Health Policy in DevelopmentLand: a practical policy simulation

This guest post comes from Cathy Elliott (UCL). A detailed instruction pack for this activity can be downloaded via the link at the end of the post.

One thing that students in my International Development class find intriguing is the fact that, in a previous career, I used to work for the British Government in Pakistan. Relatedly, one of the things I find difficult is students’ received ideas about what a job in international development like that might be like. When students join the class, some fall unreflexively into a discourse of “us” “helping” “them”. Others, meanwhile, bemoan unequal power relations in the world, imagining that a supplicant Pakistan is being pushed around by overbearing British development workers coercing them with huge amounts of conditional aid on offer.

The first position smacks of White Saviour attitudes and is at best patronising to local people and movements pushing for their visions of change. The second, meanwhile, bears little resemblance to my actual experiences of trying to spend relatively small amounts of money in ways that would be acceptable to the governments of both countries. Students also come to my class in search of solutions to global poverty and one recurrent grumble on my student evaluations is that they do not leave the ten week module knowing how it might be “fixed”. Meanwhile, I want them to question these sorts of technocratic attitudes that encourage them to seek the simplistic solutions.

In response, I have developed a 3 hour simulation game that attempts to give a glimpse of what the world of international development is actually like. It is based on my own experience of living and working in Pakistan for three years, and of course other experiences are available. However, I have found it a useful activity for getting students to understand some key ideas from the literature, including the role of power and networks in policy-making, the importance of powerful discourses including international goal-setting agendas such as the Sustainable Development Goals, and the open-ended, processual and contingent nature of political and policy-making practices.

The premise is quite simple: for the duration of the class we will be in the fictional country of DevelopmentLand, which bears a striking resemblance to Bangladesh in every way unless something different has been specified. The students (usually between 40 and 60) are split into small groups and assigned roles with detailed descriptions. The groups are broadly as follows:

• The Minister of Health and her advisory team
• The World Bank
• The UK Department for International Development
• A group representing the country’s religious leaders
• A British consultancy firm
• An international maternal health NGO
• A local national maternal health NGO
• A group representing local traditional birth attendants
• A local NGO that saves lives by teaching children to swim
• Local NGOs working on neglected tropical diseases

On their cards, students are given information about where they went to university, who they already know and whether or not they speak English. I try to organise the groups so that friendship groups within the class map onto networks that you might expect. Sometimes I also add a group of journalists.

The aim of the game is straightforward. The groups have to persuade the Minister to work with them to develop health policy in the country. Each group has to prepare a 5 minute presentation to persuade the Minister. However – and this is the really important bit – the Minister can work with more than one group if they are able to work together in a consortium. For groups that decide to work together, they can also pool their time. This means that if two groups work together, for example, they jointly get ten minutes to present. A class-wide “win win” situation is therefore possible: there is no reason in principle that all the teams could not get together and put a proposal to the Minister that she and her team would find acceptable.

This has never actually happened, though, because – in classrooms as in life – the game is rigged. The Minister and international donors are preoccupied by meeting the Sustainable Development Goals. The Minister is also keen to be re-elected and the group of religious leaders may have a role to play in enabling or, crucially, wrecking her chances. Some of the groups find that their very good cause doesn’t fit in well with her aims and it is more challenging for them to find partners to work with. Some groups don’t speak English or have dinner with the right people. And not all the groups know everything about what is going on in the other groups. They can usually find out by asking, gossiping and listening in but it often doesn’t occur to them. Intriguingly, no-one yet has produced a crumpled fiver from their wallet to grease the wheels, although I sometimes spread the mischievous rumour that previous classes have tried this!

The groups spend about 90 minutes making what they will of the situation and then they do their group presentations. Afterwards, they talk among themselves about what they think will happen, while the Minister and team make a decision, which they then present back to the group. The debrief session afterwards helps students make sense of the experience and understand, with guidance from me, how their experience fits into the broader theories we have been studying, as well as my own experiences.

One thing I like about this exercise is that it gives students an insight into ordinary everyday politics, as they are most likely to encounter them. There is no dramatic threat about to overwhelm DevelopmentLand and the always unrealised possibility of a win-win ending means that there are no bitter enmities, only ordinary political rivalries and invisibilities. The international donors are powerful, but so are the government and other local players, and all of them are operating in a landscape of power relations that they did not create and cannot reshape on their own. This gives students an understanding of the crucial point explained by Maureen Mackintosh: “Deciding what should be done is relatively easy. But achieving it requires alliances with others”.[1]  The infuriating nature of having to work with other people in conditions of unequal power is a great learning experience, above all for students of politics. As one student put it: “It helped me understand the process of politics, particularly the necessity of working with people with different agendas”. Another made me happy by remarking: “It was a challenge to cynicism – maybe things can change, but there aren’t easy answers.”

Michael Buroway once wrote that “[o]ne cannot both play the game and at the same time question the rules”.[2] This doesn’t seem right to me; surely it is only through playing the game that we can understand the rules, their consequences and possibilities for effecting change either working within them or by transforming them. Policy simulations like this give us some tools to help students begin to play the game and to ask critical questions about the rules that they probably could not access otherwise.

---

[1] Mackintosh, M. 1992 ““Creating a Developmental State: Reflections on Policy as Process” in Gregory Albo, David Langille and Leo Panitch (eds) A Different Kind of State? Popular Power and Democratic Administration Toronto: Oxford University Press Canada: p. 44)

[2] Buroway, M. 1979. Manufacturing Consent: Changes in the Labor Process Under Monopoly Capitalism Chicago: University of Chicago Press : p.79