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Struggle with the knot: push and pull systems

by Michael Keizer on May 26, 2010

Post image for Struggle with the knot: push and pull systems

Ordering systems come in two basic flavours: push and pull, plus any number of hybrid systems. All have pros and cons, and each is most appropriate for a specific situation. In this first article in a miniseries on push and pull systems, I will discuss the basics: what exactly are pull and push systems and when would you use either.

Push versus pull

In the push model, “higher”, central levels decide on supply allocation for “lower”, local levels; these decisions are typically based on supply at hand and in the pipeline, and on calculated expected consumption – the latter often approximated, based on (in the case of medical supplies) patient numbers or population data. In the pull model, “lower” levels decide on the necessary supplies for the next supply period, which are then either procured independently or obtained/ordered from the “higher” level.

The basic difference between the two models is the responsibility for timely, complete, and accurate initiation of distribution: in the push model this is the “higher” level, in the pull model the “lower” level. Click here to read more about push and pull systems


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'Crate containing Leg Lamp' by J Stewart

You have designed and implemented a pretty good logistics system and are proud of how effective and efficient your aupply line provides your programmes with any materials they need. Transport and administration cost are now at their minimum, fulfilment rates are close to 100%, and you process and fill almost every order within set timeframes. You feel pretty good about yourself (and not without reason), and are ready to hand over the system to your successor with justifiable pride.

And then the ministry of trade announces that as of tomorrow, clearing rules will be changed, adding three weeks to the current four to five days it takes you to clear your goods. Suddenly things look a lot less optimistic: your carefully balanced and trimmed-down supply chain is strained to the snapping point, and you are looking at having some of your key operations suspended. Even worse: one of those is a treatment programme for TB patients, and suspension of treatment might cause resistance to the drugs involved – making a bad situation suddenly look catastrophic. What went wrong? Click to read on.


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The challenge of reverse logistics in global health

by Michael Keizer on January 2, 2010

The Valley of the Drums, a toxic waste dump in northern Bullitt County, Kentucky. This site was one of the reasons the the U.S. Superfund law was enacted.

Have you ever thought about the reverse logistics in your supply chains? Very likely if you are involved in medical logistics, but probably not in those terms: reverse logistics is not something that comes up on a daily basis in discussions in our field.

Reverse logistics is basically what happens when goods need to flow back in the supply chain. The most obvious example is of course when expired drugs need to be sent back for proper disposal, but reverse logistics might actually be more common than you think: disposal of materials and equipment, recalls, returns of overstocks so they can be used somewhere else in the organisation: these are all examples of reverse logistics.

Yet we hardly ever put systems into place that deal with our reverse logistics; possibly because it is seen as an exception instead of the regular occurrence that it actually is in many organisations. The results are predictable: losses and negative side-effects are common. Some examples:

  • Financial losses Most organisations would have tight controls on expensive goods as they travel through the ‘normal’ supply chain. However, I have seen many instances in which these controls were absent or much less stringent when dealing with reverse logistics. In one example, when trying to see what happened with a large generator (value: several tens of thousands of dollars) after it was sent back for repairs, I discovered that nobody had actually followed up after it was sent back and a replacement arrived, and in the end it was untraceable. This was a big and unnecessary loss for the organisation.
  • Negative health effects If expired drugs are taken from the reverse supply chain and used (possibly after having been sold on the local market), they can wreak havoc on the health of the people using them; some drugs become toxic after some time, but even those who do not will probably start losing efficacy and would be as bad as under-strength counterfeit drugs – and that is even apart from the effects of uncontrolled use of e.g. antibiotics on the development of resistant strains.
  • Environmental damage Drugs might be beneficial for us, but they are not always so for our environment. Many drugs are toxic for other animals and plants; and even when they are not, it is not always clear what would be the long-term effects on the environment of uncontrolled dumping of drugs. That alone should be enough to have tight controls on what happens with expired drugs and how they are disposed of. This is even more true of e.g. used engine oil and other toxic waste: do you know what happens after an oil change? Is the oil just burned, or even worse, buried, possibly poisoning ground water for years to come? Or is it properly disposed of in an incinerator that reaches temperatures that are high enough to prevent hazardous fumes to be formed?
  • Legal liability In many countries where we work, there are strict laws surrounding disposal of drugs (especially psychotropic drugs), and ‘losing’ drugs in the reverse supply chain can open us to legal liability. Similar issues arise around environmental damage.
  • Loss of reputation Although there is still not much press attention for aid and global health organisations’ records when it comes to the effects I mentioned above, I don’t think it will be too long before our actions in this area will be put under the microscope as well (as they should be). Do you really want your organisation to be the first of the black sheep that will be singled out for our atrocious reverse logistics practices?

