Socio-ecological dynamics and challenges to the governance of Neglected Tropical Disease control
© The Author(s). 2017
Received: 12 March 2016
Accepted: 29 December 2016
Published: 6 February 2017
The current global attempts to control the so-called “Neglected Tropical Diseases (NTDs)” have the potential to significantly reduce the morbidity suffered by some of the world’s poorest communities. However, the governance of these control programmes is driven by a managerial rationality that assumes predictability of proposed interventions, and which thus primarily seeks to improve the cost-effectiveness of implementation by measuring performance in terms of pre-determined outputs. Here, we argue that this approach has reinforced the narrow normal-science model for controlling parasitic diseases, and in doing so fails to address the complex dynamics, uncertainty and socio-ecological context-specificity that invariably underlie parasite transmission. We suggest that a new governance approach is required that draws on a combination of non-equilibrium thinking about the operation of complex, adaptive, systems from the natural sciences and constructivist social science perspectives that view the accumulation of scientific knowledge as contingent on historical interests and norms, if more effective control approaches sufficiently sensitive to local disease contexts are to be devised, applied and managed. At the core of this approach is an emphasis on the need for a process that assists with the inclusion of diverse perspectives, social learning and deliberation, and a reflexive approach to addressing system complexity and incertitude, while balancing this flexibility with stability-focused structures. We derive and discuss a possible governance framework and outline an organizational structure that could be used to effectively deal with the complexity of accomplishing global NTD control. We also point to examples of complexity-based management structures that have been used in parasite control previously, which could serve as practical templates for developing similar governance structures to better manage global NTD control. Our results hold important wider implications for global health policy aiming to effectively control and eradicate parasitic diseases across the world.
KeywordsNeglected tropical diseases Lymphatic filariasis Schistosomiasis Malaria Smallpox Socio-ecological dynamics Complex dynamical systems Normal science paradigm Organizational theory Complexity-based governance
Please see Additional file 1 for translations of the abstract into the six official working languages of the United Nations.
The emerging global initiatives to control the “Neglected Tropical Diseases (NTDs)” have been described on one hand as a major humanitarian effort to reduce the disease burdens of the marginalized populations of the global South [1–3]. In this regard, advocates have used social justice and equity but also political economy arguments to signify that investments in NTD control based on mass drug administration (MDA) are pro-poor, cost-effective and welfare improving. Indeed, the current initiative is promoted as a comprehensive blueprint towards “rescuing the bottom billion from poverty” . On the other hand, the NTD strategy, like other global intervention programmes, such as those against HIV/AIDs, tuberculosis and malaria, also reflects the now long established paradigm in conducting and delivering global health interventions, viz. the transnational nature of health technology delivery in poorer countries whereby decision making and power are shifted away from national governments to globally interrelated “epistemic communities” that frame problems, generate knowledge and solutions, and develop advocacy and funding strategies for taking action [5–8]. These characteristics of global health intervention programmes, particularly their narrowly conceptualized focus on therapeutic access and dependence on an extensive external/global locus for problem formulation and solution, have thus come to underpin the features increasingly resembling public health delivery in poorer countries of the global South, particularly in the case of Africa: 1) a hollowing out of state power, 2) a fragmentation of national publics into “communities” gathered around specific needs leading to the “projectification’ of health care focused on specific diseases and islands of intervention, 3) the enactment of standardized, increasingly pharmaceutical-driven biomedical interventions based on narrow worldviews and perspectives emphasizing individual risk factors, and 4) the increasing propensities of such biomedical campaigns for controlling bodies and populations through forms of prescribed management and administration aimed at cultivating passive accepting publics [5–8]. While the study of these biopolitical outcomes has so far focused on the tensions that arise between powerful global/state discourses and local perspectives leading to failure of many of this type of planning schemes [9–11], it is equally important to reflect on the extent to which the governance strategy adopted by these programs, which emphasizes static steady state-based, blueprint-driven managerialist interventions, can effectively deal with the inevitably open socio-ecological dynamics, complexity, uncertainty, and non-linearity that underlie parasitic transmission in human communities [12–14].
