Serious games
While “games” are popularly recognized for their entertainment value (e.g., board-games and video-games), they can be more generally understood as simulated environments in which players make decisions and interact in ways that shape outcomes. “Serious games” refer to the use of games as a method to promote better human understanding and decision-making with respect to some phenomenon. Militaries around the world have used war-games of various kinds since the nineteenth century, largely for training, but also for analytical purposes [6]. More recently, the applications of serious games have expanded to other domains, especially in contexts where human decision-making and interactions are shaped by complex social, technological and/or environmental systems [7].
Most serious games are based on simplified models of a real—or potentially real—situation (a “scenario”), which enable participants to gain firsthand experience in making decisions and interacting with other actors in a dynamic environment [8]. While games are not usually meant to be predictive, they offer opportunities for participants to think about issues in contexts that can be conducive to, inter alia, identifying and thinking critically about assumptions, generating new ideas and insights, knowledge exchange and discussion, and ‘experiential learning’ [8]. There are a variety of game types, ranging from games with rigid rules and procedures and/or high-degrees of complexity in technical details (often hosted on computer systems), through to those with more flexible structures and lower complexity (e.g. unstructured role-plays).
“Matrix games” are a form of semi-structured games, in which there is a scenario that develops over the course of a number of rounds, and multiple players who implement decisions by proposing an action with a specific objective (an “argument”), and various reasons why this action should be successful. The argument is then assessed by other participants, who may propose additional reasons why the action should be (un) successful, and then adjudicated by a facilitator (or “gamemaster”), who assigns a probability of success and rolls dice to determine the outcome. For example, if an action is deemed likely to succeed, a roll of four or higher on two dice might be required; if it was unlikely to succeed, a nine or higher might be required. The outcomes of (un) successful actions influence the development of the scenario. The section below describes a matrix game that was developed and implemented at GAC in March 2019 in order to explore preparedness and gender-based analysis in an international response to a global health crisis.
Game design: Pangea 2030
The game was set in an alternative world, “Pangea”,Footnote 1 in the year 2030 (see Fig. 1). While many of the issues, tensions and some place names are reflected the real-world, creating an alternative setting allowed us to abstract away from some of the complexity of real-world events and actors. Pangea included three regions: Westland, Eastland and Southland. Supporting maps indicated the alignment of the regions, the location of major conurbations and border characteristics, as well as trade, travel and migration routes.
Game participants were divided into six familiar, but fictional actors: a state-like actor for each of the three regions (‘Westland’, ‘Eastland’ and ‘Southland’); the ‘Global Health Organization’, a multilateral organization with the mission to lead global health responses, but with limited budget and on-the-ground capabilities; ‘Medicine Across Borders’, a non-governmental organization advocating for, and often leading emergency health interventions; and ‘the Foundation’, a well-resourced private foundation. Each actor team was provided with a description of their interests, capabilities, and relationships with other actors. The actors shared a common goal — to contain an influenza outbreak — but not a complete ‘harmony of interests’, which meant that competition and coordination problems could occur despite a backdrop of international cooperation.
The game unfolded through a series of rounds: the first round was an international preparedness conference for a global health crisis; the second round experienced a localized influenza outbreak in Eastland; the third round experienced its spread globally; and in the fourth round the virus was contained. Each round began with ‘news injects’ projected onto a screen, presenting the state of the outbreak and broader context. In addition to headlines, tweets highlighted perspectives from social movements. During each round, the teams took turns making an argument comprising of an action (e.g., deploy the military), the intended result of that action (e.g., containment), and the reasons why it would succeed (e.g., military well-resourced). Other participants could add additional reasons for (e.g., may prevent spread across borders) or against (e.g., fear of military may compel those infected to hide) the argument. Taking these arguments into consideration, the ‘gamemaster’ then determined the likelihood of success and rolled the dice. In between rounds the gamemaster updated the news injects and state of the outbreak based on players’ actions. The game ended with a debriefing discussion and a follow-up survey.
Experiencing prioritization & co-operation challenges
The survey asked if participants found the game useful for foreign policy planning and for thinking about an international response to a global health crisis. In both cases the majority of participants agreed with these statements (see Figs. 2 and 3). Open ended responses indicated that the matrix game format was reflective of decision-making contexts, noting it emphasized, ‘The importance of thinking on your feet.’ Another respondent wrote, ‘We can try to predict how certain policy positions will play out - but there are many factors - including the roll of the dice (unpredictability) that can influence. This is a very good reflection of today’s world.’ While players expressed frustration at having to prioritize certain actions, make decisions quickly and respond to unpredictable developments, it was recognized that these frustrations were reflective of actual policy contexts. Observers felt that the progress of events mirrored real interactions, including tugs-of-war over funding and tensions between regions.
Five (out of 12) responses to the survey question ‘What was your biggest take away from the game?’ mentioned lessons related to co-operation. One respondent wrote ‘The importance of demonstrating why the position I/my organisation is taking is in the interests – at least to some degree – of the others with whom I am engaging. The actors in the game too quickly fell into a competitive mode if they didn’t understand how interests were aligned.’ Another wrote, ‘We learned the importance of respecting the motives and goals of state and non-state actors during interactions; how easy it can be to “lose” potential partners and how difficult it can be to regain them.’ Participants experienced and learned from the tensions that emerge between the pursuit of individual actor interests and the need to co-operate in response to a health crisis.
