Written by Katherine Trebeck (Edinburgh Futures Institute writer-at-large) and Professor Liz Grant (Assistant Principal for Global Health | Director of the Global Health Academy)
A few years ago, one of us – Katherine – was commissioned to write a report on what a children’s wellbeing budget might look like for Scotland. During that research, she noticed a pattern in the literature about children’s early years: in the introduction, there would be mention made of poverty, and perhaps inequality, but turning the pages beyond that, you’d barely see discussion of the way poverty and inequality impacts children, let alone what could be done about it.
Most of the ideas suggested were changes children or parents needed to make.
Professor Michael Marmot seems to have spotted a similar pattern:
interventions on individual…[are a] downstream intervention…There has been much less focus on structural interventions. If one went purely by the numbers of papers published, one would put effort into pharmacological treatment and would ignore housing; emphasise case management and ignore poverty.
The easier task is to intervene child by child, family by family, rather than to muster the effort to tackle wider dynamics which undermine children’s early years or health outcomes, such as poverty, homelessness, poor quality housing, and inequality.
There are understandable reasons why such downstream intervention might seem easier, some of which we want to explore here, but inevitably there will be much that we don’t cover (see particularly Paul Cairney’s work). Yet we hope that by recognising some of the constraints on upstream work, the task of dealing with them will become clearer. There are also a range of ways they can be dealt with, as we note at the end.
What is upstream all about?
Before turning to what upstream change is up against, it is worth reflecting on what upstream change actually entails.
Upstream change is basically about aiming for prevention: going to the root causes of a challenge. At its heart, thinking more preventatively is about asking why a situation emerged: what is the core issue (or issues) that created the problem and its visible symptoms?
Upstream prevention stands in contrast to constantly treating such symptoms, which is almost inevitably about ‘fixes that fail’: dealing with the same problem again and again, because the cause of the problem is not addressed.
The metaphor of a river is often used to explain the difference between downstream actions that come into play after the damage has been done, acting on the symptoms and helping handle the harm, on the one hand; and, on the other hand, actions upstream that prevent harm from happening.
Infact, the river metaphor reminds us that things are not always clear-cut: efforts are best mapped along a spectrum with lots of grey areas in between. So between upstream and downstream interventions, there is midstream (attending to harm that has happened and stopping it getting worse).
What do we find upstream?
Looking upstream entails understanding the contexts that people face: the circumstances we live in, the control and agency we can (or cannot exert), and the barriers that mitigate our progress. As the quote from Marmot above went on to say: ‘the causes of the causes should also be focused on’: rather than the immediate causes of ill-health, such as bad diet or smoking.
Dainius Pūras, when United Nations’ Special Rapporteur on Health, explained what these causes encompass:
People’s lives are often constrained by inequitable laws, structures of governance and power, and policies that stratify society, profoundly affecting human relationships and how people act throughout their lives…including in the political arrangements that allocate resources and enable (or restrict) the voices of those in the most marginalized situations.
Critically, Dainius Pūras makes note of power, stratification, and resource allocation. These are often functions of how the economy is configured. Prevention further upstream thus means reducing or entirely eliminating constraints such as poverty, unemployment, illness, illiteracy, homelessness, and so on. But, addressing such constraints by working on their economic roots is a heavier lift than papering over the cracks with sticking plasters. Here are some of the reasons why.
Upstream change demands long-term thinking
The holistic and long-term approach of upstream work runs counter to how governments tend to work and to how humans tend to think. For example:
- Action upstream almost inherently requires cross-departmental thinking and collaboration. In contrast, government departments often have a narrower focus that creates (the infamous) government silos, and with them the demarcated and often downstream thinking that is antithetical to upstream action. We are seeing some changes, with governments working to address this via cross-departmental and multi-agency working groups, a focus on policy coherence, shared budgets, and so on – but there is much further to do.
- People tend to be both strongly loss averse and tend to value short-term reward over longer-term gain. As seen below, this can cause problems for an agenda that is inherently hard to measure because it is about stopping bad things happening, and where results of preventative actions are invariably realised in the future.
- The same short-termism applies at the political level: long-term change of the sort required for upstream prevention often struggles to capture and preserve political attention in political contexts often characterised by short-term horizons and dominated by crisis response, downstream, issue by issue. This crowds out long-term visioning and planning and undermines exploration of different ways of doing things. Hectic responsiveness can create a sense that “now is not the right time” which can push longer-term transformation discussions onto the “important but not urgent” pile.
