Culture, Medicine, and Psychiatry

, Volume 43, Issue 4, pp 574–595 | Cite as

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

  • Dörte BemmeEmail author
Original Paper


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.


Global Mental Health Theory of change Contingent universals What works Virtuous failure Accountability 



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.


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.

Compliance with Ethical Standards

Conflict of interest

The corresponding author states that there is no conflict of interest.

Informed Consent

Written informed consent was received for all interviews.


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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department for AnthropologyUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Department of Psychiatry, Program for Global Mental HealthMcGill UniversityMontrealCanada

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