It is clear that we need to start working on our reverse logistics. It should not be too hard: the basic principles and best practices that we use in ‘normal’, forward logistics, can be used in reverse logistics too. The only question is: do we start working on this now or will we wait until it is too late?


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My previous article about I-See technology was the first post on what looks to become a mini-series on logistics information management; it gave me some fresh ideas for new posts, and why not go with the flow when you’re on a roll?[1]

This one will be about logistics data and what to do with it. Hello, are you still there?

A couple of years back, I was asked to analyse and improve on a supply line for an international NGO in an East-African country.[2] My first obvious question was: how bad is it actually? They didn’t know: although everybody knew that hardly anything was delivered on time and that there were a lot of mistakes in order fulfilment, leading to frequent stock-outs and overstocks, nobody could really give me any hard data – it was all seat-of-the-pants. When I asked what caused the problems, and where in the supply line they occurred, I was told that that was why I was hired, and could I please get on with the job?

By the time I left, I was told that the supply line had never worked as well as it did, and that I had done a sterling job; but had I?

I think it is time to let the cat out of the bag on that one: in fact, the supply line hadn’t improved a bit – at least, after I started measuring things, my indicators remained fairly flat. In fact, they showed that the supply line really didn’t do that badly even before I arrived, taking into account the context.

What did change, though, was that I used the increased supply chain visibility to give useful feedback to field managers, both logistical and operational ones. For the first time, they would know when to expect their supplies, and would be informed at an early stage if things seemed to go off-track; which meant that they could plan for it and start taking contingency measures at an early stage. I also started to churn out regular one-page overviews of how the supply chain was actually doing, which showed nicely that we didn’t do too badly. Of course I presented this as a big improvement: nobody wants to be told that they were actually quite wrong.

Now this is a nice story, but how would this have helped me if, in fact, the supply chain had been the shambles people thought it was? Having increased visibility would at least have helped me to find out where exactly in the supply line the problems occurred, and perhaps even what caused them; it would also have enabled me to see whether my remedies worked, and to which extent – it would even allow me to try out various measures, and see which one (or which combination) worked best. And finally, it would possibly have helped me to argue my case when expensive or painful measures would have been necessary.

All this turned out to be moot, and I got kudos for what was a fairly easy job. Want those kudos too? Then start working on your supply chain visibility.

[Image: Kudos Buddy by Adam Fagen. Some rights reserved.]

Back to post [1] I just love mixing my metaphors. It’s like those chemistry experiments I did in school, with sometimes similarly interesting (or malodorous) effects.
Back to post [2] Sorry, can’t be more specific than that.


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Do you see? Technology aiding supply lines – or not

by Michael Keizer on November 11, 2009

Does your organisation currently have an IC technology project running that aims to improve the supply chain? Odds are that it has, or has had one in the recent past, or is planning one for the near future – that is, if your organisation is anything bigger than a couple of volunteers with a budget of a couple of hundreds of thousands of euros. And you should: continuous improvement of your supply chain is a necessity, and ICT is indispensable to do so.

Or rather, you shouldn’t.

Too often, ICT is implemented as a stand-alone solution for supply line problems. ICT is indispensable to support any but the most trivial of supply lines, but rarely is it a solution by itself for whatever are your supply chain woes.

