literacy 2016, and the Graduate Award of the Institute for Health and Social Policy (IHSP) at McGill 2017.

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  1. Department for Anthropology, University of North Carolina at Chapel Hill, Chapel Hill, USA

    Dörte Bemme

  2. Department of Psychiatry, Program for Global Mental Health, McGill University, Montreal, Canada

    Dörte Bemme

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Bemme, D. Finding “What Works”: Theory of Change, Contingent Universals, and Virtuous Failure in Global Mental Health. Cult Med Psychiatry 43, 574–595 (2019). https://doi.org/10.1007/s11013-019-09637-6

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