Stories

Tag: learning culture

  • Experience-sharing sessions in the Movement for Immunization Agenda 2030: A novel approach to localize global health collaboration

    Experience-sharing sessions in the Movement for Immunization Agenda 2030: A novel approach to localize global health collaboration

    As immunization programs worldwide struggle to recover from pandemic disruptions, the Movement for Immunization Agenda 2030 (IA2030) offers a novel, practitioner-led approach to accelerate progress towards global vaccination goals.

    From March to June 2022, the Geneva Learning Foundation (TGLF) conducted the first Full Learning Cycle (FLC) of the Movement for IA2030, engaging 6,185 health professionals from low- and middle-income countries.

    A cornerstone of this programme was a series of 44 experience-sharing sessions held between 7 March and 13 June 2022. These sessions brought together between 20 and 400 practitioners per session to discuss and solve real-world immunization challenges.

    IA2030 case study 16, by Charlotte Mbuh and François Gasse, offers valuable insights from these experience-sharing session:

    1. what we learned from the experiences themselves and how it can help practitioners; and
    2. what we learned about the significance and potential of the peer learning process itself.

    Download the full case study: IA2030 Case study 16. Continuum from knowledge to performance. The Geneva Learning Foundation.

    For every challenge shared during the experience sharing sessions, there was always at least one member who had encountered or was encountering the same challenge and had carried out measures to resolve it.

    These sessions provided a space to share practical stories that are making a difference – and supported participants in considering their relevance to their own situations.

    Experience sharing also helped build confidence and motivation.

    Members were able to identify with experiences shared, realizing they were not alone in facing similar challenges.

    The sessions covered a wide range of critical immunization topics.

    For instance, a participant from Nigeria discussed strategies for reaching zero-dose children in Borno state.

    Facing the challenge of reaching approximately 600,000 unvaccinated children, the presenter received practical suggestions from peers, including developing a zero-dose reduction operational plan, leveraging new vaccine introductions, and partnering with the private sector for evening vaccination services.

    In another session, a subnational Ministry of Health staff member from Côte d’Ivoire presented challenges related to cross-border immunization campaigns.

    Peers shared experiences of organizing cross-border meetings to identify unvaccinated children, synchronize efforts, and involve community representatives in the process.

    Such context-specific, experience-based advice exemplifies the unique value of peer learning in addressing complex health system challenges.

    The case study of 44 sessions highlights how these sessions fostered multiple types of learning simultaneously.

    Participants reported learning from each other’s experiences, experiencing the power of solving problems together across distances, feeling a growing sense of belonging to a community, and connecting across country borders and health system levels.

    A district-level Ministry of Health staff member from Ghana encapsulated the impact: “I have linked up with expert vaccinators worldwide through experience sharing and twinning. I have become more competent and knowledgeable in the area of immunization, and work confidently.”

    This sentiment was echoed by many participants who found value not only in acquiring new knowledge but also in expanding their professional networks and gaining confidence in their problem-solving abilities.

    The case study also reveals the adaptability of the approach in responding to unique contexts.

    This resilience underscores the potential of digital platforms to democratize access to expertise and foster global collaboration.

    However, the study also identifies areas for improvement.

    • Participants expressed a desire for more follow-up support and opportunities to continue their peer learning groups beyond the initial sessions.
    • Additionally, the need for better integration of community engagement strategies was identified as a key area for future development.

    To contextualize these findings, we can turn to a 2022 study by Watkins et al., which evaluated a prototype of these experience-sharing sessions known as Immunization Training Challenge Hackathons (ITCH), conducted in 2020.

    The ITCH methodology, developed by The Geneva Learning Foundation (TGLF), informed the design of the 2022 IA2030 Movement sessions.

    Watkins et al. found that the ITCH approach fostered four simultaneous types of learning: peer, remote, social, and networked.

    1. Peer Learning: This involves participants learning directly from each other’s experiences and knowledge. In the context of immunization, imagine a scenario where a vaccination program manager from rural India shares their successful strategy for improving vaccine cold chain management with a colleague facing similar challenges in sub-Saharan Africa. This direct exchange of practical, context-specific knowledge can complement more theoretical training, as it is based on real-world application.
    2. Remote Learning: This refers to the ability to learn and solve problems collaboratively across geographical distances. For an immunization specialist, this might seem counterintuitive, as many believe that hands-on, in-person training is essential. However, the ITCH sessions demonstrated that meaningful learning can occur remotely. For example, a team in Bangladesh could describe their approach to overcoming vaccine hesitancy, and a team in Nigeria could immediately adapt and apply those strategies to their local context, all without the need for costly and time-consuming travel.
    3. Social Learning: This concept emphasizes the importance of learning within a network. In the immunization field, professionals often work in isolation, especially at sub-national levels. The ITCH sessions created a sense of belonging to a global network, community, and platform of immunization practitioners. This social aspect can boost motivation, reduce feelings of isolation, and foster a collective approach to problem-solving that transcends individual or even national boundaries.
    4. Networked Learning: This type of learning emerges from connections made across different levels of health systems and across country borders. For an epidemiologist, this might be analogous to how disease surveillance networks function across borders. In the ITCH context, it means that a district-level immunization officer could learn from and share ideas with national-level policymakers from other countries, fostering a more holistic understanding of immunization challenges and solutions.