Does this sound like a truism to you? In fact, it does to me – but I have seen several of these ICT-as-a-panacea projects in aid logistics, so I think it is fair to say that apparently not everybody agrees. Oh, of course management of these projects will pay lip service to the idea that processes, attitudes, knowledge and training, and many other aspects will need to improve too, but in reality you see that everything concentrates on the technological solution: processes are adjusted around the technology, staff are trained in using the technology, and so on. And there we go again, in a straight line towards the next round of ‘technological innovation’.

ICT can help us to build systems that help us get the right information, at the right time, to the right people, at the right price, to make the right decisions and take the right actions. (Sounds familiar? It should.)

But: the operative word here is ‘system’. No, I am not talking about computer systems – when I say system, I refer to (ahem) ’a coordinated whole of human, physical and organisational resources (including procedures and structure), striving for a common goal’. In other words: your logistical department is only just part of the organisation’s logistics system (striving for logistical effectiveness and efficiency), which in its turn is part of the system that is your organisation as a whole (striving to perform whatever is its stated mandate as effectively and efficiently as possible), which in its turn… you get the idea. What is not a system is the shiny new ERP software that your director of resources has just bought after a slick demonstration; it could be part of an effective and efficient system – or it could break it.

I said it before and I will say it again: information and communications technology are indispensable to run anything but the most trivial supply lines; but it is there to serve the goal of those supply lines, and not the other way around. Technology should be part of an integrated system with more or less clearly defined goals. The systems should not be built around the technology, because that will hardly ever lead to real integration; instead technology, procedures, and people should be seen as a indispensable parts of the whole system, giving us eyes to see what is coming – I-see technology instead of IC technology.

(Image: Airborne Caffeine Delivery System by Todd Lappin. Some rights reserved.)


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Supply chain risk management

by Michael Keizer on May 25, 2009

A lot has been written about how to deal with logistics disasters, or how to avoid specific types of mishaps. Much less attention is given to the process of managing those risks.

Risk management for the supply chain is not really different from generic risk management. Like all risk management processes, you start by making an inventory of possible risks, based on your environment, the programmes that you try to support, possible future scenarios, etcetera. This inventory includes the nature of the risk, its likelihood of occurrence, as well as its possible and likely impact. The result should be an overview of the possible extent of risk for each of the risks that you list. Some examples:

  • If a meteorite would hit your main logistics hub, you would be in dire straits indeed. However, the likelihood of this happening is vanishingly small. As a result, the extent of your risk is still very low.
  • If one of your 15 drivers would fall ill, it would probably not pose much of a problem; however, the likelihood of this happening in any given year approaches certainty. Still, because of its low impact, the extent of the risk would be low.
  • Having your one and only purchaser fall seriously ill would not be a big problem in a well set up system, in which everything is well documented. The likelihood of this happening is also quite small, so the extent of the risk here is very low.
  • However, if documentation is sketchy and most of the knowledge about markets and suppliers is locked up inside the head of your purchaser, the impact of this happening would be a lot bigger. Suddenly, the extent of your risk is now medium or possibly even high.

This last example points to the importance of the risk environment when performing your risk analysis. (It also points towards a possible way of dealing with it, about which more later.)

The next step is to design a strategy to deal with the risks. All risk strategies can be divided into four basic categories: avoid, reduce, transfer, and retain. In our example, this would mean:

  • Avoid: an avoidance strategy could take the form of not doing any local purchasing, or perhaps withdrawing from the programme. This illustrates that avoidance strategies are rarely feasible in the environments in which we work, but nevertheless they should be considered.
  • Reduce: ways in which we could reduce the extent of the risk include hiring a second purchaser (reducing the likelihood of being marooned without a purchaser) or ensuring good systematic registration and documentation (reducing the impact of the purchaser falling ill).
  • Transfer: we could outsource our purchasing to an external company, using service level agreements to ensure that they deliver what we we need, when we need it. This is not a very likely scenario for most of us, but it is something that we often do with e.g. air transport: we transfer the (very real) risks linked to these operations to e.g. a charter company.
  • Retain: we could decided that the extent of the risk is so small (e.g. because we hardly do any local purchasing anyway), that we take no action and leave things as they are. In other words: grit your teeth and suck it up.

