Designed to Eradicate Relevance Paradox

In the vast expanse of global health, where lives hang in the balance and challenges appear insurmountable, there emerges a beacon of hope and change. In the heart of a world grappling with crises, there? emerges a? solution that strives to reshape the landscape of global health leadership.

As the sun sets behind the slopes of Mt. Kenya, the stage is set for an extraordinary journey that transcends borders, culture, and tradition. It's a narrative born from the whispers of the past, stories of a place called Kenyatta National Hospital, where lives teetered on the brink, and every visit was a desperate act of survival. These are the stories of mahututi, a Swahili word that conveys the gravity of "at the point of death." Kenyatta was the last hope, the line between life and eternity.

A young observer, who once grappled with the fear of Kenyatta's ominous doors, now stands at the forefront of change. This observer's journey - from a patient to a medical student, from the lush Chiromo Campus to the bustling Kenyatta National Hospital Campus - serves as the backdrop for the new vision for global health.

The observer's path is marked by stark contrasts - between the easy living of Chiromo and the chaos of Kenyatta, between well-maintained facilities and dilapidated halls, between a life of abundance and one of struggle. Yet, it's amidst these disparities that the observer's transformation takes place.

The observer's eyes are drawn to a peculiar sight - decommissioned SUVs bearing logos of international agencies, abandoned relics of terminated projects. These vehicles embody resources and intentions left to wither away. But the observer's astute gaze extends beyond the surface, for these vehicles are not the only victims of abandonment.

Hundreds of patients, initially enrolled in short to medium-term health research projects , were left stranded as sponsors concluded their initiatives and returned to distant lands. Kenyatta, once a beacon of hope, had become a place of struggle and uncertainty.

This is where Actuate Blockchain comes into play, poised to unveil a revolution in global health leadership. It offers a new lens through which to understand the interconnectedness of Kenyatta's challenges with the global health movement and the potential for transformation.

Actuate Blockchain's foundation is a new way , one that centers on leadership effectiveness in global health and human development. It represents a qualitative study grounded in the principles of the learning organization, aiming to unite the fragmented pieces of global health into a comprehensive entity.

The heart of the matter lies in the paradox - the simultaneous rise of diseases and poverty in sub-Saharan Africa amidst increasing investments. Actuate Blockchain's vision seeks to bridge the chasm, where projects often falter due to the exclusion of the local population's tacit knowledge in the decision-making process. The relevance paradox, as it is termed, illustrates the vital need to incorporate the indigenous tacit knowledge within a community into the project's design structure.

This narrative embarks on a quest to understand the pivotal importance of indigenous tacit knowledge, encompassing the voices of local nationals, diaspora nationals, and the business community. These are the stakeholders whose insights, if harnessed, have the power to change the course of global health.

In a world where change is essential, Actuate Blockchain aims to solve the relevance paradox, unraveling emergent knowledge from these stakeholders and offering a transformative solution to the complex challenges of global health. Stay tuned as we navigate the uncharted waters, unveiling how Actuate Blockchain aspires to usher in a new era of global health leadership.

Kenyatta: Back in the day—verbatim

Growing up on the slopes of Mt. Kenya (the Slopes), I heard stories about Kenyatta National Hospital. You were sent to Kenyatta, mahututi, Swahili word for “at the point of death.” After working on coffee for days and nights on end, I could hear remarks among the grown-ups, “I am a case for Kenyatta.” After more than a hundred hours of working on coffee beans, you did not have the strength to stand up. You ate in bed. You were tired to the point of death.…from extreme work.

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You were sent to Kenyatta at the point of death…from extreme disease. You did not hear about people being sent to Kenyatta otherwise. You had to be at your point of death if you were to be admitted in Kenyatta. Otherwise, how could the hospital cope with a flood of patients coming from the four corners of the country? Kenyatta was the national referral hospital for Kenya. Health professionals around the country referred every difficult case in a country of 32 million people to Kenyatta. Although my mother and her friends joked about being a case for Kenyatta after weeks of hard labor on coffee, being admitted in Kenyatta was not a laughing matter. (I was admitted mahututi to Kenyatta, at one point. I know, it is no laughing matter.)