    These four types of learning operate simultaneously during ITCH sessions, creating a synergistic effect. 

    For instance, a participant might learn a new cold chain management technique (peer learning) from a colleague in another country (remote learning), feel supported by the global community in implementing this new technique (social learning), and then share their adaptation of this technique with others across various levels of the health system (networked learning).

    From an epidemiological perspective, this approach to learning could be compared to how we understand disease transmission and intervention effectiveness.

    Just as multiple factors contribute to disease spread and control, these multiple learning types contribute to knowledge dissemination and capacity building in the immunization field.

    The value of this approach lies in its potential to rapidly disseminate practical, context-specific knowledge and solutions across a global network of immunization professionals.

    This can lead to faster adoption of best practices, more innovative problem-solving, and ultimately, improvements in immunization program performance that could contribute to better disease control outcomes.

    While this approach may seem unconventional compared to traditional training methods in the immunization field, the evidence presented by Watkins et al. suggests that it can be a powerful complement to existing capacity-building efforts, particularly in resource-constrained settings where access to formal training opportunities may be limited.

    This multifaceted approach allowed participants to not only acquire new knowledge but also to expand their professional networks and gain confidence in their problem-solving abilities—findings that align closely with the outcomes observed in the 2022 IA2030 Movement sessions.

    The Watkins study emphasized the importance of building confidence and motivation through peer learning experiences, a theme strongly echoed in the Mbuh case study.

    Furthermore, Watkins et al. highlighted the potential of this approach to create a “space of possibility” for innovation and problem-solving, which is evident in the diverse and creative solutions shared during the 2022 sessions.

    Both studies underscore the significance of peer-led, digital learning experiences in accelerating progress towards global health goals.

    By fostering peer learning and digital collaboration, these approaches empower health workers to turn global strategies into effective local action.

    References

    Mbuh, C., Gasse, F., Jones, I., Sadki, R., Brooks, A., Zha, M., Steed, I., Sequeira, J., Churchill, S., Kovanovic, V., 2022. IA2030 Case study 16. Continuum from knowledge to performance. The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.7014392

    Watkins, K.E., Sandmann, L.R., Dailey, C.A., Li, B., Yang, S.-E., Galen, R.S., Sadki, R., 2022. Accelerating problem-solving capacities of sub-national public health professionals: an evaluation of a digital immunization training intervention. BMC Health Serv Res 22, 736. https://doi.org/10.1186/s12913-022-08138-4

    Image: The Geneva Learning Foundation Collection © 2024

  • Learn health, but beware of the behaviorist trap

    Learn health, but beware of the behaviorist trap

    The global health community has long grappled with the challenge of providing effective, scalable training to health workers, particularly in resource-constrained settings.

    In recent years, digital learning platforms have emerged as a potential solution, promising to deliver accessible, engaging, and impactful training at scale.

    Imagine a digital platform intended to train health workers at scale.

    Their theory of change rests on a few key assumptions:

    1. Offering simplified, mobile-friendly courses will make training more accessible to health workers.
    2. Incorporating videos and case studies will keep learners engaged.
    3. Quizzes and knowledge checks will ensure learning happens.
    4. Certificates, continuing education credits, and small incentives will motivate course completion.
    5. Growing the user base through marketing and partnerships is the path to impact.

    On the surface, this seems sensible.

    Mobile optimization recognizes health workers’ technological realities.

    Multimedia content seems more engaging than pure text.

    Assessments appear to verify learning.

    Incentives promise to drive uptake.

    Scale feels synonymous with success.

    While well-intentioned, such a platform risks falling into the trap of a behaviorist learning agenda.

    This is an approach that, despite its prevalence, is a pedagogical dead-end with limited potential for driving meaningful, sustained improvements in health worker performance and health outcomes.

    It is a paradigm that views learners as passive recipients of information, where exposure equals knowledge acquisition.

    It is a model that privileges standardization over personalization, content consumption over knowledge creation, and extrinsic rewards over intrinsic motivation.

    It fails to account for the rich diversity of prior experiences, contexts, and challenges that health workers bring to their learning.

    Most critically, it neglects the higher-order skills – the critical thinking, the adaptive expertise, the self-directed learning capacity – that are most predictive of real-world performance.

    Clicking through screens of information about neonatal care, for example, is not the same as developing the situational judgment to adapt guidelines to a complex clinical scenario, nor the reflective practice to continuously improve.

    Moreover, the metrics typically prioritized by behaviorist platforms – user registrations, course completions, assessment scores – are often vanity metrics.

    They create an illusion of progress while obscuring the metrics that truly matter: behavior change, performance improvement, and health outcomes.

