Stories

Tag: performance

  • 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.

  • 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

  • Hot fudge sundae

    Hot fudge sundae

    Through their research on informal and incidental learning in the workplace, Karen Watkins and Victoria Marsick have produced one of the strongest evidence-based framework on how to strengthen learning culture to drive performance.

    Here, Karen Watkins shares an anecdote from a study of learning culture in which two teams from the same company both engaged in efforts to reward creative and innovative ideas and projects. However, one team generated far more ideas than the other. You won’t believe what turned out to be the cause of the drastically disparate outcomes.

     

    I recorded Karen via Skype while she was helping me to perform my first learning practice audit, a mixed methods diagnostic that can provide an organization with new, practical ways to recognize, foster, and augment the learning that matters the most.

    Recognizing that the majority of learning, problem-solving, idea generation, and innovation do not happen in the training room – physical or digital–, is a key step in our approach to help organizations execute change.

    Karen is a founding Trustee of the Geneva Learning Foundation.

  • 12 questions that learning strategy seeks to answer

    12 questions that learning strategy seeks to answer

    Learning is the acquisition of knowledge, skills and competencies (behaviors) through experience and study. We all want to learn, so why is it so difficult to stop work to make time for learning, despite our best intentions? In exploring possible solutions to this question, learning strategy emerges from the existing practices and strengths of the organization – together with a diagnosis of where it needs to improve knowledge performance.

    Learning strategy examines how knowledge and learning can be improved, starting with mundane, routine or recurring questions and frustrations of daily work life, such as:

    • What can I do when I have too much e-mail?
    • How often should we meet as a team?
    • How can I experiment and innovate when I have so many urgent tasks to deliver?

    The strategy also answers questions about how we work together as a team and with people outside the organization (partners, beneficiaries, customers…):

    • How can I best learn from and with those we serve?
    • What is the best way to stay connected with co-workers who are halfway around the world?
    • How should we onboard new staff?
    • How can we support each other to do better as we work?

    Learning strategy also guides the organization in developing context-specific, best practice and evidence-based answers to questions such as:

    • How do we detect patterns and trends that matter for our work?
    • How do we make decisions in the face of information overload or, on the contrary, when we are faced with uncertainty?
    • How do we get the “eureka” moments when trying to solve difficult problems?
    • Why are our information systems (sometimes) difficult to use – and its specific case: why do we hate our LMS?
    • How can I identify and adopt technology that can make it easier to communicate, share and learning with my colleagues?

    Last but not least, learning strategy outlines what we may expect or ask from our managers and leaders, who have a key role in encouraging and developing people as well as in advocating for broader organizational change that recognizes the value and significance of learning as a key driver of the organization’s performance.

    Photo: Rainbow of Ribbons (Fleur/flickr.com)

  • Making humanitarians

    Making humanitarians

    The industry to tackle growing humanitarian and development challenges has expanded rapidly since the mid 1990s, but not nearly as fast as the scope and scale of the problems have spiraled. Professionalization was therefore correctly identified as a major challenge of its own, with over a decade of research led by Catherine Russ and others clearing the rubble to allow the sector to make sense of what needs to be done. The bottom line diagnosis is a now-familiar litany: a shortage of people and skills, lack of quality standards, inability to scale.

    Despite the growth of traditional university programs to credential specialized knowledge of these challenges and how to tackle them, young people armed with multiple masters find that they really start learning upon entering their first NGO. They face a dearth of entry-level positions (sometimes spending years as “interns” or other forms of under-recognized labor) and discover professional networks closed to them because legitimacy is based on shared experience, not formal qualifications.

    Certified professional development run by universities fail because these institutions are ill-equipped to deliver sub-degree qualifications, and rely on methods that seldom provide experience. This problem is not specific to humanitarians, but may be more acute because of the nature of the work and the knowledge involved.

    Meanwhile, specialized organizations that provide training, like REDR in the UK or Bioforce in France, have become increasingly good at developing competency-based certification for behavior that matches real-world needs. Their business model works best at small scale and high cost. They have also succeeded in establishing that the credential of value is one that is defined by and agreed upon by practitioners. However, their efforts remain mired in a legacy of transmissive training and a tradition of “workshop culture” that are difficult to overcome. Also, by the time a competency framework is described, new contexts and needs that dictate new behaviors have predictably emerged but cannot be captured by the rigidity of framework.