The importance of understanding the central role of socio-ecological dynamics for the appropriate governance of social change has been highlighted by work carried out in governance studies [12, 13, 15–19]. These demonstrate how addressing issues of system complexity, viz. that socio-ecological systems are not only complex, dynamic and dissipative, but are also adaptive and display uncertain emergent properties, need to be at the core of any attempt aiming to transform persistent societal problems. A major insight from this growing body of work is that accepting ecology-in-contexts and system uncertainty, including with respect to problem framing, means that there may be no singular path to disease control [18–20]. Instead, attention is drawn to a need to be open to the fact that there may well be multiple possible routes available for achieving successful disease control in different socio-ecological settings. Indeed, this body of work has contrasted how attempting to impose a rigid orderly outcome on an inherently complex adaptive system is often the cause of failure of such plans [13, 17]. This work has also shown how consideration of complex dynamics highlights the important need to shift to a different relationship between expertise and policy making, in which recognition of inclusive multiple framings of issues by all partners, including the local community, and reflexivity around such framings is essential to “open” up policy problems and options by addressing uncertainty, dissent, agency and controversy, rather than these be “closed down” by narrow visions of change, management, and progress [12, 17–23]. It has pointed to the need for an approach to policymaking and governance that is incremental and adaptive, based on deliberation, reflection and learning, and where political interests are brought explicitly into the picture. These insights challenge the current global governance of parasite control programmes, which true to its underlying instrumentalist vision of development [24–26], offers in this context only a limited, restricted vision of what is possible, excluding the context-driven outcomes of complex ecological dynamics and the socio-political processes of governance. These considerations underline that the basic Newtonian, normal science problem-solving paradigm that has underpinned and typifies most current parasite control initiatives has serious limitations when social issues and contexts form an integral part of the problem situation [13, 18, 20, 23, 27].
Here, our major focus is on how best to guide the management of the control or elimination of NTDs, given the context of the inherently complex, non-linear socio-ecological dynamics of parasite transmission in endemic populations. We begin by reviewing the impact of this complexity on NTD transmission, and how attention to complex system dynamics is a requirement for providing a useable guide to action. We then discuss the policy, organizational and management responses that have been proposed to deal with dynamic socio-technical-ecological problems, and highlight governance frameworks that explicitly address notions of system complexity, non-linearity, uncertainty, and resilience. We next contrast this with the current global governance of NTD control, arguing for the need to develop a more inclusive and reflexive governance model that provides scope for linking local social contingencies and priorities with disease control policy. We examine recent work in the governance of complex socio-technical change to draw out a practical organizational framework that would allow the balancing of the institutional flexibility and stability required to enact a similar system of governance for NTD control. We end by pointing to some examples of complexity-based management structures that have been applied successfully to parasite control, and to research needs for the development of similar structures that may better generate and manage sustainable pathways for accomplishing global NTD control effectively.
Complex dynamics of NTD infections
Another finding which characterizes the complexity of parasitic systems is the irreducible uncertainty connected with predicting transmission dynamics; this is underlined by the results depicted in Fig. 1e, f, which show how values of the microfilarial (Mf) production rate of adult female worms can significantly impact the values of transmission breakpoints. Given that the values of this function can never be precisely known, this fact together with the difficulty of measuring the local socio-ecological parameters (infection aggregation, acquired immunity), imply that the core challenge in eliminating complex dynamical diseases, such as LF, is fundamentally related to the problem of how best to enact strategies in the face of limits to knowledge and prediction of transmission and extinction dynamics in different local dynamic socio-ecological contexts. These observations indicate that the current top-down deterministic, command and control managerial practices, characterized by the belief that parasite populations should fundamentally respond to interventions similarly everywhere, and that technology and hierarchical health systems are the only and best forms of health delivery, are unlikely to achieve the goal of successful NTD control/elimination in all regions. Research from other complex dynamical contexts such as ecosystem or natural resource management indicates that the uncritical application of such linear, order-imposing, management models to complex problems may constitute the major source of the often unintended or pathological consequences that arise from societal interventions .