    A health worker may complete a generic course on neonatal care, for example, but this does not necessarily translate into the situational judgment to adapt guidelines to complex clinical scenarios, nor the reflective practice to continuously improve.

    The behaviorist paradigm’s emphasis on information transmission and standardized content may stem from an implicit assumption that health workers at the community level do not require higher-order critical thinking skills – that they simply need a predetermined set of knowledge and procedures.

    This view is not only paternalistic and insulting, but it is also fundamentally misguided.

    A robust body of scientific evidence on learning culture and performance demonstrates that the most effective organizations are those that foster continuous learning, critical reflection, and adaptive problem-solving at all levels.

    Health workers at the frontlines face complex, unpredictable challenges that demand situational judgment, creative thinking, and the ability to learn from experience.

    Failing to cultivate these capacities not only underestimates the potential of these health workers, but it also constrains the performance and resilience of health systems as a whole.

    Even if such a platform achieves its growth targets, it is unlikely to realize its impact goals.

    Health workers may dutifully click through courses, but genuine transformative learning remains elusive.

    The alternative lies in a learning agenda grounded in advances of the last three decades learning science.

    These advances remain largely unknown or ignored in global health.

    This approach positions health workers as active, knowledgeable agents, rich in experience and expertise.

    It designs learning experiences not merely to transmit information, but to foster critical reflection, dialogue, and problem-solving.

    It replaces generic content with authentic, context-specific challenges, and isolated study with collaborative sense-making in peer networks.

    It recognizes intrinsic motivation – the desire to grow, to serve, to make a difference – as the most potent driver of learning.

    Here, success is measured not in superficial metrics, but in meaningful outcomes: capacity to lead change in facilities and communities that leads to tangible improvements in the quality of care.

    Global health leaders faces a choice: to settle for the illusion of progress, or to invest in the deep, difficult work of authentic learning and systemic change, commensurate with the complexity and urgency of the task at hand.

    Image: The Geneva Learning Foundation Collection © 2024

  • Why health leaders who are critical thinkers choose rote learning for others

    Why health leaders who are critical thinkers choose rote learning for others

    Many health leaders are highly analytical, adaptive learners who thrive on solving complex problems in dynamic, real-world contexts.

    Their expertise is grounded in years of field experience, where they have honed their ability to rapidly generate insights, test ideas, and innovate solutions in collaboration with diverse stakeholders.

    In January 2021, as countries were beginning to introduce new COVID-19 vaccines, Kate O’Brien, who leads WHO’s immunization efforts, connected global learning to local action:

    “For COVID-19 vaccines […] there are just too many lessons that are being learned, especially according to different vaccine platforms, different communities of prioritization that need to be vaccinated. So [everyone]  has got to be able to scale, has got to be able to deal with complexity, has got to be able to do personal, local innovation to actually overcome the challenges.”

    In an Insights Live session with the Geneva Learning Foundation in 2022, she made a compelling case that “the people who are working in the program at that most local level have to be able to adapt, to be agile, to innovate things that will work in that particular setting, with those leaders in the community, with those families.”

    However, unlike Kate O’Brien, some senior leaders in global health disconnect their own learning practices and their assumptions about how others learn best.

    When it comes to designing learning initiatives for their teams or organizations, these leaders may default to a more simplistic, behaviorist approach.

    They may equate learning with the acquisition and application of specific skills or knowledge, and thus focus on creating structured, content-driven training programs.

    The appeal of behaviorist platforms – with their promise of efficient, scalable delivery and easily measured outcomes – can be seductive in the resource-constrained, results-driven world of global health.

    Furthermore, leaders may hold assumptions that health workers – especially those at the community level – do not require higher-order critical thinking skills, that they simply need a predetermined set of knowledge and procedures.

    This view is fundamentally misguided.

    A robust body of scientific evidence on learning culture and performance demonstrates that the most effective organizations are those that foster continuous learning, critical reflection, and adaptive problem-solving at all levels.

    Health workers at the frontlines face complex, unpredictable challenges that demand situational judgment, creative thinking, and the ability to learn from experience.

    Failing to cultivate these capacities not only underestimates the potential of these health workers, but it also constrains the performance and resilience of health systems as a whole.

    The problem is that this approach fails to cultivate the very qualities that make these leaders effective learners and problem-solvers.

    Behaviorist techniques, with their emphasis on passive information absorption and narrow, pre-defined outcomes, do not foster the critical thinking, creativity, and collaborative capacity needed to tackle complex health challenges.

    They may produce short-term gains in narrow domains, but they cannot develop the adaptive expertise required for long-term impact in ever-shifting contexts.

    To help health leaders recognize this disconnect, it is useful to engage them in reflective dialogue about their own learning processes.

    By unpacking real-world examples of how they have solved thorny problems or generated novel insights, we can highlight the sophisticated cognitive strategies and collaborative dynamics at play.