Hard to measure and hard to see instant impact
Upstream action is not only long term, but also complex. The causal pathways are messy and often challenging to pin down. Upstream action entails focusing on a wide population (as opposed to the unit of analysis being individuals at the downstream end of the scale). This means analysis and focus shifts from individuals to a wider cohort, presenting a challenge because benefits are more diffuse and thus harder to track.
These realities make impact difficult to track and measure. While some evaluation methods and some evaluators might be able to grapple with this, such methods and practitioners are not ubiquitous. As David Robinson says, often ‘evaluation bias[es] against the earliest action’.
Alongside an evaluation bias, there is a political bias to contend with. Politicians may not face agitation or demand for upstream action: research shows that people are ‘more likely to be concerned about an issue when [they] have experienced it, such as being directly affected by fires or floods’. Politicians also need to point to short-term actions with tangible impact so that they can promote their effectiveness as politicians.
Advocates, practitioners and policy makers also seek a sense of efficacy in their actions. This is a reflection of what motivates us as humans: the psychologist Tania Singer explains that while humans are driven by social goals and threats, we are also incentivized by a sense of achievement. When the impact of upstream work can seem intangible and into the future, the reality of human nature might divert efforts to downstream actions where it is easier to feel you are making a difference.
Upstream change also requires an approach quite different to that which many campaigners are used to. As Donella Meadows wrote, system problems are those which no one deliberately creates, or wants, but which emerge because the system produces them. Yet, this reality clashes with campaigning tendency to search for a villain. As former head of the Australian Treasury, Ken Henry, says, ‘Incrementalism sets up a single target on a battlefield occupied by well-resourced attack forces’. Geoff Edwards explains further:
When a social problem persists or a signature program fails to achieve its potential, it is common for those publicly responsible, such as the elected government, to seek to deflect blame by identifying a scapegoat. The media, and now social media (especially), join the hunt for someone to blame. This is usually complicated because every problem occupies the apex of a pyramid of causation populated by multiple actors, multiple points of vulnerability and multiple prior decisions.
Not only is upstream change about addressing the multiple elements in the ‘pyramid of causation’ as Edwards terms it, it is also about moving away from focusing on ‘heroes who save the day’. In upstream terms, heroes are those asking big questions and undertaking grand challenges.
Acute needs are real….and spending on them is rewarded
Profound immediate needs downstream mean that resources understandably get channelled there. Alongside a diversion of resources, the critical nature of immediate challenges can crowd out space for longer-term thinking and planning, let alone change. This flows from a (perhaps implicit) assumption that resources, attention and action are finite.
Perceived urgent needs can thus trump longer term change. For example, environmental protection objectives are sometimes resisted in the face of demands for the immediate imperative of job protection and job creation.
While elected officials might assert their support for investment that prevents harm in the first place (as many do), as noted earlier political realities mean they are more likely to favour “ribbon-cutting moments” of (announceable) downstream spending that allow them to portray themselves as taking action. It has been noted that a relatively easier option for politicians is to deploy money in responding to a problem. Writing a cheque tends to appease those agitating for a specific issue and seeking urgent action. And, as discussed below, it also enables avoidance of the almost inevitable disruption to the status quo that tackling root causes necessitates.
Another aspect of this challenge of working upstream is that spending on downstream responses will most likely be counted as a positive in a nation’s dominant ledger of success: Gross Domestic Product. This is one of the inherent perverse incentives of GDP: it does not distinguish between spending as a response to damage once done, nor celebrate preventing that damage occurring in the first place (as a heart-doctor friend of ours recently pointed out, the better she and her colleagues are at their job, the more likely the country is to record a recession in GDP terms).
Needs governments to go beyond ‘market knows best’
The economic system change that really goes upstream demands a profound challenge to the status quo and prevailing mindsets in many government corridors. It requires governments to proactively support particular economic activities (those aligned with the needs of people and planet) so that such activities comprise more of the economic ecosystem. For example, government might be able to use fiscal incentives to encourage certain economic activities (lowering taxes for worker cooperatives, for example) or encouraging business development practitioners to provide information about business ownership models that share wealth more equitably. Being honest about this task is likely to elicit cries of ‘market interference’ or government over-reach, despite the reality that most governments already do this for certain activities via subsidies (for example to fossil fuels) or preferential taxes (for example on labour rather than economic wealth or rents).