A risk management plan basically consists of the risk analysis, with the appropriate strategy for each of these risks. Risk management plans for multinationals often comprise whole volumes (or, more and more often, many Gigabytes of documentation, code, and data), but for most field operations there is no need to go to that length: two to five pages would normally be enough. On an organisational level, it will obviously depend on how big your organisation is as well as its nature: the risk management plan for a two-project, one-country educational organisation will probably be not much more than the one-page result of a day’s hard work, but WFP’s risk management plan will more likely resemble that of a big multinational company.

However, whatever the size or nature of your organisation: you cannot afford to go without some form of risk management; organisations that think they can tend to be unpleasantly surprised at some stage.


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What to bring on a logistics deployment

by Michael Keizer on April 22, 2009

The ever-interesting Chris Blattman published a list of things to bring for field work. A very useful list, I should add, and some of the suggestions in the comments are very worthwhile too. Just don’t try to bring everything that’s in there.

So what specifics would I add for a logistics deployment?

  • A clicker (one of those thumb model counters). Will help you immensely during verification activities.
  • Cling wrap. Has more uses than I can easily mention here, but for starters: repairing leaky containers, repairing car windows… actually, combined with some duct tape, it can repair almost anything — even, in an extreme situation, some bodily harm (but get to a doctor ASAP).
  • So the next one, obviously, is duct tape. More uses than you or I can even imagine.
  • Sticky labels, A6 size (4 on an A4 page), printable. Again, more uses than you would expect.
  • Permanent markers. You will always see that you need them when there are none around.
  • An el-cheapo digital camera, preferably one that can make rudimentary videos. Worth its weight in gold for training purposes.
  • The electronic version of the ordering catalogue of whichever organisation you are working for. Your organisation is too small to have a catalogue?[1] Get one from a bigger organisation with similar activities (so in the medical area the MSF catalogues, for education UNICEF, for water and sanitation OXFAM, etcetera). This will help you immensely when ordering yourself or when getting people to be more specific on their orders.
  • Your organisation’s logistics, admin, and financial procedures in electronic form, including the standard forms used.

So what do you take with you when you go to the field?


[1] Actually, your organisation is not too small. If it is big enough to have more than one programme, it is big enough to have a (rudimentary) catalogue.


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In my previous post on why logistics seems to be so prone to “herding cats” problem (thanks, Laura Walker Hudson!), I suggested five  reasons:

  • The complexities of logistics are “deep” complexities, and are not readily apparent.
  • Daily logistics experiences are not always applicable to large-scale logistics.
  • Our evidence base is sketchy, which has a ‘halo’ effect on all logistics activities.
  • There are hardly any aid logisticians with a recognised advanced degree in the field.
  • Aid logisticians are not the biggest fans of systems or administration themselves.

So what to do about his?

1. Work on the evidence

This is easier said than done. However, we will need something more than our gut feelings and personal experience to be able convince our colleagues. Other areas in aid routinely publish about lessons learned — why don’t we do so in logistics?

  • If you have seen (or developed) a particularly successful technique or method, or seen a received one wreak havoc in a particular setting, don’t keep it to yourself: write an article for an appropriate journal.
  • Think how you can incorporate research in your daily practice and do so. Most aid organisations, and defintely most health organisations are open to facilitate research as long as it does not inconvenience their programs too much. Health and humanitarian disciplines routinely do research within programmes, but logistics rarely does.