Governance responses to the management of complex social–dynamical systems
Contrasting paradigms of governance of the twentieth century and an alternative paradigm emerging in the twenty-first century
Dominant paradigm displayed in the twentieth century
Emerging alternative paradigms for the twenty-fist century
Problem solving/goal seeking orientation
Focus on short term gains
Focus on sustainability and the long-term
Assumed predictability and certainty
Unpredictability and uncertainty
Recognition for holistic/integrative thinking
One “truth” or best answer
No final “best” answer
Observer status objective
Observer status is constructed/subjective
Focuses on parts
Focuses on the whole
Structural changes affect function
Multiple stable states
Reliance on simple cause and effect
Recognition of emergent properties of systems
Assumes systems models to be models of the world (ontologies)
Assumes systems models to be intellectual constructs (epistemologies)
Science and technology have the required answers
Scepticism and critical evaluation of science and technology
Talks the language of problems and solutions
Talks the language of “situation of concern” accommodations
These new approaches to governance of social-technical-ecological systems also acknowledge the important roles that human agency and reflexivity play in a problem formulation and its solution, the significance of understanding how ‘governance’ shapes the direction of scientific and technological processes, including the framing and addressing of social issues, and how intervention consequences become distributed and indeed whether these are acceptable to all [12, 15–17, 20, 50]. Therefore, a second key development in modern governance arrangements has been the evolution of structures that allow for diversification of actors and institutions in policy making to enable the “opening up” of a broader analytical and political agenda that addresses the multiple processes and relationships through which the state and a wide range of non-state actors might engage in steering recognition as well as development of acceptable solutions to persistent social problems. The idea behind this evolution of modern governance systems from the traditional rule-based, hierarchical, top-down Weberian-type command and control state-led governance approaches into forms, such as networked governance, public-private partnerships, and adaptive multi-tiered and multi-actor/stakeholder governance, is that incorporation of such diversity of interests into the policy and governance process is not only thought to represent a more effective way to cope with complexity and incertitude, but it is also believed to produce a more flexible and responsive governance process for solving complex social problems [17–20, 50, 51]. The development of newer forms of reflexive and transition governance or management structures, which emphasize combinations of stakeholder involvement, trial-and –error policy experiments, and context-specific but network-based adaptive policy making, is in this regard an attempt to take a fuller account of dynamic and complex system responses in order to develop measures to steer rather than control system dynamics to negotiated ends [17–19, 21, 50]. However, note that while a diversification of actors may increase the range of values and perspectives to be brought into the policy arena, power imbalances (both in terms of financial and knowledge disparities) between actors mean that these approaches can also be considered as neoliberal strategies that aim to implement non-state-led solutions based on self-interest and commercially-driven incentives to reach social goals, as has been noted to constitute an emerging problem with current health policy in developing country settings [5–7].
Contemporary governance and management of NTD control
While some argue that such networks, by promoting shared problem-framings amongst people and institutions across globally-connected spaces, are an important means for placing issues of the marginalized on state agendas as well as for exerting moral pressure on governments to act [1, 4, 8], this needs to be balanced against several less positive outcomes. First, as noted above, problem definitions and solutions are largely driven by external global discourses leading to a hollowing out of the state and thus locally-relevant or context-specific solutions. Indeed, in this governance heuristic, the state is conceived simply as the implementing agency of policies developed largely by external actors/institutions. Paradoxically, thus while there is an attempt to open up policy making at the highest level of the hierarchy, the state is fundamentally seen as leading the delivery of what are essentially prescriptive, top-down solutions . While this shift can be considered as an example of a “hollowing out” of the state by leaching power away vertically , it is also instructive to note how such a hollowing out could be orchestrated by the state to work in favour of sustained, even enhanced state control [51, 54]. In this view, the state “manages” the risk of overload and failure by devolving some activities and powers, but retains key influence over policy agendas and strategies. A key result of this “crowding out” or hollowing out of regional planning contexts and perspectives, however, is a lack of knowledge and consideration of different preferences for public goods, which can impact local uptake and compliance with proposed interventions, including giving rise to conflicts regarding potential benefits at multiple scales and between different actors [8–11]. A growing body of anthropological work shows how such resistance to external disease control programmes may be closely linked to local understandings of disease, relationships to health and government officials, and past experiences with development projects . Second, as noted by many authors, the cultivation of “epistemic” networks of practitioners that share a common philosophical and theoretical mental construct in policy making also leads to the discipline-bounded vertical solutions typically observed in global health delivery. These solutions have been instrumental in the increasing fragmentization and “projectification’ of health care focused on specific diseases [6, 7], and the development of standardized, often pharmaceutical-driven biomedical interventions, based on perspectives emphasizing individual risk factors rather than the social determinants underlying health outcomes (eg. poverty, inequity, lack of development [5–8]. Finally, the approach reinforces the normal science technicist, managerial, command and control-type interventions with its attendant assumptions that preferences and solutions are well known and established, and a downplaying of system complexity and incertitude.