    A few organizations are trying to organize the online delivery of click-through information modules. Unfortunately, this approach has yet – to put it politely – to show measurable positive performance outcomes. And, admittedly, it is going to be tough to prove that three hours of clicking through bullet points followed by an information recall quiz corresponds to what 21st century humanitarians need to deliver. (Having said that, it is probably no worse than sitting in a workshop with a ‘trainer’ doing the clicking, whether in terms of learning efficacy or sheer pleasure).

    Save The Children’s Humanitarian Leadership Academy stands out in a number of ways in the current landscape. Their analysis is grounded in the rock-solid research by Russ and others, and they have assembled a ferociously professional team that combines all of the right job functions, encompassing both folks from the sector and those who are new to it. The project is rightly ambitious, given the scope and scale of the challenges faced, and they have succeeded in securing a large chunk of their funding needs from the UK government. They aim to serve not just Save’s training needs, but to become the connector for a broad set of organizations working together, trying to convert decades of preaching about capacity building in developing countries into practice. Last but not least, they are trying to think strategically about their use of digital technology for learning.

    Has the time come, as a defrocked high priest of corporate learning recently suggested, for a “Pan Humanitarian College of Conscience”? Could it be as simple as bringing everyone together to share content, resources, and determine quality and credentialing standards together? I don’t think so, mostly because the existing content, resources, and approaches are not getting the job done. We need to do new things in new ways, not an educational “We are the world”.

    Truly disruptive humanitarian education leverages the affordances of educational technology to offer continual learning experiences that foster sense-making and network formation linking young and old humanitarians in global practices, strengthening existing professional networks because collaboration and team work are how you complete the mission. Such experiences could focus on precisely what is unsaid and untaught in formal curricula, and considered unattainable by training. Even formal courses that are about acquiring foundational knowledge can have learners co-constructing knowledge together. These peers then find themselves part of a knowledge community where, as alumni, they are now in a position to provide support – and benefit from the new learnings of others in a virtuous cycle. This paradigm shift occurs when how we learn is aligned to how we work: collaboration, team work and leadership are premised on peer-to-peer relationships, across the diversity of contexts and people that humanitarians find themselves in.

    Such an approach fosters critical thinking and practice around specific areas of work but – and perhaps more importantly – around cross-cuting ways of thinking and doing. Yes, you could build courses that tap into knowledge communities around climate change, logistics, or market-based approaches. Focus on an area of work, zero in on its wicked problems, and drive learning efforts where they are most needed, producing knowledge that is directly applicable to work. Going further, new ways of learning foster new forms of leadership and innovation in the face of a volatile, uncertain, complex and ambiguous (VUCA) world, through courses that teach and deepen realist evaluation or tap into experiences from outside the sector – linking resilience and sustainability – to help new ways of thinking and doing emerge.

    Last but not least, this new humanitarian learning needs to include not just future professionals but also volunteers. As the Red Cross Red Cross Movement has taught us , volunteers are far more than part-time humanitarians. They are embedded in their communities and learn to use the cultural and tacit knowledge from belonging to empower themselves, their families, neighbors, and every member of the community – whatever their status, in a fully inclusive way. Making sense of what happens in your community in this century, more so than ever before, requires that you establish a fluid two-way connection to global knowledge.

    While these are admittedly lofty objectives, the science of learning combined with educational technology are poised to make this more than just wishful thinking. Scaling up is currently center stage in both education (thank you, MOOCs) and humanitarian realms. There have been a small but significant number of well-researched, successful, small-scale pilots to foster new forms of humanitarian learning. The learners who participated in such experiments got it – even if some managers and decision makers did not. The missing link remains the network of learning leaders willing and able to think and fund the foundations for such an endeavor, and then to start building its scaffolding. And, who knows, such a group might find that Pan Humanitarian College of Conscience is a good fit to name what we might make together.

    Photo: Young man at a vocational education and training center, Marrakesh, Morocco. © Dana Smillie / World Bank

  • Mission performance

    Thanks to Karen E. Watkins (University of Georgia) and Maya Drobnjak (Australian Army).