    We can show how they constantly question assumptions, synthesize diverse perspectives, and iterate solutions – all skills that are essential for navigating complexity, but are poorly served by rigid, content-focused training.

    The goal is not to dismiss the need for foundational knowledge or skills, but rather to emphasize that in the face of evolving challenges, adaptive learning capacity is the real differentiator.

    It is the ability to think critically, to imagine new possibilities, to learn from failure, and to co-create with others that drives meaningful change.

    By tying this insight directly to leaders’ own experiences and values, we can inspire them to champion learning approaches that mirror the richness and dynamism of their personal growth journeys.

    Ultimately, the most impactful health organizations will be those that not only equip people with essential skills, but that also nurture the underlying cognitive and collaborative capacities needed to continually learn, adapt, and innovate.

    By recognizing and leveraging the powerful learning practices they themselves embody, health leaders can shape organizational cultures and strategies that truly empower people to navigate complexity and drive transformative change.

    This shift requires letting go of the illusion of control and predictability that behaviorism offers, and instead embracing the messiness and uncertainty of real learning.

    It means creating space for experimentation, reflection, and dialogue, and trusting in people’s inherent capacity to grow and create.

    It is a challenging transition, but one that health leaders are uniquely positioned to lead – if they can bridge the gap between how they learn and how they seek to enable others’ learning.

    Image: The Geneva Learning Foundation Collection © 2024

  • Klepac and colleagues‘ scoping review of climate change, malaria and neglected tropical diseases: what about the epistemic significance of health worker knowledge?

    Klepac and colleagues‘ scoping review of climate change, malaria and neglected tropical diseases: what about the epistemic significance of health worker knowledge?

    By Luchuo E. Bain and Reda Sadki

    The scoping review by Klepac et al. provides a comprehensive overview of codified academic knowledge about the complex interplay between climate change and a wide range of infectious diseases, including malaria and 20 neglected tropical diseases (NTDs).

    The review synthesized findings from 511 papers published between 2010 and 2023, revealing that the vast majority of studies focused on malaria, dengue, chikungunya, and leishmaniasis, while other NTDs were relatively understudied.

    The geographical distribution of studies also varied, with malaria studies concentrated in Africa, Brazil, China, and India, and dengue and chikungunya studies more prevalent in Australia, China, India, Europe, and the USA.

    One of the most striking findings of the review is the potential for climate change to have profound and varied effects on the distribution and transmission of malaria and NTDs, with impacts likely to vary by disease, location, and time.

    However, the authors also highlight the uncertainty surrounding the overall global impact due to the complexity of the interactions and the limitations of current predictive models.

    This underscores the need for more comprehensive, collaborative, and standardized modeling efforts to better understand the direct and indirect effects of climate change on these diseases.

    Another significant insight from the review is the relative lack of attention given to climate change mitigation and adaptation strategies in the existing literature.

    Only 34% of the included papers considered mitigation strategies, and a mere 5% addressed adaptation strategies.

    Could we imagine future mapping to recognize the value of new mechanisms for and actors of knowledge production that do not meet the conventional criteria for what currently counts as valid knowledge?

    What might be the return on going at least one step further beyond questioning our own underlying assumptions about ‘how science is done’ to actually supporting and investing in innovative indigenous- and community-led, co-created initiatives?

    This gap highlights the urgent need for more research on how to effectively reduce the impact of climate change on malaria and NTDs, particularly in areas with the highest disease burdens and the populations most vulnerable to the impacts of climate change.

    While the review emphasizes the need for more research to fill these evidence gaps, this begs the question of the resources and time required to fill them.

    This is where there is likely to be value in the experiential data from health workers on the frontlines to provide insights into the mechanisms of climate change impacts on health and effective response strategies.

    The upcoming Teach to Reach 10 event (background | registration) , a massive open peer learning platform that brings together health professionals from around the world to network and learn from each other’s experiences, offers a unique opportunity to engage thousands of health workers in a dialogue that can deepen our understanding of how climate change is affecting the health of local communities.

    Experiential data has been, historically, dismissed as ‘anecdotal’ evidence at best.

    The value and significance of what you know because you are there every day, serving the health of your community, has been ignored.

    The expertise and knowledge of frontline health workers are often overlooked or undervalued in global health decision-making processes, despite their critical role in delivering health services and their deep understanding of local contexts and challenges.

    Yes, the importance of incorporating the insights and experiences of health workers in the global health discourse cannot be overstated.

    As Abimbola and Pai (2020) argue, the decolonization of global health requires a shift towards valuing and amplifying the voices of those who have been historically marginalized and excluded from the dominant narratives.

    This concept, known as epistemic justice, recognizes that knowledge is not solely the domain of academic experts but is also held by those with lived experiences and practical expertise (Fricker, 2007).

    Epistemic injustice, as defined by Fricker (2007), occurs when an individual is wronged in their capacity as a knower, either through testimonial injustice (when a speaker’s credibility is undervalued due to prejudice) or hermeneutical injustice (when there is a gap in collective understanding that disadvantages certain groups).