A complexity-based governance structure for NTD control
The preceding sections indicate that parasite control may represent a complex problem with uncertainty, non-linear dynamics and social involvement comprising the predominant characteristics, and that as such they are likely to defy reduction and empirical testing by the traditional normal science paradigm. These characteristics also underline the increasing recognition that the failure of science to resolve certain trenchant social problems may be due to uncertainty about whether the appropriate questions are being asked, and whether problems are addressed with the relevant theoretical and methodological tools and within an appropriate paradigm [15, 16, 20, 48]. These features indicate that the key components of a complexity-based governance framework for NTD- and indeed other parasitic diseases – control must, at the very minimum, include the means to reliably meet three major needs. First, structures and processes are clearly required that can assist with the inclusion of diverse perspectives. Second, development of approaches to enhance institutional learning are needed at all levels for both reflexively enquiring into and resolving the process by which values are constructed and used in making public choices so that these can be adapted according to local contexts and development needs. And finally, methods are required to institute recognition and accommodation of the effects of emergent system properties, i.e. that these are likely to produce unpredictable and uncertain future system behavior. Thus, the main objective of management in this regard should be to implement interventions that will facilitate steering of the parasite system towards a desired state while having the flexibility and adaptive capacity to cope with the inevitable surprise and unpredictability that will arise along such pathways [18, 38].
These are not merely theoretical arguments for a need for change in current NTD governance arrangements; this requirement is also underscored by the outcomes of previous global disease control/eradication governance configurations. Thus, while the global smallpox eradication began initially by rolling out a highly prescriptive approach (based on a simple and cheap technology blueprinted, designed, and specified at the top and to be implemented uniformly by rote at the bottom), it had to be replaced by a more incremental and adaptive implementation approach that even led to a complete revision of the original faulty assumptions (80% vaccination coverage applied uniformly everywhere was adequate for elimination, for example) and derivation of locality specific implementation strategies that had to mesh with health system deficiencies, difficult terrain, climate, and cultural beliefs (see Henderson, D. 1999: http://www.cdc.gov/mmWR/preview/mmwrhtml/su48a6.htm). Similarly, the history of the Global Malaria Eradication Programme (1955–1969) supports the same conclusion, viz. that a heavily top-down prescriptive approach based on simple technological tools will more than likely fail. Lessons from that failure highlight the fact that no single strategy can be applicable everywhere and that a long-term commitment with a flexible strategy that includes both active community involvement and integration with the local health system will be needed for successful parasite control [13, 55–57]. By contrast, examples of the governance of the soil-transmitted helminth, schistosomiasis and lymphatic filariasis control programmes implemented successfully in China and Japan point to how construction and application of a pluralistic framework based on: 1) local policy development accompanied by strong political commitment, 2) use of multiple interventions in an integrated fashion through intersectoral action, 3) adaptation of control options for specific eco-epidemiological settings and over time as the challenge of control changes, 4) active participation of the community and other stakeholders (both private and public), and 5) formation of strong linkages to research and learning activities using surveillance and monitoring data [58–60], will be important if we are also to similarly accomplish global NTD control.