2. Explain, explain, explain — and learn

Too often, we do not explain why we want to do certain things a certain way: why is it necessary to fill in that request form, why can’t we just go to the pharmacy and take what is needed, why do we need to make consumption forecasts? Be didactic; and be proactive about — don’t wait for your colleagues to ask, because they will only do so when their irritation level is already high. And if you feel that you cannot explain, rethink — perhaps we are on the wrong track.

This holds true the tactical planning level as well: why do you elect to go for six-monthly order cycles and not three-monthly ones? Why do you select these suppliers and not those? Why do you procure your drugs in Europe and not locally? Include in your explanations why logistical solutions that work at the level of one patient, one time, will not work at the level of a large-scale intervention.

Make sure that everybody understands (or at least has a chance to understand) what you are doing and why, and you will see that it will suddenly is much easier to implement your systems. You will also get much better feedback — and who knows, that feedback might lead you to reconsider your plans and improve them beyond recognition.

3. Get a recognised qualification

Get that master’s degree in aid or health logistics, and see how much more recognition you suddenly get (and how much deeper your understanding of what you do will be).

I am working on my second master’s degree now (in public health, specialising in health logistics for develing countries), but my first one was only sidewise related to aid/health logistics. Already I notice that people take more account of what I am saying, just because they feel that I somehow ‘earned’ that by studying the field. Utter nonsense, of course, but it is how the game plays — and you’d better play along if you want to have the impact you know you can.

Working on my MPH has also given me an opportunity to better integrate my knowledge. It haven’t yet learnt much that was completely new to me, but I am now better able to put things in their context, and to see links between seemingly disparate pieces of knowledge that I did not see before. It also enables me argue more convincingly (not necessarily better, but definitely more convincingly) because it has given me better knowledge of the language of health and health professionals. And finally, it has enabled me to expand my network in global health, which means that I know who to call next time I have a problem that I don’t have a good solution for, or when I think that I need specialist input for.

Get that qualification — it’s worth it.

4. Don’t undercut yourself

When the unexpected happens, don’t throw your logistics systems overboard and get into emergency mode. First think how you can accommodate the issue within your existing systems. By giving the right example, you can show the importance of those systems and that they are not just impediments to getting our work done.

Don’t change systems without in-depth understanding. Many logistics managers in aid, especially in emergency aid, have very clear ideas about how things should be run and do not hesitate to change things in the first couple of weeks (or sometimes even days) after they have arrived. However, your predecessor probably was not a fool either, and would have had reasons to implement the systems the way they did — based on what they knew after having worked for some time in that particular setting. Don’t change systems before you have been in the programme at least six weeks to two months — and for developmental programmes even longer. Changing things too fast, too soon, will only serve to undercut yourself and future logisticians.

And finally: follow the systems yourself. Nothing will undercut your authority as quickly as a ‘do what I say, not as I do’ attitude.

(Image by Todd Lappin)


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Vaccination; 041028-N-9864S-021 Yokosuka, Japan (Oct. 28, 2004) - Hospital Corpsman 3rd Class Tiffany Long of San Diego, Calif., administers the influenza vaccination to a crew member aboard USS Kitty Hawk (CV 63). Currently in port, Kitty Hawk demonstrates power projection and sea control as the U.S. Navy's only forward-deployed aircraft carrier, operating from Yokosuka, Japan. U.S. Navy photo by Photographer's Mate Airman Joseph R Schmitt (RELEASED)

“That would never work here.”

I have had to listen to this reply more times than I can easily remember. It will usually come up when I propose to put procedures into place instead of continous ad-hoc decisions, standardisation instead of reinventing the wheel time after time, or proven solutions from other places in a new setting. There is a little devil in all of us that tells us that we are unique, that what works there will never work here, that every little decision we take needs our 100% attention.

Reality is different, and we only need to look at our daily lives to see everyday proof. Do you agonise daily which to put on first, your socks or your shoes? Do you feel that, in your case, it really is a good idea to keep on breathing while you swallow your soft drink? Do you try to walk through closed doors, just to see if that might lead to better results? Or will you today drive to work in reverse, just to see whether that will work better? Of course you don’t; you are aware of best practice from a lifetime of experience and from the example set by peers (classmates, siblings, friends…) and authority figures (parents, teachers, driving instructors…), and you do not go about testing those practices every day again.