I have found that life has an interesting way of dealing with me. The stories I heard about Kenyatta growing up on the Slopes left me thinking: Kenyatta is the last place I would want to be. At the age of 15 or so (no one maintained the age book in my village, as far as I know), I was admitted in Kenyatta, mahututi. For what seemed like an interminable period of time (this could have been a week, I do not remember how long, I stayed there), I shared a bed with different patients. The first day I had an elderly looking man. He could have been in his 30s, but he seemed as if he was in his 70s. He slept with his head on one end of the bed, and I on the other end.

My bedmate was too sick to talk. He could not stand. He could not sit. He vomited blood all night. His skin was cold and dry. He was very thin. On the second day, the nursing staff removed his body. He had died in the night. I was too sick to know or register what was happening. After that the hospital staff brought other patients to the very crowded ward. Everything was a blur. I remember vaguely about sharing bed with other patients. I remember getting an intravenous line. I remember unpalatable porridge like substance given to us for food. More than anything else, I remember the smell.

An overwhelmingly choking pungency issuing from a hundred or so un-bathed humans crammed into a space created to accommodate only 32 people. The smells of human excretions, bodily secretions, combined with the scent of the disinfectant solution to produce an unbearable stench. I was too sick to care. So was everyone else in the ward. When my aunt came to visit, she thought that I was going to die there. She convinced the doctor to discharge me. She took me to her house, bathed, and fed me warm soup. She then went to the market came back home with medicines. I recovered slowly. I have never forgotten the smell. That was my first encounter with Kenyatta.

As fate would have it, years later, I found my way back to Kenyatta….this time not as a patient, but as a medical student. Yes, who would have thought! OK, I am here at the University of Nairobi. After two years of slogging through the basic sciences of human anatomy, biochemistry and physiology in College of Sciences in serene Chiromo Campus on Riverside Drive in Westland’s, Nairobi, I am transferred to College of Clinical Studies in Kenyatta National Hospital Campus in Upper Hill, Nairobi.

The transition was from serene Chiromo Campus to Kenyatta National Hospital Medical School Campus was a culture shock of sorts. Chiromo is couched in a lush green wooded area next to the Nairobi Arboretum, in an upscale neighborhood.? Life was easy in Chiromo, everything was clean; fresh air, great food. Everyone seemed happy, in the lush green campus….except for the continuous assessment tests coming at the end of every week.

Kenyatta was crowded; too many people everywhere. The place was dusty, with many high-rise buildings crammed in a small space. The halls of residence seemed very old and dilapidated, compared to the halls in Chiromo. Utilities were dysfunctional. Water was available sporadically, and many times we had to go to another hall to take a shower. The kitchen was disorganized and the dining hall was rarely clean. The place was visibly crying for cleaning and maintenance in general.

I noticed many beautiful sport utility vehicles (SUVs) parked next to the Medical Students’ Kitchen building. The SUVs bore logos for UNICEF, WHO, CARE, UNIFEM, and similar international agencies. I wondered what SUVs were doing parked next to the kitchen. I learned that the SUVs were decommissioned from terminated project. The programs that imported the vehicles had come to an end, and the sponsors had moved on to other things. The vehicles were dumped. The area next to the kitchen building was a graveyard for SUVs whose projects had come to an end. These were functional cars abandoned by their owners because they did not need them anymore. The owners were done to with their projects. They parked the cars up, and abandoned them. Many of these cars were in good condition. The university could not use them, because among other administrative problems, there was no money for gasoline and maintenance. The SUVs were parked for live. For the next three years, I witnessed addition of more almost new SUVs to the pile, as more projects came to a close.

I also noticed that international project sponsors did not only abandon the vehicles next to the medical school kitchen. Also abandoned were hundreds of patients who were enrolled in short to medium term health projects . The sponsors of the programs, would leave abruptly and go back to where they came from (mainly Europe and United States) leaving hundreds of patients stranded. At the introduction of a new disease program, the sponsors would employ local doctors, medical students, nursing students to go out and recruit patients. Many of the projects involved a heavy research component, as a part of a clinical trial on infectious diseases. Other projects were community-based campaigns against disease of public health concern such as tuberculosis, or acquired immunodeficiency syndrome. Patients would travel hundreds of miles from their villages, at enormous costs, coming to Nairobi seeking care provided in various projects at Kenyatta National Hospital. As far as I can remember, all the projects lasted one to two years, after which period the sponsors returned home, leaving the patients stranded in the city.

