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Tag: health systems research

  • Five examples of double-loop learning in global health

    Five examples of double-loop learning in global health

    Read this first: What is double-loop learning in global health?

    Example 1: Addressing low uptake of a vaccine program

    Single–Loop Learning: Improve logistics and supply chain management to ensure consistent vaccine availability at clinics.

    Double–Loop Learning: Engage with community leaders to understand cultural beliefs and concerns around vaccination, and co-design a more localized and trustworthy immunization strategy.

    What is the difference? Double-loop learning questions the assumption that the primary goal should be to increase uptake at all costs. It considers whether the program design respects community autonomy and addresses their real concerns. It may surface competing values of public health impact vs. community self-determination.

    Example 2: Responding to an infectious disease outbreak

    Single–Loop Learning: Rapidly mobilize health workers and supplies to affected areas to contain the outbreak following established emergency protocols.

    Double–Loop Learning: Critically examine why the health system was vulnerable to this outbreak, and work with communities to redesign surveillance, preparedness and response systems to be more resilient.

    What is the difference? Double-loop learning interrogates whether the existing outbreak response system is built on the value of health equity. It asks if the system privileges the needs of some populations over others and perpetuates historical power imbalances. It strives to create a more inclusive, participatory approach to defining outbreak preparedness and response priorities.

    Example 3: Implementing a maternal health intervention that shows low adherence

    Single–Loop Learning: Retrain health providers to improve their counseling skills and provide better patient education on the intervention.

    Double–Loop Learning: Conduct participatory research with women and families to understand their needs, preferences and barriers to care-seeking, and collaborate with them to iteratively adapt the intervention design.

    What is the difference? Double-loop learning challenges the implicit assumption that the intervention design is inherently correct and that non-adherence is a ‘user error’. It examines whether the intervention embodies values of respect, humility and co-creation with communities. It seeks to align the intervention with women’s self-articulated reproductive health values and preferences.

    Example 4: Evaluating an underperforming community health worker (CHW) program

    Single–Loop Learning: Strengthen CHW supervision, increase performance incentives, and optimize the ratio of CHWs to households.

    Double–Loop Learning: Facilitate a joint reflection process with CHWs and community representatives to examine program strengths, challenges and equity gaps, and co-create a revised strategy that better aligns with community priorities and integrates CHWs’ insights.

    What is the difference? Double-loop learning questions whether the CHW program is driven by the value of empowering communities as agents of their own health vs. treating CHWs as an instrument of technocratic public health aims. It re-centers the program on the value of CHW leadership and community-driven problem definition.

    Example 5: Reforming a health financing policy to improve population coverage

    Single–Loop Learning: Adjust the premium amounts, enrollment processes and benefit package based on initial uptake data.

    Double–Loop Learning: Convene citizen panels and key stakeholders to deliberate on the fundamental goals and values underlying the financing reforms, and recommend redesigning the policy to better advance equity and financial protection.

    What is the difference? Double-loop learning interrogates whether the true intent of the policy is to advance equity and financial protection for marginalized groups or simply to expand coverage as an end unto itself. It opens up debate on the core values and theory of change underlying the reforms. It aims to re-anchor the policy in a wholistic vision of equitable universal health coverage.

  • Learning culture: the missing link in global health between learning and performance

    Learning culture: the missing link in global health between learning and performance

    Learning culture is a critical concept missing from health systems research.

    It provides a practical and actionable framework to operationalize the notion of ‘learning health systems’ and drive transformative change.

    Read this first: What is double-loop learning in global health?

    Watkins and Marsick describe learning culture as the capacity for change. They identify seven key action imperatives or “essential building blocks” that strengthen it: continuous learning opportunities, inquiry and dialogue, collaboration and team learning, systems to capture and share learning, people empowerment, connection to the environment, and strategic leadership for learning (Watkins & O’Neil, 2013).

    Crucially, the instrument developed by Watkins and Marsick assesses learning culture by examining perceptions of norms and practices, not just individual behaviors (Watkins & O’Neil, 2013).

    This aligns with Seye Abimbola’s assertion that learning in health systems should be “people-centred” and occurs at multiple interconnected levels.

    Furthermore, this research demonstrates that certain dimensions of learning culture, like strategic leadership and systems to capture and share knowledge, are key mediators and drivers of performance outcomes (Yang et al., 2004).

    This provides compelling evidence that investments in learning can yield tangible improvements in health delivery and population health.

    Learn more: Jones, I., Watkins, K. E., Sadki, R., Brooks, A., Gasse, F., Yagnik, A., Mbuh, C., Zha, M., Steed, I., Sequeira, J., Churchill, S., & Kovanovic, V. (2022). IA2030 Case Study 7. Motivation, learning culture and programme performance (1.0). The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.7004304

    As Watkins and Marsick (1996) argue, to develop a strong learning culture, we need to “embed a learning infrastructure”, “cultivate a learning habit in people and the culture”, and “regularly audit the knowledge capital” in our organization or across a network of partners.

