Research from LICs is discounted early on
Our informants have extensive experience translating, or attempting to translate, innovations from low-income countries into the US, including conditional cash transfer programs, community services, hospital accreditation schemes, and educational policies such as teaching HIV education in schools. Others have many years experience at the executive levels of hospital and broader healthcare systems or teach international health policy. Speaking to their experience working with evidence from low-income countries regarding innovations that they believed would work well in the US, we asked whether they experienced any particular reactions or sentiments during the persuasion process with colleagues or other actors in the US. Informants consistently recognized that the source of the innovation or the evidence seems to matter, and that, in particular, evidence from low-income countries is often discounted early on:
‘I’m certain that if I say, Narayana Heart Hospital [in India] has lower infection rates than in the US, they’ll be very skeptical, but if I were to say that the Hernia Hospital in Montreal has better outcomes and lower costs than any operations here, they would probably be more receptive to that.’ (1st Oct 14 Professor of Law)
‘We had a conversation with a funder about a project saying this model has been implemented in 12 different countries, all of them low income, we think it has a lot of relevance for the US and we’d like to bring it to the US. And they were really nervous, really nervous, really nervous. And then we said, oh by the way, its actually also been adapted to the UK. And all of a sudden they were like, oh, the UK, great. It would probably work here then.’ (1st Oct 14 Manager, Innovation Think Tank)
The differentiated reaction noted above suggests that attitudes towards evidence may change based merely on knowledge of where such evidence is from. Many informants expressed a deep dissatisfaction with this, a sense of injustice or unfairness, frustrating efforts to communicate evidence and experience from low-income countries, which in some cases could hold potential benefits for US populations. These attitudes are important because without receptivity, persuasion of the potential benefits of a new innovation or model becomes much more difficult – breaking down barriers of prior expectation and becoming a process of convincing rather than learning. Informants recognized that it is not a level xplaying field, and that in their experience actors tend to downplay the effectiveness or benefits of an innovation from a low-income country often drawing on any number of reasons to refute or undermine the validity and value of models that were from surprising sources:
‘It was a very expected reaction….“of course they can do it there. Everything’s cheap”’ (1st Oct 14 Director, Innovation Think Tank)
The role and complexity of perceived context similarity
Examining more closely the reasons why these reactions occur, informants noticed that it is not just because the innovator context was foreign, but that it was different. More specifically, that it was perceived to be different. Informants noted that on the basis of perceived context dissimilarity, the likelihood that actors would be more receptive would decrease:
‘If the innovation is coming from a country that is dissimilar to the system in which it is being donated, or being suggested, to then that’s going to raise a certain set of biases in the receiver that shuts them off – the receptiveness to that.’ (10th Oct 14 Vice President, Innovation Think Tank)
‘I think there’s a very kind of understandable, at least initial, reaction that you want to look to places that are maybe similar to you in economy or population, because that may be where things are most transferable.’ (1st Oct 14 Director, Innovation Think Tank)
‘Canadians look more similar [to the US], many more Americans have been, the visuals in the media are more relatable, and so there’s a likeness that makes people more willing to see that it could be applicable.’ (1st Oct 14 Senior Manager, Innovation Think Tank)
At first sight, this could pose little in the way of complexity. By and large, we can conceive of countries as having, broadly, some similar characteristics and intuitively the basis to looking towards countries that are similar to one’s own seems sound. However, with probing, there also seemed to be very little consensus about how contexts are perceived, and the criteria used to describe them. We asked the informants what were the features of context that people bear in mind when they make decisions about similarity and we could find very little commonality in response. For some, the language and cultural cues seemed important, for others the socio-economic level, or the training of the health professionals was important:
‘I think it probably depends on what domain one is thinking of. We probably would presume, rightly or wrongly, that other countries that speak English are more like us than countries that don’t. I think we would think other rich countries are more like us than countries that are poor.’