As medical students, we started clinical clerkship in Kenyatta hospital in third year of medical school. During clerkship, we attended the ward rounds in the morning with the attending physician and the resident physician, and the nursing staff. The morning rounds involved reviewing patients admitted to the ward in the previous 24 hours. The resident worked all day, and all night, admitting patients to the ward. During a 24-hour period, the resident admitted about 120 patients into a ward with bed capacity for 32 patients. The work of the nurses was incredibly difficult. They did not have room to keep the patients who kept coming throughout the night. At the end of a 24 hour there were patients everywhere in the ward. Some on the floor, multiple patients on the same bed, sometimes three or four patients on a bed…..

We did not have medical supplies to take care of such a huge volume of patients.? We recycled disposable gloves by boiling. We did not have intravenous solutions for volume support. We sent families to go out and buy intravenous kits from pharmacy down town. Many a time the patient would die of dehydration before the family could return with the intravenous kit and fluid. Family members did not have cash needed to buy these supplies. Intravenous fluid was just the beginning of a list supplied needed, which ranged from pain killers to antibiotics, to anti-hypertensives, to anti-cancer drugs. This severe shortage of medical supplies in Kenyatta, and all the other hospitals throughout the country, followed implementation of the principle of cost sharing in the structural adjustment program mandated by the International Monetary Fund. It was amazing to see how seemingly harmless policies enforced by an international development can have a profound effect on the lives of millions of people. This effect left an indelible mark in me.?

Never before had I seen so many sick people in one place. Hundreds of sick people, all crammed in one place hoping for treatment that was not there. Years earlier, before the structural adjustment program, Kenyatta was different. It was clean, and efficient. Now, the likelihood of leaving the hospital alive was close to zero for many patients. Patients became sicker, in the ward; they acquired new hospital borne diseases, nosocomial infections that complicated their own illnesses. Life was easily wasted. I knew we had to do something. We had to change that. This book is about my effort to understand how events in Kenyatta connected with the global health movement, and how we can do things differently so that we can be effective in our work, as designers of global health care systems.

Laying Foundation for a New Theory

In this book, I focus on the problem of leadership effectiveness in the practice of global health and human development. I will report findings of a study I conducted using a qualitative method. The idea was to explore how we can apply the disciplines of the learning organization by Senge (described the fifth discipline) to inform a theory about global health leadership developed using the emerging grounded theory design proposed by Glaser and Strauss in 1967 in their book, The Discovery of the Grounded Theory: Strategies for Qualitative Research (Aldine Transaction, New Brunswick, New Jersey, USA). Specifically, I wondered how we can ground our thoughts in the fifth discipline, or systems thinking, the corner-stone of the learning organization, to develop strategies of conceptualizing, describing and explaining global health as a comprehensive entity. We needed to move out from our current approach to global health, in which we respond to snapshots of reality. Solutions for global health problems were focused on these snapshots, rather than the whole picture.

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I will explain briefly here, how I framed the problem in my mind. I viewed the problem of leadership effectiveness in the practice of global health as the paradoxical increase in the incidence of diseases and poverty in sub-Saharan Africa, at a time when there was increasing investment in fighting the diseases and poverty. I had noted that although expenditures to fight the diseases and poverty continued to increase, poverty in sub-Saharan Africa continued to proliferate, creating a relevance paradox, whereby highly relevant projects brought about negative results, and many unintended consequences. I had learned from the work of Charnock (1980) that relevance paradoxes occurred because of implementation of projects without awareness of the social or individual tacit knowledge within a target community. I surmised that the understanding of the individual and the social tacit knowledge in a given community, which is a function of knowledge emergence, would be the foundation of effectiveness of global health.

I found that that the existing literature failed to address the process of emergence of relevant knowledge from the stakeholders of global health and human development in sub-Saharan Africa. Armed with this understanding, my work was cut out. I set out with an objective to assemble a systems thinking sensitive organizational model that would provide leaders of global health with strategies of conceptualizing, describing and explaining global health as a comprehensive entity, rather than seeing global health in snapshots of reality.

