Two decades have passed since the Positive Deviance (PD) approach was created. It has had a fascinating journey, from the rice paddies of Vietnam in 1990, where the first PD seeds were planted, to new seedlings in the deserts of Egypt and Mali and the tropical lands of Indonesia and Congo. It has even flowered in the intensive care units of some American hospitals in the past five years.
What is Positive Deviance? It is an approach that brings successful and lasting results to seemingly intractable problems that cannot be resolved by expert-driven methods or technology alone. It starts with the observation that in any ‘community’ (this could be a village or a company), there are individuals whose uncommon behaviours and strategies allow them to solve problems where others have failed. The community in question takes the lead in identifying these Positive Deviants and their behaviours, and then takes action to begin practising these solutions (as opposed to merely giving people information about them).
While looking for existing solutions already practised in our midst sounds like common sense, this is rarely the way we solve problems. The most common solution is to call in an ‘expert’ or copy a ‘best practice’ developed somewhere else. Sometimes this works, but often the solution is inappropriate for a particular context or faces resistance from the community. As well as starting with existing solutions that have proven successful in the local context, PD can be distinguished from other approaches by a number of elements.
First, the community takes ownership of the process from the get-go. Second, all stakeholders are involved, not just the usual suspects. Third, ‘leaders’ do not lead, but rather facilitate, the PD process, removing barriers so that community members can take action. Fourth, the process results in the expansion of existing formal and informal networks and the creation of new ones.
PD is most powerful when confronted with stubborn challenges that other approaches have failed to resolve. Worldwide, child malnutrition contributes to the deaths of almost seven million children under five and results in permanent stunting and reduced educational achievement for millions more who survive. In Egypt, 97% of women who are (or have been) married have suffered the trauma of female circumcision. These are issues for which ‘technical’ solutions are known but have proven hard to put into practice. Using the PD approach, poor communities with a high level of malnutrition in 41 countries around the world have significantly and sustainably reduced childhood malnutrition. In Egypt, advocacy agencies and their local partners have been able to prevent the circumcision of thousands of girls.
How, then, does PD, which emerged in the early 1990s from NGOs working on typical international development issues, relate to entrepreneurship? There are at least two ways in which PD can be useful: by helping social entrepreneurs to improve their performance and by helping to unlock the entrepreneurial spirit in the public sector.
While PD originated in the NGO sector, for-profit businesses have used the approach to improve efficiencies and increase revenues in ways that are of particular interest to social entrepreneurs. One example is the case of pharmaceutical corporation Merck. In 2005, Merck Mexico’s sales of Fosomax – the blockbuster osteoporosis drug – ranked last among all countries in which it was sold. With the patent expiring in 2008, Merck Mexico was desperate to improve its sales. Through a participatory process and the involvement of all the district managers and sales reps, it discovered why, out of more than 200 sales reps in 41 districts, only 15 were meeting or exceeding their sales targets. By shadowing PD reps for several days, district managers and sales reps learnt to identify a range of enhanced marketing, sales and post-sale follow-up tactics that deviated from the norm. Some of these were techniques that might have been suggested by an outside expert. But the fact that the staff whose behaviours needed to change ‘discovered’ the tactics themselves, and saw them being practised by their peers, meant that they were less likely to reject them. In fact, the debrief meeting ended with all participants committing to try out at least one of the PD behaviours. The results: by the end of the year, all 41 districts met their Fosomax sales quotas and Merck Mexico achieved and maintained the highest market share (45%) of all countries in Latin America.
PD can also help social entrepreneurs to identify enhanced practices that may enable them to thrive (or at least survive) in some of the most challenging economic environments. While many donors have tried to promote the small and medium-sized businesses that are an important source of employment and growth, these top-down efforts are often stymied by barriers including lack of access to finance, bureaucracy, poor infrastructure and corruption. Yet the informal sector in many countries is incredibly dynamic and offers potential lessons.
On the Frontier (OTF), a for-profit organisation, supports social enterprises in more than 24 countries across three continents, from Southern Sudan to Guatemala. OTF plans to use the PD approach to boost entrepreneurship in some of the most fragile states. The challenge for OTF will not be to identify who is successful, but rather to enable the local community of social entrepreneurs to work out why the PD businesses are successful so they can begin practising those behaviours and strategies that work. PD is not about identifying a single individual and then copying them in every way; it is about identifying the behaviours and strategies of a number of positive deviants and getting others to practise as many of these behaviours as possible. In this way, it taps into the collective wisdom of all the local positive deviants, as opposed to trying to replicate
a single successful model.