(2nd Oct 14, Chief Executive, Health System)
I’m probably assuming income levels, education levels, societal rules, laws and regulations, the role of the Church…things of that nature. I think these are natural things that one measures for growth and development in a society….educational system, law enforcement, what kind of opportunities do people have, are they equal opportunities, how does business function with government, is the system democratic or dictatorial?’ (14th Oct 14 Board member, Innovation Think Tank)
‘The other characteristics that people think of to judge if their context is comparable to anothers….that is an interesting question….there’s something around sort of the training and licensing of providers….’ (1st Oct 14, Manager, Innovation Think Tank)
‘It depends what hat I am wearing. Ask me as a health policy person…well, you’ve got Canada with a very different financing system but practice patterns that don’t look all that different. Australia, mixed public/private system, lots of private insurance. Brazil, because of its reliance on private insurance for its middle and upper classes. Canada, because of its language and proximity. Its an interesting question because I have a little bit of knowledge and the differences are quite real…really quite severe, at every level. (15th Oct 14, Professor, Public Health)
Informants recognized that context similarity is based not on data but on perceived characteristics and that determination of which contexts could be construed as similar to the US depended highly on the criteria that one was considering. Nonetheless, each informant had little difficulty stating, with some confidence, which countries were, in their opinion, similar to the US or completely dissimilar to the US:
‘Oh, I would guess China, Russia, to some extent India, Congo, Nigeria, Venezuela, Argentina, probably, Columbia, Jamaica…there are a number of countries [that are too different to the US to learn from]’ (14th Oct 14, Board member, Innovation Think Tank)
‘I guess I’d say Canada, UK, maybe Japan [are the most similar to the US]. Japan because we shaped so much of its society after World War II. We really rebuilt the society, the political system…and the way of doing business.’ (14th Oct 14, Board member, Innovation Think Tank)
‘People in the United States would look to Canada and the UK as the two….you know, they’re English-speaking; I mean we share a common history and, you know, I think that differences between Canada, the US and the UK are much smaller than they are with, really, any other country…..(14th Nov 14, Vice President, Research foundation)
although including the caveat, no less important, that each person would likely have a different view:
‘Does it matter which country it [an innovation] came from for transportability? I think probably the answer is yes. I think some places are more likely to take up the innovation because it comes from the US. Some places may be more likely because it comes from Europe or from China.’ (28th Oct 14, Professor, Applied Psychology)
Conflating levels of analysis
Another issue is that there is a conflation of levels of analysis. External validity or generalizability of an intervention is a poorly defined construct as it is, and depends on whether the causal mechanisms that explain the interaction between an intervention and an outcome in one context are present in another. Interventions happen locally, requiring change agents, leaders and managers, in local services. This nuance is lost, however, when assumptions concerning the causal mechanisms at a local level are conflated into national level characteristics. Our informants describe a process where actors seem to be drawing on country-level general characteristics to explain causal mechanisms at the local level and then to draw conclusions as to whether these causal mechanisms exist in their own context. The success of an intervention locally is unlikely to be, singularly, because of the GDP per capita of the country, and yet the GDP per capita of the country, or other general mental image, is used to ‘make the leap of faith’ about whether this intervention would work in one’s own context:
‘If you imagine [the] infrastructure, like roads, and schools, and governance systems look like yours, then you can make the leap of faith that the medical systems are similar enough…you could picture a school in Canada being like a school in the US….you sort of believe that its got the same active ingredients that make it feel more similar to the US.’ (1st Oct 14, Senior Manager, Innovation Think Tank)
‘I think part of it is preconceptions about how generalizable things are. There are parts of North Carolina that if you looked at a population, the demographics would look almost entirely the same, or with lower income groups, than parts of Kenya, parts of India. When you generalize [though]…of course the thing to say is that the [innovation] from Canada is going to be more like what we would use and we would need.’ (1st Oct 14, Director, Innovation Think Tank)
This is a mental shortcut that is probably pervasive, and likely to be more pronounced for countries towards which we either hold strong prior attitudes or know very little about. Low-income countries, on the whole, fit this category well because, within the US at least, it is likely that actors will be less familiar with such contexts and rely therefore on media representations that are, if anything, presenting skewed and outdated images:
‘I don’t think that many individuals in this country are well travelled enough to believe that those parts of the world have health systems that could be operating with a degree of functional excellence that could make them relevant….If you have never been to India, you will have an outdated view of it, from National Geographic.’ (1st Oct 14, Senior Manager, Innovation Think Tank)
Succinctly summarized by the following narrative, the informant’s observation that ‘they hear “Africa” and they think there can’t be any good services’ is a worrying exposé of the stereotypes occurring on a frequent basis. Needless to say that not only is Africa not homogeneous, but it also comprises hot spots of innovation that out-perform high-income countries:
‘…they hear “Africa” and they think that there can’t be any good services….and these are people in Georgetown [very affluent neighborhood in Washington DC] who travelled. It wasn’t like it was people who had never left, not like in the hinterland.’ (24th Oct 14, Professor, Education Policy)
The significant generalization and over-simplification that in turn influences one’s perceptions of what is or is not possible lead people to hold, often firm, beliefs regarding the fundamental capacity of the country to deliver anything other than that which they expect from them:
‘I think that the starting position is we have nothing to learn from these people….the fact that in India, in selected circumstances, can deliver first world results in highly complicated case, at a fraction of the cost is simply dismissed as got to be sub-quality care…..when you are sure of something, you don’t have to explain it’ (15th Oct 14, Professor, Public Health)