Revisiting the starfish story

I’m sure you’ve heard some version of the Starfish story:

An old man comes out on the beach one morning, and like every other morning, he sees that the ocean’s tides have washed up dozens of star fish.  There is a young boy patiently picking up starfish, one by one, and tossing them back into the ocean.  “What are you doing, son?”  The old man asked, “there are hundreds of starfish beached.  You’ll never be able to get them all back in the water.  What difference does it make to toss a few back?”

And then punch line: 

The boy silently throws one back to the sea and says, “It made a difference to that one.”

And there we have it.  The notion that what matters is just what we do—the number we help.

This thinking pervades development.  Look at any annual report and you’ll see the “number of people served” in various forms—i.e. number of surgeries performed, assets distributed, people trained.  We’ll call this the “starfish mentality.”

My problem with this mentality is that is ignores the denominator—that is, what is the size of the total population that need this support?  Is it 50 or 5 million?  What percentage of the people that needed help were you able to reach?

At an event last week in Chennai, I was really inspired by a story that I heard about India's Aravind Eye Hospital.  After avidly reading about them for years, it was really exciting to hear in first person about their operations and strategy.

Aravind is the largest eye hospital in the world.  They perform many surgeries to restore eyesight and using a tiered pricing structure, are able to provide a number of free and reduced costs procedures while remaining sustainable.  They perform close to 370,000 eye surgeries a year, which just as a point of comparison, is about equal to the entire number of eye surgeries performed in England annually!

Most look at Aravind and say, well done!  But Aravind looked at its activities and said, there are seven million people that need these eye surgeries worldwide.  There is no way we can get to all of them on our own.  And so set up a programs designed to teach others how to establish their own eye hospitals following the successful Aravind model.  People have come from around the world to learn from them.  In Bangladesh, Grameen has set up three eye hospitals with much engagement with the Aravind team.  Aravind’s direct impact may be around 400,000 but its true impact, if you include the other hospitals it’s fostered, is much more.

In the 2013 annual report for Aravind’s Medicial Research Foundatiom, their founder chairman Dr. G. Venkataswamy writes,

Much has been done, but much remains to be done… we look to the future with renewed strength to continue the mission of providing  quality eye care and hope that some of what we have learned will be useful to other eye care  workers around the world.

Why don’t we see this philosophy more often?  The starfish mentality and all the factors that perpetuate it is a big problem.  Rarely are we asked for a denominator and consequently it becomes easy to think about impact through a telescope.

I like to think about scale in four categories loosely based on a old paper written by Uvin and Mills (full citation below):

Quantitative—how many starfish you toss back in the ocean

Functional—the range or depth of services that you offer the starfish.  Is it only tossing, or also a health check up, education, etc.

Organizational—teaching other groups how to toss starfish back effectively

Political—influencing policy to make sure that tossing starfish is promoted or even required

Generally the impact of non-profit organizations is measured by their quantitative and functional scale.  Yet I would argue that organizational and political enable successful models to scale far faster and broader than their creators could ever manage on their own.  For big problems—poverty, sanitation, literacy, etc. there needs to be much more emphasis on understanding the most effective models and actively working to disseminate them worldwide.  Donors in particular need to think about how to stop asking grantees to count starfish and instead set their sights on how to affect an entire population.

Kudos to Aravind Eye Hospital for thinking about indirect scale and going beyond themselves!  I’m very inspired and would love to know about more efforts like these.

Reference:

Uvin, P. and D. Miller. 1996. “Paths to scaling-up: Alternative strategies for local nongovernmental organizations.” Human Organization 55(3): 344-354.