I used a qualitative method, with an emerging grounded theory design to explore the activities and characteristics of stakeholders of global health and human development (i.e., the international development community, country governments, international business, diaspora nationals, and local nationals of developing countries). The use of a qualitative research method provided the opportunity to uncover concepts about the health and development ecosystem in sub-Saharan Africa. The grounded theory design facilitated the development of a process of emergence of relevant knowledge from within the stakeholders of global health and human development.

In the section that follows, I provide a brief description of the background of the problem. I also articulate the problem the way I understood it. The section contains the purpose of the work, and a discussion on the significance of the study to future research and leadership. Finally, I offer a brief description of the grounded theory research design and a discussion of the mechanism of decay of the indigenous tacit knowledge from the perspective of systems thinking.

Traditional salient stakeholders of global health and human development include (a) the members of the international development community (e.g., the World Bank, the World Health Organization, the International Finance Corporation, the United Nations Organizations, and the International Monetary Fund); and (b) country governments. Perversely, the fringe stakeholders of global health and human development include the local nationals of developing countries, diaspora nationals of developing countries, and the business community.

In this context, the members of the international development community design the global health and human development programs such as the structural adjustment program, the poverty reduction strategic papers, the global fund, roll back malaria, and the millennium development goals. The national governments of the developing countries facilitate the implementation of the development projects.

Global health and human development decisions directly affect the local nationals and the diaspora nationals of developing countries in sub-Saharan Africa. These two groups of stakeholders remain in the fringes, if not exterior to the decision-making organs. The business community is a stakeholder of health and human development, because business is a social construct requiring a healthy society as a market for its products, and a source of a healthy workforce. In the current context, researchers perversely consider business as a fringe stakeholder of global health and human development.

Exclusion of the local people, the diaspora, and the business community from the design of solutions to problems that affect them excludes the possibility of gaining access to the tacit knowledge from these groups. Exclusion of the tacit knowledge from a community during the design of a project results in failure to incorporate important details in the design structure of the project, with attendant failure of the emergence of knowledge that is relevant to the success of the project. Projects that lack important details in their design structure are problematic, and fail at implementation because of not being relevant to the problem at hand.

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Charnock (1980) described the phenomenon of project failure that results from the lack of acknowledging the tacit knowledge within a target community in project implementation as the relevance paradox. According to Charnock, the relevance paradox is a condition where interveners do not see the relevance of certain information that is of critical importance for making better decisions. Because the interveners are blind to this information, they do not seek it, resulting in inevitable, unintended, and undesirable consequences from project implementation.

According to Polanyi (1983), focusing on the tacit knowledge provides the point of access to the knowledge resources of a human being, or a group. The problem is that, unlike the easily expressed explicit knowledge, the tacit knowledge is internal, not codifiable, and only transmitted through experience. Tacit knowledge does not lend itself easily to identification by project implementers. Tacit knowledge converts by through socialization, externalization, combination, and internalization, on a special platform of knowledge emergence.

Conclusion

In conclusion, the crux of the matter revolves around a paradox - the concurrent surge of diseases and poverty in sub-Saharan Africa amid escalating investments. Actuate Blockchain's vision aims to bridge this gap, where projects always falter due to the exclusion of local communities' tacit knowledge in the decision-making process. This paradox, known as the "relevance paradox," underscores the imperative need to incorporate indigenous tacit knowledge into the structural design of projects.

This narrative embarks on a quest to fathom the pivotal significance of indigenous tacit knowledge, giving voice to local nationals, diaspora nationals, and the business community. These stakeholders, if their insights are harnessed, wield the power to reshape the trajectory of global health.

In a world where change is not merely a choice but a necessity, Actuate Blockchain endeavors to unravel the relevance paradox in global health, unveiling the emergent knowledge from these stakeholders. It offers a transformative solution to the intricate challenges of global health. Stand with us as we navigate uncharted waters, revealing how Actuate Blockchain aspires to usher in a new era of global health leadership. Together, we will bring about a brighter and healthier future for all.

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