What might the practical form of a complexity-based NTD governance organization look like? Recent work on governance structures better equipped to address and manage processes characterized by complex change suggests that this task technically requires addressing both institutional stability and change [15, 16], as well as the bridging of multilevel linkages [17, 18, 22, 23]. In this view, institutional stability is necessary for accumulating resources, including those needed for coordinating and implementing cooperative programmes, but at the same time, organizations need to be flexible, i.e. able to change in order to adapt to novel circumstances. It is thus thought that key to the establishment of these institutional structures is the efficient resolution or management of the tension that exists between the need to achieve “explorative” activities with the “exploitative” capacity of institutions, which contrastingly requires stable structures (and so some rigidity) [20, 61]. Accordingly, these practitioners have highlighted how constructs from organizational theory can be used to design or retrofit such a governance structure to enhance complexity-handling performance.
Future work and governance templates
Additional questions that need resolving for developing such a system would touch upon how best to create institutional rules and mechanisms to ensure incorporation of all perspectives into and cooperation among all actors in the NTD global-regional governance system, so that efficient discovery of methods and delivery of NTD control to endemic communities is made possible. This may also include establishment of means to leverage the existing power relations among dominant local/external stakeholders who direct current agendas and discourse in global NTD control so that parasite control can be delivered in a more locally-acceptable manner. Such processes will therefore also need to include structural forms best able to align preferences of citizens in the provision of control, including the means for making choices that give citizens a voice in collective decision making. Key needs here may include ways of how best to promote recognition by individuals of their interdependencies and their dependence on the global community to address certain issues, and the forms of incentive schemes that will lead to transformation of beliefs so that agents at various levels can internalize collective issues in their own system of preferences. The proposed establishment of village health committees in Tanzania identified by the government as an entry point for promoting community engagement in NTD control may be seen in this regard as an organizational approach to achieve this goal, particularly in terms of aligning interventions with local priorities and social norms .
A second question related to how best to enhance the explorative abilities of institutions at different levels engaged with NTD control, would be the derivation of management structures focused on nurturing learning and undertaking experiments, and the ability to respond reflexively and effectively to complex adaptive change over time. This also needs to include the means to address the politics of knowledge production for guiding generation of alternative local knowledge more effectively, and ensuring its diffusion so that stakeholders at all levels can make informed collective assessments, preferences and decisions better. An important requirement connected with learning and reflexivity is related to creating the institutional capacity for analyzing and explicating clearly the paradigms, philosophies and assumptions that underpin both chosen and proposed approaches to problem setting and solutions. Such explicit expositions will be critical for not only assessing the effectiveness of proposed methods for achieving sustainable NTD control but also for investigating how biases in thinking and action affect how programmes are evaluated and judged as successful or as failures [12, 18, 20, 27]. This conclusion echoes similar arguments made by Marchal et al.  for the importance of increasing capacity-building at all levels of the health administration for experimenting and learning about how NTD campaigns and general health systems interact.
Finally, there is a need to improve recognition at all levels that knowledge of the future is made difficult due to the uncertainty of future system dynamics. This means that there is a need to enhance management and scientific capacity to: 1) use monitoring data within a framework of multiple perspectives, values and needs, and 2) support adaptation of interventions as information grows so that rather than aiming for a set “optimized” solution, which assumes certainty in outcomes and hence linear cause-effect controllability, hypotheses and options are generated, tested and explored over time and under different socio-ecological contexts to steer an infection system towards effective, long-term control. It is interesting to note, in this context, that Madon et al.  found that village leaders in Tanzania have the potential and willingness to become involved with local monitoring of NTD control programs and to help find local solutions to reduce the burden of disease. This suggests that exploitable capacity may exist even at the local level for developing the type of learning frameworks required for searching and implementing bottom-up adaptive parasite control solutions in NTD endemic countries.