Perhaps more pertinently, most of us would really not appreciate if our doctor or dentist would start experimenting with new procedures or home-made drugs when we go to our next appointment (at least, not while there are other, proven possibilities to use first). We really don’t want our electrician to try out a revolutionary new insulation method he recently thought up. Yet when it comes to aid logistics, suddenly there is no such thing as received wisdom, because “every situation is different.”

What causes this behaviour? Why do we behave so differently when it comes to aid logistics?

I think there are a number of issues here:

  • Everybody is a logistician. Or at least, everybody thinks they are. “Just get the bloody stuff here when we need it, can’t be that hard cannit?” Unlike medicine, dentistry, or electrical engineering, the complexities of logistics are much further beneath the surface — so it is not as clear to the average aid worker that logistics management sometimes requires a bit more than just common sense.
  • Unlike many other areas, our daily logistics experiences are not scalable. Logistics routinely deals with complexities of scale: techniques that can be used at small scales will break down at the large scale. Vaccinating one patient is not much different from vaccinating 10,000: draw up, check, swab, inject, discard — and then times 10,000. However, the logistics of a 10,000 person vaccination campaign is many times more complex than those for a one-patient ‘campaign’. A vaccination nurse would have experience organising the logistics for a one-patient (or perhaps 10- or 100-patient) vaccination, but not a 10,000-patient campaign; and consequently would not realise how much more complex the issues become. I will write more about complexities of scale in an other post.
  • The evidence base for much of aid logistics’ best practices is comparatively sketchy. Unlike e.g. medicine, we do not have a history of formal trials; most of our evidence is based on case descriptions and anecdotal evidence. There is a small base of formal trials in logistics in corporate settings, but there results can only be applied very tentatively to aid work. As a result, those techniques that do have a base in evidence are usually not accepted as authoritative by aid workers because they are applied to logistics. No doctor would deny the usefulness of treatment protocols; the advantages of protocols (or procedures, or algorithms, or whatever you would like to call them) have been amply demonstrated, but apply this to logistics and people will loudly complain about imposed bureaucracy.
  • There are no recognised degrees for aid logisticians. Doctors need to pass medical exams. Electricians need to sit for their tests. Drivers need to pass a driver’s test before they get their licence (well, in most developed countries anyway). We expect a degree in public health from a public-health specialist. But aid logisticians come in all kinds and shapes, some with more logistics knowledge and skills than others. There are now a couple of specialised aid logistics master’s degrees, but as they are very new there are hardly any graduates in the field yet. The results are double-edged: on the one hand, not all aid logisticians have the knowledge to recognise the importance and usefulness of standard logistics operational solutions and methods; and on the other hand logisticians do not get recognition as specialists in their own right, and hence their authority is not recognised or accepted.
  • Aid logisticians tend to be an unruly, desk-hating lot. We come from all walks of life, but especially amongst field aid loggies there is an over-representation of people with backgrounds that pre-dispose them against accepting anything remotely smelling of authority, or of desk work[1]; and that includes things like procedures, administration, standardisation, etcetera. In this sense we are our own worst enemies, and tend to sabotage our own systems.

So what can we do to improve on this? How can we change this behaviour from logisticians and other aid workers alike? More in my next post, after Easter.

(Images by the US Navy and Martin Deutsch.)


[1] Or as one colleague once told me, with obvious pride: “We are the last adventurers — and the rest of them are just pale bureaucrats.”


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Sometimes I really wonder why we haven’t seen Madoff coming. Harvard Business School is one of the most high-profile business universities, and when a Harvard assistant professor of organisational behaviour talks about business ethics, you pay attention; so it should be no surprise that a recent interview with Michel Anteby, in which he seemed to support various sorts of fraudulent behaviour, drew quite some attention. His argument is that ‘leniencies’ are part of the standard managerial toolkit and that they are necessary to be able to our work well.