Respondents also commented on the inclusion of non-state actors in the game: ‘I think it was a really good idea to have a company foundation represented in this game. More and more international cooperation is looking to partner with the private sector. But the private sector has its own agenda, and one that we traditionally would not have considered in a global pandemic scenario. Including this non-state actor provided an opportunity to think through how they would act in a crisis and how we, as the government, would likely react was really valuable.’ The participants who played the Foundation role noted that it was challenging to separate its commercial interests from its charitable activities, which they felt was an authentic experience.
Outbreak preparedness
Recognizing that lack of outbreak preparedness is a prominent global health challenge [iii], one of the objectives of the exercise was to encourage critical thinking about preparedness for a global pandemic scenario. Overall, the majority of players felt they knew more about preparedness after playing the game, though the challenges of preparing for an unknown outbreak also resulted in almost a third disagreeing (see Fig. 4).
During the first round of the game, teams were told they were attending an international conference on preparedness, but had no knowledge of the crisis that would eventually unfold. Through their actions they determined the priorities of the conference - mobilizing resources for vaccine development and an emergency response fund. There was little discussion of preventing or preparing to address the social determinants of outbreaks, other than earing-marking some funding for GBA+ initiatives, though what these would be was not clarified. During post-game reflections participants noted that the early focus on vaccine development, which continued throughout the game, led to neglect of other aspects to preparedness. Participants were particularly frustrated that by the time they succeeded in developing a vaccine (during the third round), the outbreak had spread exponentially and lack of communication had led to vaccine hesitancy among vulnerable groups. This led to further discussions on why such aspects were deprioritized over technical solutions.
Many players also noted that it was challenging to come to agreements with other actors during the preparedness stage of the game, with seven out of the 10 complete answers to the question on what was learned about preparedness again focusing on cooperation. For example, ‘GH [global health] preparedness requires input from multiple stakeholders domestically and internationally. Galvanizing this prior to a crisis is extremely challenging.’ And another respondent noted, ‘Relations are important. It is important to understand everybody’s interest and vision.’ Post-game discussions included recognition that while cooperation was challenging during the preparedness round, as the game progressed and the crisis situation heightened, actors became more willing to cooperate. Respondents recognized that if greater cooperation had been achieved during the preparedness conference the response to the epidemic would have been more effective.
(not) applying gender-based analysis
The game explicitly aimed to incorporate gender-based analysis in recognition of Canada’s Feminist International Assistance Policy, which aims, among other goals, to ‘focus its efforts on programs and projects that put gender at the heart of their efforts to improve health care. .. [including] initiatives that help fight infectious diseases through equity-based approaches’ [9]. To support feminist policy implementation, Status of Women Canada developed the Gender-based Analysis Plus (GBA+) framework. GBA+ ‘is an analytical tool used to assess how diverse groups of women, men and gender-diverse people may experience policies, programs and initiatives’ [ix]. It was expected that as most players were employees of the Government of Canada, which has dedicated substantial resources and training programs to promoting GBA+, they would have some previous knowledge of and exposure to GBA+.
GBA+ was incorporated into game development through the inclusion of incentives and prompts for players to consider how different genders, sexualities, races and other social groups experience disease outbreaks and responses, and to recognize the social-determinants of health more broadly. Each actor package included guidance on GBA+ approaches, and each round of the game included news injects and tweets highlighting how the outbreak and response was affecting different genders and social groups. During debates over actions, a subject matter expert presented GBA+ arguments for or against actions.
However, players only sporadically incorporated GBA+ and rarely took actions to address the social determinants of health. Of the 24 actions proposed by actors, only seven (29%) included a GBA+ element. Three included support for maternal and child health, with two simply noting a GBA+ lens would be applied to other actions, and one noting that social and cultural characteristics would be taken into consideration when developing awareness materials. Survey respondents commented on the lack of integration of GBA+, with one writing, ‘I felt like this exercise didn’t touch upon GBA+ issues as much as I would have hoped - although there were some mentions of it, we didn’t have a chance to really explore it.’
Despite lack of application, the majority of players agreed that the game promoted critical reflection on applying GBA+ (see Fig. 4). One survey respondent noted, ‘My biggest takeaway was the difficulty in making decisions through a GBA+ lens and that political considerations are always prevalent, even during a humanitarian crisis.’ The lack of opportunity to apply GBA+ was attributed by respondents to the game structure, which allowed one action per turn, simulating the real experience of priority setting. It was noted that while players included GBA+ in their internal team discussions, it was rarely prioritized when it came to proposing actions. A survey respondent noted, ‘As usual, when we want to act quickly on an issue, we often think the GBA+ consideration is less important, which results in bad planning.’ Others noted that they did not emphasize GBA+ because they felt it made cooperation with other actors more difficult.
Such responses suggest that many of the challenges documented regarding limited application of gender-analysis during crisis response, such as it being de-prioritized compared to technical solutions [ii], were experienced and reflected on by the players. The final report on the exercise by GAC noted, ‘With the knowledge that outcomes for women in situations of crisis are significantly worse when gender needs are not incorporated into disaster responses, watching it play out in a fictional scenario (when participants are supposed to be doing the opposite) is a red flag that more understanding is needed on how this phenomenon is replicated and that specific guidelines and oversight are needed to adequately address the issue’ (Fig. 5) [10].