Positive deviance in the public sector
In the current fiscal environment, the debate about the role of the state has regained prominence, with many suggesting that the scope of public-sector activities needs to be reduced given the poor performance, lack of incentives and generally sclerotic character of the public sector compared with the supposed nimble efficiency of the private sector. PD is one tool that has proven effective in dramatically improving public-sector performance, in terms of both incentives and results.
Nowhere is the role of the public sector more debated today than in relation to healthcare, with Barack Obama’s fiercely contested reforms in the US and Britain’s perennial hand-wringing over the performance of the NHS. Contrary to popular perception, the US does have a major public-sector health delivery mechanism: the Veterans Administration (VA) Health Services, which provides care to former service personnel through a network of 153 hospitals.
Like private hospitals, the VA system has struggled to contain the threat of MRSA. The number of annual MRSA infections in the US has steadily increased from 2,000 cases in 1993 to 380,000 in 2005. MRSA is particularly difficult to treat, since it is resistant to many or all of the standard drugs usually used to treat the infection. About 20% of those with serious MRSA infections die and those who survive often need additional medicines and surgeries (MRSA adds an average of $27,000 to the cost of treatment). Thankfully, the ways to prevent transmission of MRSA are well known and fairly basic: hand washing, proper gowning and protection, rigorous disinfection of hospital environments and so on. Why, then, does MRSA continue to kill? It turns out to be much more difficult than expected to ensure that hospital staff – even highly educated surgeons and infection control specialists – regularly practise these precautions, despite the efforts of countless consultants and expert panels.
In 2005, the VA Pittsburgh hospital decided to try using the PD approach to address the MRSA problem. They brought together all the departments in the hospital to identify
PD behaviours in their midst. The majority of the practices they found came from unlikely people who had never been included in the previous top-down efforts to control MRSA: the janitor who knew how to clean the hard-to-reach places in a patient’s room, the priest who made sure to sanitise his Bible as he went from patient to patient and the nurse who knew how to subtly violate the unwritten power rules so that she could remind surgeons to wash their hands without getting in trouble.
Following the success in Pittsburgh, where there was a 60% reduction in infections, the PD approach, once integrated into an MRSA prevention bundle, was expanded to 17 beta-site hospitals in 2007 and to the VA system nationwide in early 2008. A recently published study of all 153 VA hospitals nationwide found a 62% drop in the rate of infections caused by MRSA in intensive care units over a 32-month period.
PD has been used in another famously challenging area of public service delivery: education. The school system in the Argentinian province of Misiones was able to bring the previously feuding parents, teachers and school administrators together to achieve a 50% reduction in primary school dropout rates. These experiences suggest that PD can be a valuable tool in identifying those within the public sector who have innovated. By unlocking the entrepreneurial spirit of service providers, it can drive significant improvements in performance.
Many entrepreneurs already take a PD-like approach, looking for elements that may already be working and combining them to create something even better. The innovation in enterprises usually comes from the bottom up, with most top-down efforts to encourage entrepreneurship encountering only limited success. Many entrepreneurs demonstrate the truth of ‘learning by doing’; it is through continual practice, rather than academic knowledge, that they are able to succeed. Entrepreneurs are famous for starting with their own resources and building things up with minimal external assistance (at least until they start meeting their angel investors).
There is perhaps one major difference between the PD practitioner and the typical entrepreneur. To be a successful entrepreneur, it is important to jump in, take risks and personally assume the lead in launching the new enterprise. With PD, the objective is to encourage others – whether they are hospital staff, entrepreneurs or rural villagers – to take the lead. PD forces us to play a more facilitative role, leading from behind. In this sense, PD practitioners are probably not entrepreneurs themselves. Instead, they aim to cultivate dozens or hundreds of other ‘entrepreneurs’ who can themselves address a range of socioeconomic issues.
Monique Sternin is a senior adviser at the Positive Deviance Initiative at Tufts University and Sam Sternin is a field director at the Development Innovations Group. Richard Pascale kindly provided feedback on this article.
The Power of Positive Deviance: How Unlikely Innovators Solve the World’s Toughest Problems, by Richard Pascale, Jerry Sternin and Monique Sternin, is published by Harvard Business Press.
Photography: Axel Lauerer/Getty