    In the context of global health, epistemic injustice often manifests in the marginalization of knowledge held by communities and health workers in low- and middle-income countries, as well as the dominance of Western biomedical paradigms over local ways of knowing (Bhakuni & Abimbola, 2021).

    By engaging health workers from around the world in peer learning and knowledge sharing, Teach to Reach can help to challenge the epistemic injustice that has long plagued global health research and practice.

    By providing a platform for health workers to share their experiences and insights, Teach to Reach – alongside many other initiatives focused on listening to and learning from communities – can contribute to ensuring that the fight against malaria and NTDs in the face of climate change is informed not only by rigorous scientific evidence but also by the practical wisdom of those on the ground.

    That is only if global partners are willing to challenge their own assumptions, and take the time to listen and learn.

    Moreover, the decolonization of global health requires a shift towards more equitable and inclusive forms of knowledge production and dissemination.

    This involves challenging the historical legacies of colonialism and racism that have shaped the global health field, as well as the power imbalances that continue to privilege certain forms of knowledge over others (Büyüm et al., 2020).

    By fostering a dialogue between health workers and global partners, Teach to Reach can help to bridge the gap between research and practice, ensuring that the latest scientific findings are effectively translated into actionable strategies that are grounded in local realities and responsive to the needs of those most affected by climate change and infectious diseases.

    The value of experiential data from health workers in filling evidence gaps and informing effective response strategies cannot be understated.

    As the Klepac review highlights, there is a paucity of research on the impacts of climate change on many NTDs and the effectiveness of mitigation and adaptation strategies.

    While more rigorous scientific studies are undoubtedly needed, waiting years or decades for this evidence to accumulate before taking action is not a viable option given the urgency of the climate crisis and its devastating impacts on health.

    Health workers’ firsthand observations and experiences can provide valuable insights into the complex mechanisms through which climate change is affecting the distribution and transmission of malaria and NTDs, as well as the effectiveness of different intervention strategies in real-world settings.

    This type of contextual knowledge is essential for developing locally tailored solutions that account for the unique social, cultural, and environmental factors that shape disease dynamics in different communities.

    Furthermore, engaging health workers as active partners in research and decision-making processes can help to ensure that the solutions developed are not only scientifically sound but also feasible, acceptable, and sustainable in practice.

    The involvement of frontline health workers in the co-creation of knowledge and interventions can lead to more effective, equitable, and context-specific solutions that are responsive to the needs and priorities of local communities.

    References

    Abimbola, S., & Pai, M. (2020). Will global health survive its decolonisation? The Lancet, 396(10263), 1627-1628. https://doi.org/10.1016/S0140-6736(20)32417-X

    Bhakuni, H., & Abimbola, S. (2021). Epistemic injustice in academic global health. The Lancet Global Health, 9(10), e1465-e1470. https://doi.org/10.1016/S2214-109X(21)00301-6

    Büyüm, A. M., Kenney, C., Koris, A., Mkumba, L., & Raveendran, Y. (2020). Decolonising global health: If not now, when? BMJ Global Health, 5(8), e003394. https://doi.org/10.1136/bmjgh-2020-003394

    Fricker, M. (2007). Epistemic injustice: Power and the ethics of knowing. Oxford University Press.

    Klepac, P., et al., 2024. Climate change, malaria and neglected tropical diseases: a scoping review. Transactions of The Royal Society of Tropical Medicine and Hygiene. https://doi.org/10.1093/trstmh/trae026

  • 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

  • Why lack of continuous learning is the Achilles heel of immunization 

    Why lack of continuous learning is the Achilles heel of immunization 

    Continuous learning is lacking in immunization learning culture, a measure of the capacity for change..

    This lack may be an underestimated barrier to the “Big Catch-Up” and reaching zero-dose children

    This was a key finding presented at Gavi’s Zero-Dose Learning Hub (ZDLH) webinar “Equity in Action: Local Strategies for Reaching Zero-Dose Children and Communities” on 24 January 2024.

    The finding is based on analysis large-scale learning culture measurements conducted by the Geneva Learning Foundation in 2020 and 2022, with more than 10,000 immunization staff from all levels of the health system, job categories, and contexts, responding from over 90 countries.

    YearnContinuous learningDialogue & InquiryTeam learningEmbedded SystemsEmpowered PeopleSystem ConnectionStrategic Leadership
    202038303.614.68–4.814.685.104.83
    202261853.764.714.864.934.725.234.93
    TGLF global measurements (2020 and 2022) of learning culture in immunization, using the Dimensions of Learning Organization Questionnaire (DLOQ)

    What does this finding about continuous learning actually mean?

    In immunization, the following gaps in continuous learning are likely to be hindering performance.

    1. Relatively few learning opportunities for immunization staff
    2. Limitations on the ability for staff to experiment and take risks 
    3. Low tolerance for failure when trying something new
    4. A focus on completing immunization tasks rather than developing skills and future capacity
    5. Lack of encouragement for on-the-job learning 

    This gap hurts more than ever when adapting strategies to reach “zero-dose” children.