So let’s have a look at some of Anteby’s examples, try to find equivalents in health and aid logistics, and see how this works out.

Managing the store manager

[An] employee setting aside a clothing item in a storage room to later purchase for himself when the item will be deeply discounted is a gray zone as well. In high-end department stores such practices are often tolerated. This leniency when moderately exhibited is widely seen as “good” practice, a small favor done to reward deserving employees, and as such qualifies as a moral gray zone.

The equivalent here seems to be the store manager who ‘sets aside’ spare parts until the equipment for which they are used is superseded, and then buys them at a discount; or the medical store manager who ‘sets aside’ materials until they are almost expired in the knowledge that they will be donated to a befriended charity to prevent expiration. Is this acceptable? Not in my view — but the parallel with Anteby’s example is striking, and suggests that ‘business ethics’ would endorse acceptance of these practices.

Pulping the punch card

… a student who worked in the U.S. pulp industry was asked by his co-workers to punch them out later than they actually finished work. Management apparently was aware of this practice and allowed it.

I dont think I will need to spell this one out.

Medical paras

Paramedics are supposed to bring patients to attending physicians (most often in emergency rooms) and are not supposed to perform many medical acts. Officially, attending physicians are the ones performing the acts. Yet in some instances, to save “crashing patients” (meaning patients who seem about to die), paramedics will perform acts that they are not officially allowed to perform. Not all paramedics, however, are given such leeway—only the trusted ones. When physicians are aware of these breaches, yet remain silent, we are in the midst of a moral gray zone.

A logistics equivalent here would be to allow a storekeeper in an emergency to circumvent certain procedures so the program does not get bogged down in bureaucracy. Seems a good idea, doesn’t it? My view, however, would be that there is no need for it: include an emergency clause in your process description that allows your logistics manager to give dispensation of certain rules, but only after approval from another line manager, only for a limited period, and stipulating that this has to be formalised in writing or an email message. No need to break the rules: the rules should be flexible enough to deal with these situations — most definitely in aid organisations.

… by allowing trusted paramedics to “save lives” even if this means bending the rules a bit, physicians cater to the paramedics’ occupational identities. Paramedics become who they aspire to be, namely “saviors.” These paramedics are also more likely to cooperate with the physicians in the future. Thus, moral gray zones enable both managers and workers to perform their roles.

Anteby himself points the way here to a much better solution. In many countries, paramedics have a much larger role in patient management, in which they are allowed to and have received the training to be able to cope with crashing patients; e.g. in some countries paramedics can intubate, defibrillate, administer certain lifesaving drugs etcetera, and all this at their own initiative. Similarly, store managers who have received adequate training, tools, and discretionary authority, should be able to deal with almost any emergency while staying within the set procedures.

Upping the ante

Two broader implications can be drawn from this example. First, leniencies are part of the managerial toolkit. They allow for “local regulation”: in other words, they allow work to be done.

… Obviously, some level of organizational control is lost because “control” now occurs at the field level between the physician and the paramedic. In a way, top management loses power over its employees. In gray zones involving material pursuits—such as when a clothing item that could have been sold at a higher price to a customer is kept hidden until it becomes deeply discounted—direct losses can be calculated. At the same time, managers gain the employees’ engagement, and perhaps, more importantly, managers get to decide who benefits from its leniencies.

Anteby’s conclusion seems to be a total non-sequitur: as his own examples illustrate, work can be done without breaking the rules, without his ‘leniencies’; and employees can be engaged by other means, e.g. by sufficient training , remuneration, and career options. The telling point seems to be his last clause: power to the managers, whatever the cost.

And in the next episode…

My current project focuses on potentially contested practice where few norms seem to prevail. Whole-body donations for medical education and research provide the setting for this project. The goal is to understand how individuals and organizations operate in this context.

Right, everybody, hold on to your kidneys…


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