So reshaping the economic system to prevent the harm that the prevailing economy creates inherently challenges prevailing ‘common sense’. As Mason and Büchs conclude, champions for upstream economic change within government:
face opposition within their own institutions, which is likely to limit what they feel able to say and do. Economists in ministries and other political organizations have predominantly received neoclassical economics training; and thinking around GDP as a measure, economic growth as goal, and capitalism as we currently know it, are still widely accepted among their colleagues.
Challenging current systems of power and privilege
Similarly, the shifts in power and distribution of resources required to build an economic system which works for people and planet amounts to transformation of the current regime. There is no shying away from that, but such transformation of power and privilege is evidently harder to muster support for, let alone deliver, than reforms to the existing system.
Shifts that call for too much change and or are perceived as ‘radical’ are likely to be resisted. As mentioned, as human beings we are infamously loss averse – so fear of change, even change from difficult circumstances, is rife. We gravitate to decisions that offer ‘cognitive ease’.
Speaking of what humans gravitate to, certain groups find it easier to elicit support – such as children. Yet upstream analysis would reveal that children’s experience does not exist in isolation. For example, children’s lives are impacted by the labour market experience of their parents and careers, by the safety of their local community, by the housing their family is able to afford and access, by how well education services are delivered, and so on. Efforts in these realms is where upstream action needs to sit, whereas channeling focus on children themselves might divert effort to more downstream interventions.
Outside government, reshaping the prevailing economy will be hindered by recalcitrance from those who feel the current system is adequate. These actors tend to use their channels and influence to reinforce and uphold dominant thinking, thus perpetuating tinkering around the edges of the current set-up and responding to its symptoms, downstream, one at a time.
Asking big questions and working to change the system will also confront those who believe the current economic model benefits them and who worry that shifting to an economy designed for greater fairness and sustainability might bring a loss of pride, status, power or influence that they enjoy by virtue of the current economic model. In such instances, they might seek to block interventions needed for upstream change. This can manifest as outright hostility: creating political heat, picking off soft supporters by briefing against the agenda, and creating divisions among allies of the agenda.
And even if both government and public were up for it, is it possible given the current institutional set up?
Not only does upstream change require challenging prevailing systems of power and privilege, it also needs to either be undertaken via the current institutional and governance configuration. Unless this configuration itself is transformed to enable the economic shifts that are necessary for upstream change, things will remain static and the best we can do will be improving the sticking plasters put on downstream damage.
However, the current economic configuration derives staying power due to the very nature of its incumbency, held in place by routine ways of doing things, existing legislation and policies, and path dependencies. As Bache explains, bureaucracies come with an ‘inbuilt inertia…that give a comparative advantage to existing ideas and practices’. One aspect of this is informal and cultural: current systems have around them established networks, relationships and hierarchies of status. Consequently, there is a powerful weighting against change, no matter how sensible.
Conclusion
These challenges are significant, but they are not solid. They can be attended to and addressed, via, for example:
- Governance innovations such as Future Generations legislation which help extend decision makers’ horizons
- Governmental ways of working that enable cross-departmental collaboration such as diagonal budgeting, working groups comprising representatives from a range of departments, secondments, and multi-departmental budget bids
- Evaluation processes that incorporate theories of change, causal pathways, contribution analysis, and the precautionary principle to enable mapping of the benefits
- Additional pump priming parallel investment in upstream change so there is no conflict between that and attending to acute needs
- Beyond-GDP measures of success that focus on beneficial outcomes rather than tallying up spending on downstream harm as a positive
- Pluralism in economic teaching and advice to government, alongside work to change the terms of the debate about economic change possibilities
- Deliberative dialogues to demonstrate public appreciation of the need for upstream change and to build a broad base of support for upstream economic system change that can counter blockers
- Bringing thinking about one’s legacy to the fore
- Sharing examples of how change will make a difference in terms of stronger communities, less harried work life, a restored environment and so on, even if those who currently sit atop huge wealth will have less of it in the process
- Rewards for politicians and civil servants making long term investments, for example via civil society recognition of their efforts and internal promotion, funding, and so on
- Investing in systems changers, not just heroes that slay villains
- A movement of upstream change agents to support each other and celebrate the contributions each are making
These are practical actions that can be taken to bolster upstream economic change. There are instances where they have been implemented in various parts of the world, demonstrating that it is entirely possible to train the policy gaze upstream and to shift away from the treadmill of crisis-by-crisis responsiveness.