    These are children who have not been reached when immunization staff carry out what they usually do.

    The traditional learning model is one in which knowledge is codified into lengthy guidelines that are then expected to trickle down from the national team to the local levels, with local staff competencies focused on following instructions, not learning, experimenting, or preparing for the future.

    For many immunization staff, this is the reference model that has helped eradicate polio, for example, and to achieve impressive gains that have saved millions of children’s lives.

    It can therefore be difficult to understand why closing persistent equity gaps and getting life-saving vaccines to every child would now require transforming this model.

    Yet, there is growing evidence that peer learning and experience sharing between health workers does help surface creative, context-specific solutions tailored to the barriers faced by under-immunized communities. 

    Such learning can be embedded into work, unlike formal training that requires staff to stop work (reducing performance to zero) in order to learn.

    Yet the predominant culture does little to motivate or empower these workers to recognize or reward such work-based learning.

    Furthermore, without opportunities to develop skills, try new approaches, and learn from both successes and failures, staff may become demotivated and ineffective. 

    This is not an argument to invest in formal training.

    Investment in formal training has failed to measurably translate into improved immunization performance.

    Worse, the per diem economy of extrinsic incentives for formal training has, in some places, led to absurdity: some health workers may earn more by sitting in classrooms than from doing their work.

    With a weak culture of learning, the system likely misses out on practices that make a difference.

    This is the “how” that bridges the gap between best practice and what it takes to apply it in a specific context.

    The same evidence also demonstrates a consistently-strong correlation between strengthened continuous learning and performance.

    Investment in continuous learning is simple, costs surprisingly little given its scalability and effectiveness.

    Calculating the relative effectiveness of expert coaching, peer learning, and cascade training

    How does the scalability of peer learning compare to expert-led coaching ‘fellowships’?

    That means investment in continuous learning is already proven to result in improved performance.

    We call this “learning-based work”.

    References

    Watkins, K.E. and Marsick, V.J., 2023. Chapter 4. Learning informally at work: Reframing learning and development. In Rethinking Workplace Learning and Development. Edward Elgar Publishing. Excerpt: https://stories.learning.foundation/2023/11/04/how-we-reframed-learning-and-development-learning-based-complex-work/

    The Geneva Learning Foundation. From exchange to action: Summary report of Gavi Zero-Dose Learning Hub inter-country exchanges. Geneva: The Geneva Learning Foundation, 2023. https://doi.org/10.5281/zenodo.10132961

    The Geneva Learning Foundation. Motivation, Learning Culture and Immunization Programme Performance: Practitioner Perspectives (IA2030 Case Study 7) (1.0); Geneva: The Geneva Learning Foundation, 2022. https://doi.org/10.5281/zenodo.7004304

    Image: The Geneva Learning Foundation Collection © 2024

  • Protect, invest, together: strengthening health workforce through new learning models

    Protect, invest, together: strengthening health workforce through new learning models

    In “Prioritising the health and care workforce shortage: protect, invest, together,” Agyeman-Manu et al. assert that the COVID-19 pandemic aggravated longstanding health workforce deficiencies globally, especially in under-resourced nations. 

    With projected shortages of 10 million health workers concentrated in Africa and the Middle East by 2030, the authors urgently call for policymakers to commit to retaining and expanding national health workforces. 

    They propose common-sense solutions: increased, coordinated financing and collaboration across government agencies managing health, finance, economic development, education and labor portfolios.

    But how can such interconnected, long-term investments be designed for maximum sustainable impact?

    And what is the role of education?

    Rethinking health worker learning

    In a 2021 WHO survey across 159 countries, most health workers reported lacking adequate training to respond effectively to pandemic demands. This exposed systemic weaknesses in how health workforces develop skills at scale. Long before the COVID-19 pandemic, limitations of traditional learning approaches were already obvious.

    Prevailing modalities overly rely on passive knowledge transfer rather than active learner empowerment and engagement with real-world complexities. While assessment and credentialing are important, ultimately learning must be judged by its relevance, application and impact on people’s lives and health systems.

    Between April and June 2020, I had the privilege of working with a group of 600 of Scholars of The Geneva Learning Foundation (TGLF) from 86 countries. Together, we designed an immersive learning cycle integrating skill-building and peer exchange for those on the frontlines of the epidemic. We called it the “COVID-19 Peer Hub”. 

    It grew into an ecosystem that connected over 6,000 health professionals across 86 countries to share unfiltered insights, give voice to on-the-ground needs, and turn shared experience into action.

    Within three months, a third of participants had already implemented COVID-19 recovery plans, citing peer support as the main driver for turning their commitment into results.

    By the end of 2020, TGLF’s immunization platform, network, and community had tripled in size.

    In 2022, this network transformed into a Movement for Immunization Agenda 2030 (IA2030).