    While investments in learning can be a challenging sell in resource-constrained global health settings, this evidence establishes that learning culture is in fact an indispensable driver of health system effectiveness, not just a “nice to have” attribute.

    Subsequent studies have also linked learning culture to key performance indicators like care quality, patient satisfaction, and innovation.

    Why lack of continuous learning is the Achilles heel of immunization

    To advance learning health systems, it is important to translate this research in terms that resonate with the worldview of global health practitioners like epidemiologists and to produce further empirical studies that speak to their evidentiary standards.

    Ultimately, this will require expanding mental models about what constitutes legitimate and actionable knowledge for health improvement.

    The learning culture framework offers an evidence-based approach to guide this transformation.

    References

    Abimbola, S. The uses of knowledge in global health. BMJ Glob Health 6, e005802 (2021).

    Watkins, K. E. & O’Neil, J. The Dimensions of the Learning Organization Questionnaire (the DLOQ): A Nontechnical Manual. Advances in Developing Human Resources 15, 133–147 (2013).

    Watkins, K., & Marsick, V. (1996). (Eds.). In action: Creating the learning organization (Vol. 1). Alexandria, VA: ASTD Press.

    Yang, B., Watkins, K. E. & Marsick, V. J. The construct of the learning organization: Dimensions, measurement, and validation. Human Resource Development Quarterly 15, 31–55 (2004).

  • What is double-loop learning in global health?

    What is double-loop learning in global health?

    Argyris (1976) defines double-loop learning as occurring “when errors are corrected by changing the governing values and then the actions.” He contrasts this with single-loop learning, where “errors are corrected without altering the underlying governing values.”

    • Double-loop learning involves questioning “not only the objective facts but also the reasons and motives behind those facts”.
    • It requires becoming aware of one’s own “theories-in-use” – the often tacit beliefs and norms that shape behavior – and subjecting them to critical reflection and change. 

    This is challenging because it can threaten one’s sense of competence and self-image.

    Checking for double-loop learning: ‘Are we doing things right?’ vs. ‘Are we doing the right things?’

    In global health, double-loop learning means not just asking “Are we doing things right?” but also “Are we doing the right things?” It means being willing to challenge long-held assumptions about what works, for whom, and under what conditions.

    Epistemological assumptions (“we already know the best way”), methodological orthodoxies (“this is not how we do things”), and apolitical stance (“I do health, not politics”) of epidemiology can predispose practitioners to be dismissive of a concept like double-loop learning. 

    Learn more: Five examples of double-loop learning in global health

    Seye Abimbola is part of a growing community of researchers who argue that double-loop learning is critical for advancing equity and self-reliance in global health systems, because global health tends to overlook its own assumptions.

    Is it reasonable to posit that some global health interventions have been driven by unchecked assumptions – assumptions about what communities need, what they value, and what will work in their context? How often have we relied on a one-size-fits-all approach, implementing ‘best practices’ from afar without fully understanding local realities? How do we know to what extent programs have thereby failed to meet their goals, wasted precious resources, and may have even caused unintended harm?

    As Abimbola (2021) notes, “double-loop learning goes further to question and influence frameworks, models and assumptions around problems and their solutions, and can drive deeper shifts in objectives and policies.”

    For example, affected communities hold vital expertise to mitigate health risks.

    However, fully leveraging this potential requires global health professionals to fundamentally rethink their roles and assumptions.

    • For research to serve the needs of affected communities, it is likely to be useful to reframe these roles and assumptions to see themselves as “subsidiary” partners in service of “primary” community actors (Abimbola, 2021).
    • Institutionalizing double-loop learning requires enabling critical reflection and co-production between health workers, managers and citizens (Sheikh & Abimbola, 2021).
    • It also depends on developing the learning capacities of communities and health workers in areas like participatory governance, team-based learning and innovation management.

    The next logical question is ‘how’ to implement double-loop learning.

    Learning culture is a critical concept missing from health systems research.

    It provides a practical and actionable framework to operationalize the double-loop learning notion of ‘learning health systems’ and drive transformative change.

    Learn more: Learning culture: the missing link in global health between learning and performance

    Further reading

    Learning-based complex work: how to reframe learning and development

    What learning science underpins peer learning for Global Health?

    How do we reframe health performance management within complex adaptive systems?

    References

    Abimbola, S. The uses of knowledge in global health. BMJ Glob Health 6, e005802 (2021). https://doi.org/10.1136/bmjgh-2021-005802

    Argyris, C. Single-loop and double-loop models in research on decision making. Administrative science quarterly 363–375 (1976). https://doi.org/10.2307/2391848

    Argyris, C. Double-loop learning, teaching, and research. Academy of Management Learning & Education 1, 206–218 (2002). https://www.jstor.org/stable/40214154

    Kabir Sheikh & Seye Abimbola. Learning Health Systems: Pathways to Progress. (Alliance for Health Policy and Systems Research, 2021).

    Image: The Geneva Learning Foundation Collection © 2024