There are currently few examples of national NTD control programmes that have elements of these organizational requirements formally built into their management structures. However, the examples from China and Japan alluded to above indicate that specific structures that can accommodate an inclusive, pluralistic design to facilitate diverse perspectives from different stakeholders, are flexible and adaptive to the choice of interventions, and have learning included into policy and programme development, will be important. The exact organizational structures used in these countries are not well known, but work by Spiegel et al.  on how intersectoral action for health (IAH) programmes are implemented in Cuba at the municipality level offer a glimpse of the type of organizational structures that could serve as a template for developing a complexity-based NTD intervention programme. The key institutional innovation here is the Municipal Health Council linked to the health system that has representatives from various population sections, including the community, different sectors of the state, the local political party, and entrepreneurs, for serving as a forum to deliberate, adapt, and formulate local plans and activities for implementing agreed upon national health programmes . Another example is afforded by the Nepal Urban Ecosystem Health Project, wherein on finding that a purely epidemiological approach to echinococcus disease control was not sufficient to interrupt the transmission cycle, participatory approaches to engage relevant stakeholders in mutual learning and behavioral change – based on a negotiated vision and action plan, were enacted and found to be more effective . The key institutional changes made were: 1) creation of a decision space for ward officials and different community stakeholders to come together to work on practical initiatives to improve community life (but with echinococcus disease control forming one focus), 2) development of local “clubs” that took on specific tasks like organizing recycling drives and garbage pick-up, and 3) mobilization of support for on-the-ground action via organization of grass roots meetings with people from the community to analyze, resolve competing interests, and search for and act on feasible locally-acceptable solutions (https://www.idrc.ca/en/article/health-urban-environments). It is instructive here to note how incorporating community interests may require programmes to refocus disease-specific goals to also address the under-lying structural drivers of parasitic disease transmission (to include garbage collection and urban reneval activities, in this case), which could in turn help build long-term societal resilience to disease re-emergence [8, 47]. We indicate that social and organizational research into the configuration of similar systems tailored to different social settings, and how they may be practically constructed, implemented, sustained and evaluated, is now critically required to open up the debate on appropriate governance structures for undertaking parasite control in response to the complexity, variability and change typically representative of highly dynamic contexts.
Our discussion indicates that a more sustainable approach to NTD control critically requires a joining together of non-equilibrium thinking about the operation of complex systems from the natural sciences with social science perspectives to allow development of governance structures better designed to cope with the uncertain socio-ecology of NTD transmission and control. We have outlined and discussed an analytical framework that could be used to develop a governance process and structure that allows integration of these approaches for enabling the goal of achieving sustainable parasite control. What makes such an approach different from the traditional, positivist, reductionist, managerial, forms of governance is the focus on clarifying the strong link between content and process, and the emphasis placed on the importance of being open to policy searching, learning, deliberation and experimentation, while simultaneously having stable institutional components focused on achieving “exploitative” functions. It is founded on understanding the dynamics of complex, adaptive, socio-ecological systems, and how such understanding provides insights into the opportunities, limitations and conditions under which it is possible to steer or direct such systems in a collective, inclusive, manner. The justification for taking account of system complexity, review of the governance literatures, and the organizational analysis presented in this paper present a first attempt to point a way forward in this challenging but vitally important topic, not only in the context of NTD control but also with regard to the effective control of other major global diseases. Given the crucial role that social science methods play in clarifying the normative components and dimensions of such a complexity-based governance approach, this also means that social science research, including organizational and management science, must together with the natural sciences be at the heart, and not be pushed towards the periphery, of scholarship on NTD control. We echo Bardosh  in suggesting that the development of such coupled social and natural science scholarship is now critical given the increasing initiatives being developed for achieving the control of parasitic diseases globally.
Critical slowing down
Mass drug administration
Neglected tropical disease
World Health Organization
We acknowledge the technical support of Brajendra Singh in the assembly of the modelling results.
E.M. acknowledges the financial support of the Eck Institute for Global Health, University of Notre Dame, while S.M. thanks the British Academy for supporting the undertaking of this work.
Availability of data and materials
Please contact author for data requests
EM, SM: conceived and designed the study; EM: constructed the modelling review; SM, EM: conducted the complexity governance reviews; EM SM: interpreted the results and wrote the paper. Both authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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