    Informing health workforce decisions

    What insights can health workforce policymakers draw from the Geneva Learning Foundation’s unique work to achieve the ambitious growth and support targets outlined by Agyeman-Manu et al.?

    First, expert-driven, top-down  approaches alone cannot handle emergent real-world complexities. In TGLF’s learning cycles, the most significant learning often occurs in lateral, one-to-one networking meetings between peers. These defy boundaries of geography, gender, ethnicity, religion, and job roles.

    Second, thoughtfully-applied technology can exponentially accelerate learning’s reach, access and connections following learner needs. New digital modalities opened by pandemic disruptions must be sustained and optimized post-crisis, despite the tendency to revert back to previous norms of learning through high-cost, low-volume formal trainings and workshop.

    Third, relevance heightens learning and application. Learning and teaching should not just be centered on learners’ needs and problems to boost motivation and effectiveness. Learning cannot be detached from its context.

    Finally, nurturing cultures that support effective learning matters for performance and human achievement. Systems enabling peer reward and accountability build resilience.

    Protect, invest, together in a learning workforce

    Health policymakers are manifesting intent to act on the health workforce crisis.

    Alongside urgent investments, applying systemic perspectives from learning innovations like those The Geneva Learning Foundation has pioneered presents a path to growing motivated, capable workforces ready for the challenges ahead.

    Rethinking assumptions opens eyes – when we commit to support health workers holistically, the rewards radiate across health ecosystems.

    Reference: Agyeman-Manu et al. Prioritising the health and care workforce shortage: protect, invest, together. The Lancet Global Health (2023). https://doi.org/10.1016/S2214-109X(23)00224-3

  • Digital bridges cannot cross analog gates

    Digital bridges cannot cross analog gates

    I’ve been doing a lot of thinking recently about an interesting question, as I’ve observed myself and colleagues starting to travel again: “Why are we again funding high-cost, low-volume face-to-face conferences that yield, at best, uncertain outcomes?”

    I am surprised to have to ask this question. I was hoping for a different outcome, in which the experience of the COVID-19 pandemic led to a lasting change in how we bridge physical and digital spaces for a better future. We were brutally forced to work differently due to the COVID-19 pandemic’s restrictions on freedom of movement. Nevertheless, we discovered that it is possible to connect, meet, collaborate, and learn without sinking budgets into air travel and accommodation. At least some of work-related travel was due to habit and convention, not necessity. Yes, there were limitations, especially due to the emergency nature of the pivot to online. But the debate is open whether the limitations we experienced being forced to work online are more or less severe than those of the offline medium.

    In global health, traditional face-to-face meetings, workshops, and conferences have been part and parcel of professional life for decades. They served their intended purpose, helping staff connect formally and informally, providing the connective tissue to learn, share, and coordinate. They have been – and remain – deeply ingrained in the culture of global health. Why should this modus operandi be reconsidered?

    As someone who is often required to attend face-to-face conferences, despite being a vocal advocate for more efficient, inclusive models, here is how I understand both sides of the dichotomy that this scenario presents.

    Traditional face-to-face meetings, workshops, and conferences offer a unique charm. They allow the select few to reconnect with colleagues, stay updated on institutional developments, and keep fingers on the pulse of the latest changes in our fields. Information can be shared informally, which is far more difficult to do online. (This is not inherent to the online medium, but due to the technologies we have developed that assume, support, and structure formal communication.) If you were invited or selected to be at the meeting, that indicates to those in the room that you are a valid stakeholder.

    There is a considerable downside. These events are exclusionary by definition. Not everyone’s costs can be covered. Selection is often based on hierarchy. Often, only the most senior get to go. When less senior practitioners are included, tokenism is difficult to avoid. Then, there is the high cost. It is primarily expenditure on travel and hotels, not event quality. There is also the cost to the environment. Think of the carbon footprint. They are disruptive to everyday work, as attendance requires absence. Strangely, their impact is seldom measured, evaluated, or questioned.

    The same donor who will unquestionably plunk down $150,000 for the plane tickets and hotels rooms of 100 people might require the evidence of a randomized controlled trial (RCT) before investing in a new digital learning approach that might include 1,000 or 10,000 people for the same cost and produce far more significant outcomes than a meeting report.

    So why are face-to-face events still being funded, at high cost and questionable return, when global health is supposed to be evidence-based and focused on impact?

    Ironically, as Girija Sankar made the case recently in The Lancet, the very conferences designed to push the boundaries of research and collaboration in global health often act as “gates,” creating a divide between insiders and those on the outside. These gatherings are often arranged by the gatekeepers of global health, the credentialed leaders who control funding and policy. Their decisions shape the future of health at a global level, conferring agency upon a select few while inadvertently excluding many others.

    It is undeniably satisfying – and deeply so – to connect with colleagues over the course of several days, sharing conversation, meals, coffees. It is not only about listening and learning. It is about being human together, despite the constraints and urgencies of the work. So, if you are in a position to fund such an event for yourself or for your colleagues, why would you say no, given the obvious benefits and zero incentive to deny your colleagues what they are used to getting?

