This month we saw the release of the banking and financial services royal commission and it got me thinking about systems and unintended consequences.

Clearly, the banks wanted profits but also wanted to keep their customers and, one would hope, be good corporate citizens. Many banking and financial services institutions have at their core values to be customer focused, ‘doing what is right’ for customers, and acting with integrity. The results, however, were clearly less than ordinary.

What do cobras have to do with systems change?

The German economist, Horst Siebert, termed the uninterested consequence for a simple solution to a complex problem, the ‘cobra effect’.

Back in the time of the British Raj, the colonial governor in Delhi decided to fix the public health issue of deadly cobra bites by offering a bounty for dead cobras. The governor had limited manpower at his disposal, he needed others to conduct the cull. So, a small bounty was offered for every dead cobra handed in to the authorities. It had seemed a sensible policy. It also seemed to work – as dead Cobras came in; while rupees went out.

The governor basked in his success. There was just one problem. The number of cobra bites didn’t decrease – in fact, they increased. The problem was the bounty was for killing cobras, not reducing bites. So, of course, it generated a new industry, that of cobra farms.

The ‘cobra effect’ Siebert popularised may have been about the Raj – but it’s a story we know well in Australia.  And in Delhi, it didn’t stop with the cobra farms.

When the Delhi governor discovered his mistake, he ended the bounty. Good, right? Well, unfortunately, that was his second mistake. The system here was built on economic value and, as the cobras became worthless, the snake-farmers let them loose, so the original problem was now worse than ever.

Think about how the cobra effect has played out in Australia, not just in terms of banking and financial services, but in all those other ways – stolen generation, cane toads, the media take on My Health, to name but a few.  We all know of an instance either in the public domain or just in our everyday lives when the result of an action is opposite of what was intended.

Complexity makes it harder

While we have always had complex systems and had to deal with complex design making and design in everything from policy to communication to product development - one of the biggest issues with today is that we live in a complex world which is becoming more complex by the minute. So, while in the past, complexity was often seen as something mostly only government had to think of with its multiple stakeholders and large remit, it’s now likely to impact in every sector. We work in organisations that are larger than small countries. This means the ability to control a system in a directive manner and assume people understand where the boundaries are is difficult. In addition, we can’t argue companies are solely about profit and the government about the public good.

When the solution doesn’t meet the need

This presents a number of issues for organisations. The challenge is, often simple targets to complex problems have an insidious effect. Too often the metric and reward system used to gauge success isn’t related to the values or vision of the organisation or the overarching aim. This can lead to unintended consequences where, in the financial sectors case, greed or a system that forgets the human drives decisions. Too often we defer to a system or benchmark rather than common sense when things get complicated. Think of Catherine, the mother of a disabled boy who had a debt of $1500 one Christmas, and who paid over $8000 in late fees and interest.

Bank employees aren’t the only organisations that sometimes struggle to get it right. This is especially the case when the consequence on the person we’re trying to help isn’t part of the equation. Here’s a smaller example in the accessibility space.  Jutta Treviranus from the IDRC recounts her experience in a school which proudly claimed all their online tests were fully accessible. They were from a ‘benchmark perspective’, in that they fully met the Web Content Accessibility Guidelines. The child demonstrating the test, however, needed 30 keystrokes more than other students to just answer one multiple choice question. The cognitive load to operate the system for that child was higher than that of answering the question. Again, the process that was built to help the ‘customer’, in this case, the child, had the opposite effect.

There are ways to solve this using inclusive design. To see the cobra effect, as we make decisions and create products or policies. It can start with two simple questions all of us can ask. ‘Why’ and ‘how else’?  These questions allow us to reframe the question and can transform projects.

Why are we doing this?

The ‘why’ questions call for the reframing of the problem to its broader causes. It allows us to see what it is we are really trying to solve. While similar to Simon Sinek's why, what we want to do is see if the ends are served by the means. So, for instance, in the accessibility example, a person may first say the why is to have the child be able to do the online test. By repeating the question, however, it would become clear the aim is to see if the child had learned the material, their times table for example. So, the way the test was conducted made it harder for this to occur.  With the cobra effect, the why was for people to not be bitten by snakes, not to kill all snakes.

What can we do?

Inclusive design allows for multiple answers and multiple experiences.  The ‘how else’ allows for this. For example, think of something like a smartphone. It’s much more than a phone. It was developed using insights from the edge. The thing is, while we all have a similar device, we all use it differently. It speaks to the ‘how else’. Just as there could be other solutions for the child with the standardised test, the idea is one size won’t fit everyone. We have several solutions to suit different use cases.

The second question, ‘how else’, offers other possibilities and the idea of the extreme user really comes into its own. Extreme users are like canaries in a mine shaft, they point out things we are often blindsided by, especially when it comes to complex systems.

If the banks or the governor had a baked-in way of asking the ‘why’ and ‘how else’, we can imagine what the conversation would have been like. If the potential issues and challenges were thought of first and solved during the time of the Raj, our cobra story may have seen the rise of the first cobra boots, accessible crowd sharing cobra spotting, health benefits from cobra venom, and the list goes on.

We have the opportunity to learn through reflection. I’m looking forward to seeing what we design as a result of design failures of the past.