    The value of such events is in part premised on their exclusivity. Letting everyone in could dilute their value. Furthermore, digital experience remains awful: a Zoom call is undeniably inferior to the experiential richness and pleasure of a meeting in a shared physical space.

    Unfortunately, as long as such wonderful moments are reserved for the few – due to the nature of the medium, despite the best intents –, such communion stops at the conference walls – and excludes everyone outside them.

    The Geneva Learning Foundation’s Teach to Reach program presents a stark contrast to this traditional model. Our online, digital, and networked peer learning events are dynamic, inclusive, connecting local practitioners from everywhere. With no upper limit on participants, these digital events rally thousands from all corners of the globe, providing an unparalleled platform for shared learning and action.

    The upcoming Teach to Reach 8 event on 16 June 2023 is a testament to this, with over 16,000 anglophones and francophones already registered to join. Most notably, the majority of participants are government health workers working on the frontlines in Africa and Asia. Teach to Reach is led by an “organizing committee” composed of 282 Teach to Reach Alumni from 35 countries who are founding Members of the Global Council of Learning Leaders for Immunization in November 2020.

    Some global-level colleagues who have rejoined the mission travel, conference, and workshop circuit share that they struggle to understand Teach to Reach. It is just too different from what they are used to. They have to painstakingly listen to staff with lousy connectivity who share local experiences, problems, and challenges that seem quaint, compared to the abstract global-level strategies they usually engage peers who are almost exactly like themselves. Such sameness is reassuring. Comparatively, Teach to Reach is too chaotic and noisy. So many voices, speaking from so many different pespectives. Too time-consuming. Too confusing. Too different from what “we” are used to. Too messy. 

    Yet, the real world is messy. We know that the probability of finding a solution locally increases with the number and diversity of inputs available. At Teach to Reach, thousands share their experience, using a robust, proven peer learning model. The global experts who do attend do so as “guides on the side” rather than “sages on the stage”.

    The unstated, underlying assumption of many so-called capacity-building initiatives is that the locals do not know. Therefore, “we” must teach them. There is no way to call this anything other than a colonial assumption. Recognizing the value and significance of local expertise and experience may have been less important in the past, when countries successfully carried out effective top-down strategies that moved the needle of vaccination coverage across the world. Today’s more complex immunization challenges require problem-solving approaches that recognize that context is central. What you know, because you are there every day, side-by-side with families and communities that you serve, turns out to be more important than generalities.

    For example, the Foundation’s research has shown that reaching zero-dose or underimmunized children calls for local creativity to tailor and adapt strategies, rather than apply a cookie-cutter guideline. Should we be searching for generalizations that can be turned into norms and standards, when every zero-dose context is different? What if the opportunity were to hone in on the ‘how’ of local action, to better understand what makes the difference at the last mile of service delivery?

    Should we assume that it is local staff who need to develop their capacity and change, when behavior change is probably necessary for everyone, at all levels?

    Change is hard, but it is definitely happening. The last two editions of Teach to Reach have been in partnership with UNICEF and since 2022 with support from Wellcome. Ephrem T. Lemango and Kate O’Brien, who lead immunization at UNICEF and WHO respectively, prefaced the latest Teach to Reach report, writing: “Uniquely, the Geneva Learning Foundation’s platform and its Teach to Reach events provide a way to link such people together, so that they can share experiences about what works and equally important, what doesn’t work, while learning from each other. Learning happens best when people seek answers to their specific daily challenges. Teach to Reach is proof that immunization professionals are hungry to learn, and hungry to share.”

    Furthermore, they note that “it is humbling to hear how committed people are to sharing experiences in the hope that they will benefit someone else, how the inadequacies of internet connections fail to deter people participating, and how so many are using precious digital data to take part. The digital space allows everyone to participate, irrespective of national boundaries or positions in an immunization hierarchy.”

    Girija Sankar also reminds us that gatekeeping is not only for the leaders. It is also an opportunity for each of us to consider our roles and responsibilities. When deciding on invites, we should ask ourselves, “Is the limitation due to budget constraints or based on our perception of who has the most valuable input or the most funding to contribute?” It is also a call to action for those of us who have access to closed-door meetings or sit on advisory boards. We must pause and reflect on our roles and use our authority to pave the way for those who might not traditionally have a voice in these important discussions.

    So, while I, and many others, have to travel to face-to-face conferences to stay “in the loop”, it is essential to recognize the limitations of these gatherings and work towards more inclusive and efficient models. The need to shift our mindset is more pressing than ever in the field of global health. In our quest for a healthier world, let’s ensure that the gates of knowledge and decision-making are open to all. Let’s embrace models like Teach to Reach, breaking down barriers and creating an inclusive platform for dialogue, learning, and action.

    Imagine if the World Health Organization’s unspent mission travel budget in 2020 – around $400 million – had been invested in digital infrastructure to support continuous learning to explore and support new kinds of collaboration between different levels of the health system.